CLINICAL INVESTIGATION
Do Patients Still Require Admission to an Intensive
Care Unit After Elective Craniotomy for Brain Surgery?
Ossam Rhondali, MD,* Ce´line Genty, BSc,w Caroline Halle, MD,* Marianne Gardellin, MD,*
Ce´line Ollinet, MD,* Manuela Oddoux, MD,* Joe¨lle Carcey, MD,* Gilles Francony, MD,*
Bertrand Fauvage, MD,* Emmanuel Gay, MD, PhD,z Jean-Luc Bosson, MD, PhD,w
and Jean-Franc¸ois Payen, MD, PhD*
Background: After elective craniotomy for brain surgery,
patients are usually admitted to an intensive care unit (ICU).
We sought to identify predictors of postoperative complications
to define perioperative conditions that would safely allow ICU
bypass.
Methods: This observational cohort study enrolled 358 patients
admitted to neuro-ICU after elective intracranial procedures.
Postoperative complications were defined as unexpected events
occurring within 24 hours of surgery that required imaging or
treatment for neurologic deterioration.
Results: Fifty-two patients were transferred postoperatively to
neuro-ICU with sedation and mechanical ventilation. Of the
remaining 306 patients subjected to an attempt to awake and
extubate in the operating room, 26 (8%) developed 1 postoperative
complication, primarily a new motor deficit, unexpected awaken-
ing delay, or subsequent deterioration in consciousness. Four
intracerebral hematomas required surgical evacuation and each of
these was detected within 2 hours after surgery. Predictors of
postoperative complications included failure to extubate the
trachea in operating room [odds ratio 61.8; 95% confidence
interval (CI) 12.2-312.5], and, to a lesser extent, a duration of
surgery of more than 4 hours (odds ratio 3.3; 95% CI 1.4-7.8), and
lateral positioning of the patient during the procedure (odds ratio
2.8, 95% CI 1.2-6.4).
Conclusions: Our results encourage prospectively testing the
hypothesis that patients with immediate, successful tracheal
extubation after elective craniotomy for brain surgery, with a
surgical duration of less than 4 hours in a nonlateral position
could be monitored safely in the postanesthesia care unit before
being discharged to a neurosurgical ward.
Received for publication July 28, 2010; accepted November 15, 2010.
From the Departments of *Anesthesia and Critical Care; zNeuro-
surgery; and wDivision of Biostatistics, Michallon Hospital, and
Joseph Fourier University, Grenoble, France.
All of the authors have disclosed that they have no financial relationship
with or interest in any commercial companies.
Reprints: Jean-Franc¸ois Payen, MD, PhD, Pôle d’Anesthésie-Réanima-
tion, Hôpital Albert Michallon, BP 217, F-38043 Grenoble, France
(e-mail: jfpayen@ujf-grenoble.fr).
Copyright r 2011 by Lippincott Williams & Wilkins
118 | www.jnsa.com
Key Words: intensive care unit, neurosurgery, postoperative,
resource
(J Neurosurg Anesthesiol 2011;23:118–123)
A fter elective craniotomy for brain surgery, it is advised
that all patients should be closely monitored in an
intensive care setting for a period of time, usually
overnight.1,2 Even the majority of relatively healthy (the
American Society of Anesthesiologists’ physical status I
and II) patients undergoing elective neurosurgery still
receive intensive or intermediate care.3 The rationale for
this routine practice is that intensive care unit (ICU)
admission allows the early detection of serious post-
operative complications, thereby facilitating prompt
intervention and optimizing recovery. However, the
reality of such postoperative management strategies on
patient outcome is unknown. ICU resources are scarce
and expensive, and using ICU beds in this way may limit
their availability for emergency admissions as well as for
other neurosurgical procedures. In this era of constrained
medical economics, many traditional patterns of practice
are being questioned, the most illustrative example
coming from postoperative ICU management in cardiac
surgery.4
Elective craniotomy for brain surgery carries the
risk of various complications, most notably intracerebral
hematoma and seizures. Although the effects of post-
operative hematoma are potentially devastating on
patient outcome, their overall incidence is low, between
0.8% and 2.2%.5–8 Rates of postoperative seizures are
less than 5% within 24 hours of surgery.9 Various factors
associated with the occurrence of postoperative hemato-
ma have been identified in the retrospective chart reviews:
surgery for meningiomas,5 patients above 70 years of
age,10 a preoperative use of antiplatelet agents,5 a
perioperative elevation of arterial blood pressure,7 and a
large amount of intraoperative blood loss.8 However,
clinical practices in anesthesia have changed recently and
an attempt to awake and extubate in the operating room
is routinely performed to allow immediate neurologic
assessment.11 Therefore, the effectiveness of routine
postoperative ICU admission after neurosurgery should
be investigated.12–14
J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011
J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011
To develop the best strategy between quality of care
and control of scarce resources, we conducted an
observational cohort study involving adult patients
consecutively admitted to neuro-ICU after an elective
craniotomy for a neurosurgical procedure. We deter-
mined both the incidence and timing of unexpected events
within 24 hours of surgery that required imaging or
treatment for neurologic deterioration. Our aim was to
identify perioperative conditions that could safely allow
ICU bypass after elective brain surgery.
PATIENTS AND METHODS
This observational cohort study was conducted
