Schär Ralph T, Fiechter Michael, Z'Graggen Werner J, Söll Nicole, Krejci Vladimir, Wiest Roland, Raabe Andreas, Beck Jürgen
Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
PLoS One. 2016 Apr 14;11(4):e0153499. doi: 10.1371/journal.pone.0153499. eCollection 2016.
Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data.
Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings.
Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11-62.37]).
Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention.
ClinicalTrials.gov NCT01987648.
择期开颅手术后的患者管理通常包括术后常规计算机断层扫描（CT）。我们分析了早期拔管并密切进行神经监测而不进行常规CT的方案是否安全，并将术后急诊神经外科干预率与已发表的数据进行了比较。
对492例患者进行前瞻性分析；其中360例为幕上病变，132例为幕下病变。所有病例均目标在皮肤缝合后1小时内拔管。仅在出现意外神经学表现的情况下才在48小时内进行CT检查。
492例患者中有469例（95.3%）在1小时内拔管，20例（4.1%）在3小时内拔管，3例（0.6%）在3至10小时内拔管。492例中有43例（8.7%）在48小时内进行了急诊CT检查。术后出血患者在48小时内的再次开颅率为0.8%（n = 4），0.8%（n = 4）需要放置外部脑室引流管（EVD）。在1小时内拔管的469例患者中，3例需要再次开颅，2例需要放置EVD。在23例延迟拔管的患者中，1例需要再次开颅，2例需要放置EVD。未能在1小时内拔管与48小时内进行手术干预的风险显著更高相关（发生率13.0%，p = 0.004，优势比13.9，95%置信区间[3.11 - 62.37]）。
早期拔管联合密切神经监测是安全的，并且无需术后常规CT检查。未在1小时内拔管的患者确实需要早期CT检查，因为他们需要急诊神经外科干预的风险显著增加。
ClinicalTrials.gov NCT01987648。
