Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA.
Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA.
Clin Neurol Neurosurg. 2020 May;192:105716. doi: 10.1016/j.clineuro.2020.105716. Epub 2020 Feb 3.
BACKGROUND/OBJECTIVE: Following cranial neurosurgical procedures, intensive care unit (ICU) admission is routine; however, our institution's growing referral network has led to more frequent bed shortages. Consequently, there are increased requests to transfer our postoperative patients out of the ICU early in the monitoring window. We aimed to find risk factors to prioritize which postoperative neurosurgical patients that should remain in the unit.
An unmatched case-control study was conducted following retrospective chart review of patients who underwent common cranial procedures between August 2015 and June 2016 at our institution. Patients receiving postoperative ICU intervention were defined as cases. Several perioperative events were investigated for association with postoperative ICU level care. Individual risk factors were analyzed using Chi-squared tests for categorical variables (reported as odds ratio) and independent sample two tailed t-tests for continuous variables. Regression models were used for multivariate analysis.
We identified 282 patients who met inclusion criteria, with 148 cases and 134 controls and no statistically significant differences between group demographics. Elective cases carried an odds ratio (OR 0.12, 95 % CI 0.05-0.26, p < 0.001), suggesting decreased likelihood of postoperative intensivist intervention. Single variable analysis showed ICU level of care was more more likely with general anesthesia (OR 3.72, 95 % CI 1.90-7.25, p < 0.001) and American Society of Anesthesiologists (ASA) class IV patients (OR 3.28, 95 % CI 1.59-6.78, p < 0.001). Continuous variables (blood loss and operative time) both demonstrated statistically significant differences (p < 0.001) between case and control groups with higher blood loss (100 ± 167 mL) and operative times (245 ± 119 min) seen in the ICU intervention group. Our regression model identified non-elective cases, operative time, and blood loss having associations with postoperative intensivist intervention.
Growing demand for ICU beds at our institution has us looking for more objective data guiding decisions on lower-risk patients who could transfer early out of the ICU in times of overcapacity. Elective endovascular aneurysm treatment and DBS are cranial procedures least likely to receive postoperative ICU level intervention. Consideration to procedural blood loss of 100 cc or more and operative time greater than 4 h should also be given as these risk factors were associated with more likely needing postoperative ICU intervention. These results should not spur drastic changes in ICU protocols, but continued quality improvement projects should investigate these correlations to add more objective data for ICU utilization.
背景/目的：在颅脑神经外科手术后，通常需要入住重症监护病房（ICU）；然而，我们机构不断扩大的转诊网络导致 ICU 床位更加紧张。因此，越来越多的要求是将我们的术后患者在监测窗口早期转移出 ICU。我们旨在寻找风险因素，以便优先确定哪些术后神经外科患者应留在 ICU 中。
对 2015 年 8 月至 2016 年 6 月在我院行常见颅脑手术的患者进行了回顾性病历回顾匹配病例对照研究。术后接受 ICU 干预的患者被定义为病例。研究了围手术期的几个事件与术后 ICU 级别的护理之间的关系。使用卡方检验（报告为比值比）对分类变量进行个体风险因素分析，使用独立样本双尾 t 检验对连续变量进行分析。使用回归模型进行多变量分析。
我们确定了 282 名符合纳入标准的患者，其中 148 例为病例，134 例为对照，两组人群的人口统计学特征无统计学差异。择期手术的比值比（OR 0.12，95 % CI 0.05-0.26，p < 0.001）较低，提示术后需要干预的可能性较小。单变量分析显示，全身麻醉（OR 3.72，95 % CI 1.90-7.25，p < 0.001）和美国麻醉医师协会（ASA）IV 级患者（OR 3.28，95 % CI 1.59-6.78，p < 0.001）的 ICU 护理水平更有可能。连续变量（失血量和手术时间）在病例组和对照组之间均存在统计学差异（p < 0.001），在 ICU 干预组中，失血量（100 ± 167 ml）和手术时间（245 ± 119 min）较高。我们的回归模型确定了非择期手术、手术时间和失血量与术后强化治疗干预有关。
我们机构对 ICU 床位的需求不断增长，促使我们寻找更多客观数据，以指导在 ICU 容量过大时，对风险较低的患者进行早期转移。择期血管内动脉瘤治疗和 DBS 是最不可能接受术后 ICU 级别的干预的颅脑手术。还应考虑到 100cc 或更多的手术失血量和超过 4 小时的手术时间，因为这些危险因素与更有可能需要术后 ICU 干预有关。这些结果不应引起 ICU 方案的重大变化，但应继续进行质量改进项目，以调查这些相关性，为 ICU 利用增加更多客观数据。