between November 2005 and May 2007 at the University
Hospital of Grenoble. The local Institutional Ethical
Committee approved the design of the study and,
considering its observational nature, waived requirements
for informed consent from the patients. We enrolled
patients aged 15 years or above who underwent an
elective craniotomy for brain surgery and were admitted
postoperatively to the neuro-ICU. Patients were excluded
if they required an emergency surgery, or a neuro-
surgical procedure with no craniotomy. For each patient,
we collected a set of variables that included demo-
graphics, preoperative clinical findings, brain lesion
characteristics, details of the surgical procedure, and
intraoperative management. Patients were anesthetized
by using a continuous intravenous infusion of propofol
(target-controlled infusion 4 to 5 mg/mL) and remifentanil
(0.25 mg/kg/min reduced to 0.1 mg/kg/min after dural
opening), to maintain a systolic arterial blood pressure
of over 100 mm Hg. Mechanical ventilation was adjusted
to maintain end-tidal CO2 between 30 and 35 mm Hg
at normal oxygen levels (arterial pulse oximetry above
95%). Measures were taken to prevent postoperative
nausea and pain, that is, droperidol, acetaminophen, and
morphine, respectively. Steroids were given during the
procedure in the presence of peritumoral edema. In
addition, anticonvulsants were given during the proce-
dure if the patient was considered at particular risk for
seizures, for example, after cortectomy for palsy, caver-
nous angioma, or meningioma. After surgery, an attempt
to awake and extubate was performed in the operating
room under the following conditions: body temperature
above 361C, no evidence of hemodynamic instability or
respiratory failure during spontaneous ventilation, no
signs of postoperative neuromuscular blockade, unevent-
ful surgery, and the cessation of anesthetic drugs. If the
neurologic status was normal (or unchanged from the
preoperative status) and the patient obeyed commands,
then extubation was attempted. All extubated patients
were transferred to the postanesthesia care unit (PACU)
for 2 hours and then on to the neuro-ICU for 24 hours,
with hourly monitoring of their vital signs. If the tracheal
extubation was not possible in the operating room, the
patient was transferred directly to the neuro-ICU. In our
institution, extubated patients only are allowed to go to
PACU. The anesthesiologist in-charge decided whether to
r 2011 Lippincott Williams & Wilkins
Complications After Elective Neurosurgery
attempt to awake and extubate in the operating room or
whether to transfer the patient directly to the neuro-ICU,
and at no point did this study interfere with standard
patient care.
Postoperative complications were defined as unex-
pected events occurring within 24 hours of surgery that
required imaging or treatment for neurologic deterioration.
These included: new motor deficits, seizures, unexpected
awakening delays, diabetes insipidus, subsequent dete-
rioration in consciousness, respiratory failure, and arterial
hypotension requiring vasopressor use. Accordingly, we
classified patients into 2 groups: patients with an unevent-
ful 24 hours stay in the neuro-ICU, and patients with at
least 1 postoperative complication occurring within 24
hours after surgery.
Descriptive statistics included frequencies and per-
centages for categorical variables, and mean and SD for
continuous level variables. We evaluated the univariate
association of perioperative variables with postoperative
complications using the w2 or Fisher exact test for
categorical variables, and the Student t test for contin-
uous variables (Stata 10.0, Stata Corporation, College
Station, TX). Preoperative and intraoperative variables
with a P value of less than 0.20 and no interaction
between each other were subjected to a stepwise logistic
regression model to investigate possible factors predicting
postoperative complications. We then associated the
absence of those predictors with the postoperative
findings. Statistical significance was declared when the
P<0.05.
RESULTS
We recruited 358 consecutive patients during the
study period (Fig. 1). Of these, 52 patients (15%) were
transferred to the neuro-ICU after surgery without
attempting awakening and extubation in the operating
room. By comparison with the remaining 306 patients,
these 52 sedated and mechanically ventilated patients
had a longer duration of surgery (421 ± 167 min vs
239 ± 105 min; P<0.01), received more colloids during
surgery (532 ± 450 mL vs 218 ± 294 mL; P<0.01), re-
quired more blood transfusions (11 of 52 patients vs 7 of
306 patients; P<0.01), and needed more vasopressor
agents (22 of 52 patients vs 18 of 306 patients; P<0.01)
during surgery. Ten of these 52 patients (19%) had at
least 1 postoperative complication.
Of the 306 patients subjected to an attempt to
awake and extubate at the end of surgery, 26 patients
(8%) had at least 1 complication within the 24 hours after
surgery: new motor deficit (n=17), unexpected awaken-
ing delay (n=7), subsequent deterioration in level of
consciousness (n=6), seizures (n=2), and diabetes
insipidus (n=1). Complications were detected in the
operating room (n=15 patients) and in the first 2-hour
monitoring in the PACU (n=7 patients). For 4 patients,
complications were detected in the neuro-ICU: diabetes
insipidus (3 h after surgery for craniopharyngioma), new
motor deficit (3 h after surgery for meningioma), severe
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Rhondali et al J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011

