A Novel Protocol for Reducing Intensive Care Utilization After Craniotomyh

INTRODUCTION: There is increasing evidence that ICU admission may be unnecessary for all craniotomy patients. However, there are no guidelines for level of care requirements in this population. We sought to devise and implement a standardized protocol for craniotomy patients who would be eligible to transition directly to the ward the NonIntensive CarE (NICE) protocol. METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with the age <65 criterion and ASA Class of 1, 2, or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams and each patient was observed in the post-anesthesia care unit for stable hemodynamics and satisfactory pain control. Exclusion criteria included surgical/anesthetic concerns as well as need for significant pain, blood pressure or blood sugar management. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations. A retrospective review of the prospectively enrolled cohort was conducted. Demographics, clinical characteristics and surgical outcomes were collected. RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a mean age of 45 yr and 65% female predominance. ASA Class breakdown was as follows: ASA1 9/5%, ASA2 57.1% and ASA3 33.3%. Of the operations performed, 38% were microvascular decompressions, 31.7% were craniotomy for tumor and 15.9% were cavernous malformation resections. About 7 operations were redos. Overall, no patients required transfer to the intensive care unit. Mean length of stay was 1.8 d (range 1-5 d) and 96.8% of patients went home. There was an 11.1% overall readmission rate within the mean follow-up period of 74.2 d. About 3 patients required reoperation (postoperative subdural hematoma, pseudomeningocele, and wound infection). CONCLUSION: Appropriately selected craniotomy patients may be safely transferred to a neurosurgical ward with low risk of transfer to intensive care.