358 patients with elective intracranial

surgery

52 patients directly transferred to the neuro-ICU with

sedation and mechanical ventilation

306 patients with attempt to awake

and extubate

280 patients with no

postoperative complication

26 patients with at least one

postoperative complication

15 detected in the 7 detected in 4 detected in

operating room the PACU the neuro-ICU

FIGURE 1. Patient flow diagram showing the number of analyzed patients. ICU indicates intensive care unit; PACU,
postanesthesia care unit.

acute respiratory failure (20 h after surgery for meningio-
ma in a parkinsonian), and seizures (24 h after surgery for
meningioma). Of the 26 complicated patients, 25 required
a cerebral computed tomography (CT) scan without delay
(<15 min) before leaving the operating room (n=15
patients), during their stay in the PACU (n=6 patients),
or in the ICU (n=4 patients). Cerebral CT scan allowed
the diagnosis of an extradural or intracerebral hematoma
(n=5 patients), brain ischemia (n=3 patients), focal
brain edema (n=4 patients), and mild pneumocephalus
(n=2 patients), although the CT scan was normal or
unchanged in 11 patients. Immediate interventions
included anticonvulsant therapy (n=2 patients), osmo-
therapy (n=1 patient), vasopressors (n=1 patient), and
reintubation (n=2 patients). No patient needed naloxone
to reverse the effects of opioids. After imaging, there
was surgical hematoma evacuation for 4 patients.
Sixteen patients did not require active treatment during
their neuro-ICU stay. All patients were eventually
discharged from the neuro-ICU with the same neurologic
status as their arrival to the ICU, except for the patient
with acute respiratory failure, who was the only 1 to die in
ICU.
We found no significant difference in the preopera-
tive variables between the 26 patients who developed
postoperative complications and the remaining 280
patients (Table 1). Neither the preoperative neurologic
findings nor the location of the brain lesion were
associated with the occurrence of postoperative complica-
tions. Patients with complications were more likely to
have undergone a surgical procedure that lasted for more
than 4 hours, were more likely to be laterally positioned,
and received more than 500 mL hydroxyethyl starch
solution as colloids more frequently during surgery. In
this cohort of 306 patients subjected to an attempt to
awake and extubate in the operating room, 296 were
successfully extubated in the operating room. Of these,
there were 99% of patients (278 of 280) with no
complications, whereas only 69% (18 of 26) of patients
who subsequently developed complications were extu-
bated successfully (P<0.01) (Table 1). The 10 patients
who were attempted to wake but remained intubated in
the operating room and transferred to the neuro-ICU had
CT scan findings: intracerebral hematoma (n=1 patient),
brain ischemia (n=3 patients), or focal edema (n=2
patients).
With an odds ratio of 61.8 (95% CI 12.2-312.5;
P<0.01), the ability to safely extubate the patient in the
operating room was strongly associated with a low rate of
postoperative complications. However, as some patients
might have been kept intubated and transferred to ICU
with no evidence of immediate complications, tracheal
extubation was excluded from the multivariate analysis.
The 2 additional variables found to be independently
associated with postoperative complications were an
operating time of more than 4 hours and a lateral posi-
tion during the procedure: odds ratio 3.3 (95% CI 1.4-7.8;
P<0.01), and odds ratio 2.8 (95% CI 1.2-6.4; P=0.02),

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J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011 Complications After Elective Neurosurgery

TABLE 1. Preoperative and Intraoperative Variables Collected From the 306 Patients Subjected to an Awakening Trial in the OR
After Elective Brain Surgery, According to the Occurrence of Complications Within the First 24 Hour After Surgery
No Complication (n=280) Complications (n=26) P
Age, mean (SD) (y) 52 ± 16 54 ± 13 0.68
Sex, n (% male) 131 (47) 14 (54) 0.49
Body mass index, mean (SD)* 25 ± 5 25 ± 4 0.93
ASA physical statusw, n (%): 0.75
ASA I 74 (27) 7 (27)
ASA II 156 (56) 16 (62)
ASA III 48 (17) 3 (11)
Patient historyz, n (%)
Chronic arterial hypertension 71 (25) 5 (19) 0.48
Other cardiovascular disease 19 (7) 0 (0) 0.17
Chronic respiratory disease 39 (14) 4 (15) 0.84
Tobacco use 77 (28) 4 (15) 0.18
Diabetes 14 (5) 0 (0) 0.62
Preoperative neurologic statusz, n (%)
Motor deficit 101 (36) 12 (46) 0.32
Altered consciousness 7 (3) 2 (8) 0.17
Signs of intracranial hypertension 45 (16) 2 (8) 0.39
Convulsions 49 (18) 4 (15) 1.00
Normal examination 121 (43) 9 (35) 0.39
Surgical procedurey, n (%) 0.79
Meningioma 72 (26) 8 (31)
Malignant glioma 80 (29) 6 (23)
Brain metastasis 40 (14) 2 (8)
Cortectomy for palsy 20 (7) 3 (11)
Cavernous angioma 17 (6) 1 (4)
Aneurysm 12 (4) 2 (8)
Other 37 (13) 4 (15)
Description of brain lesion, n (%)
Supra/infratentorialJ 245/34 24/2 0.75
Lateral/medianz 191/31 19/3 1.00
Mass effect 84 (30) 9 (35) 0.63
Edema 123 (44) 10 (38) 0.58
Duration of anesthesia, mean (SD) (min) 353 ± 108 419 ± 208 0.12
Anesthesia >400 min, n (%) 84 (30) 11 (42) 0.20
Duration of surgery, mean (SD) (min) 235 ± 97 285 ± 162 0.13
Surgery >240 min, n (%) 106 (38) 17 (65) 0.01
Positioning during surgery, n (%) 0.02
Supine 155 (55) 12 (46)
Lateral 87 (31) 14 (54)
Prone 38 (14) 0 (0)
Colloids, mean (SD) (mL) 203 ± 270 375 ± 465 0.07
Colloids >500 mL, n (%) 12 (4) 4 (15) 0.04
Crystalloids+colloids#, mean (SD) (mL) 1444 ± 612 1754 ± 971 0.13
Blood transfusion, n (%) 5 (2) 2 (8) 0.11
Use of mannitol, n (%) 28 (10) 3 (11) 0.74
Use of vasopressors, n (%) 16 (6) 2 (8) 0.66
Tracheal extubation in the OR 278 (99) 18 (69) <0.01
*51 missing values.
w2 missing values.
zThe number of patient history results and neurologic status exceeds the total number of included patients.
y2 missing values.
J1 missing value.
z62 missing values.
#11 missing values.
ASA indicates American Society of Anesthesiologists; OR, operating room.

respectively. We found no interaction between these
2 variables (P=0.52). In the absence of these 2 intra-
operative variables, the rate of postoperative complica-
tions decreased significantly, in both the cohort of 306
patients (4.2% vs 11.3%; P=0.03) and in the 296 patients
with successful tracheal extubation in the operating
room (2.5% vs 8.4%; P=0.04). Of the 118 patients with
immediate tracheal extubation and no intraoperative
predictors, 3 patients (2.5%) developed postoperative
complications: 1 patient developed an extradural hema-
toma 2 hours after surgery for a meningioma while in the
PACU, 1 patient developed seizures 30 minutes after
surgery for a meningioma (PACU), and the third patient
was the one who developed an acute respiratory distress

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Rhondali et al
on day 1 after surgery, probably because of an aspiration
pneumonitis while receiving insufficient doses of anti-
parkinsonian drugs. This patient was the only 1 to have
no intraoperative predictors among the 4 patients with
delayed postoperative complications.
DISCUSSION
In this cohort study of 306 consecutive patients
admitted to neuro-ICU after elective craniotomy for
brain surgery and an attempt to awake and extubate in
the operating room, the overall postoperative complica-
tion rate was less than 10%, with most complications
occurring mostly within 2 hours of surgery. Successful
postoperative extubation in the operating room was
tightly associated with a lower rate of postoperative
complications. In addition, surgery lasting longer than
4 hours and a lateral position during the procedure were
2 intraoperative factors that we found to be indepen-
dently associated with a higher rate of postoperative
complications. Providing further prospective validation,
the absence of these 2 factors in patients with successful
postoperative extubation within the operating room after
an elective craniotomy for brain surgery could be criteria
to safely allow ICU bypass.
Postoperative complications during the early recov-
ery period that follows elective neurosurgical procedures
are frequent and include respiratory events, pain, arterial
hypertension, shivering, nausea, and vomiting. However,
the incidence of more severe complications, requiring
ICU care, is much lower. In 2 clinical studies, all com-
plications occurred in more than 50% of patients overall,
whereas less than 6% experienced early neurologic
complications.15,16 Brain infarction and large subdural
hematomas occurred in 5 of 105 patients during the first
24 hours after surgery for unruptured intracranial an-
eurysms.17 Postoperative seizures occurred in 23 of 538
patients within 24 hours of elective craniotomy, in
relation to inadequate anticonvulsant prophylaxis.18
Postoperative intracranial hematoma has been studied
extensively, and its overall incidence ranges between 0.8%
and 2.2% in patients after elective brain surgery.5–8 In our
study, we recorded neurologic events requiring possible
intervention and found those rates to be in line with
earlier findings. All but 1 of the events in our study
required prompt brain imaging, except the parkinsonian
patient who developed acute respiratory failure 20 hours
after surgery, and 10 of 26 of our patients received active
treatment. As early as 1981, research reported that
patients admitted to the ICU after uncomplicated elective
neurosurgery rarely required active intervention.12 Inter-
estingly, the time course of these complications also
influences the best use of postoperative resources. In a
retrospective chart review, the time from elective or
emergency craniotomy to clinical deterioration was less
than 6 hours in 44 of 50 patients with an intracranial
hematoma.6 Similarly, in 69 patients who developed
a postoperative intracranial hematoma, the majority
developed this complication within the first 4 hours after
122 | www.jnsa.com
J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011
craniotomy.7 In our study, 22 of 26 postoperative events
were detected within 2 hours of surgery, either in the
operating room or in the PACU.
We failed to find any preoperative condition that
could predict the development of severe postoperative
neurologic complications. In particular, neither the age of
patient nor his American Society of Anesthesiologists’
physical status predicted the likelihood of a postoperative
event after an elective craniotomy, in line with findings
elsewhere.14 The total intravenous anesthesia protocol
used for our patients probably did not affect the rate of
postoperative complications, as suggested elsewhere.16 In
a retrospective study of 158 patients after brain tumor
resection, the risk of a prolonged stay in ICU for more
than 24 hours was found to relate to tumor location and
its mass effect, the use of substantial intraoperative fluids,
and postoperative extubation failure after surgery.19
Patients with an intraoperative blood loss of more than
1000 mL were more likely to require subsequent surgical
evacuation for postoperative hematoma8 that might be
related with blood loss-induced hemostatic disorders.10
Although we did not record intraoperative blood loss
(because of uncertainties in its estimation), we found that
the group of patients who developed complications had
received greater volumes of colloids, which might
indirectly argue in favor of that observation. Whether
colloids infusion would directly impact on the incidence
of complications cannot be established as only 5% of
patients (16 of 306) received more than 500 mL colloids,
never exceeding 20 mL/kg of body weight. Intraoperative
changes in hemoglobin would have been a better
predictor of blood loss. However, the monitoring of
hemoglobin content is not systematically required in
those elective intracranial procedures. Lateral positioning
of the patient during surgery and a prolonged surgical
duration were the most relevant factors independently
associated with postoperative complications in our multi-
variate analysis. These might reflect the complexity of the
neurosurgical procedure, and probably encompasses
factors such as significant intraoperative fluid require-
ments and tumor location. Furthermore, we confirm that
successful, immediate tracheal extubation is a key marker
for an uneventful postoperative period. This study
strongly emphasizes the value of a rapid attempt to
awake and extubate in the operating room, as reported
earlier.20 Patients with successful tracheal extubation in
the operating room who do not fulfill the criteria listed
above could be then monitored in the PACU before being
discharged to the neurosurgical ward. Over the 4 patients
with events occurred after PACU discharge, 3 had
intraoperative predictors. They would not have been
candidates to bypass the neuro-ICU according to our
results.
The decision between performing an attempt to
awake and extubate in the operating room and direct
transfer to the neuro-ICU while mechanically ventilated is
complex. There are systemic and cerebral conditions that
favor a delayed recovery from anesthesia, for example,
hypothermia, arterial hypertension, hypovolemia, a large
r 2011 Lippincott Williams & Wilkins
J Neurosurg Anesthesiol  Volume 23, Number 2, April 2011
tumor resection with mass effect, and a long duration of
surgery.2 We found that 15% of our overall study
population still required ventilation in the early phase
of recovery, which agrees with the results of others.15
Although these patients did have statistically significant
differences in terms of their intraoperative conditions
when compared with patients who were subjected to an
attempt to awake and extubate, the decision whether to
wake each individual at the end of surgery was, in part,
based on the clinical assessment made by the anesthesio-
logist managing the patient, including his own experience
and the timing of the surgical termination. It would be
valuable to determine the conditions that influence that
decision, to establish objective criteria to help physicians
to optimize their postoperative resources.
This study has several limitations. First, this was a
single-institution study, which therefore reflects local
patterns relating to the experience of the medical team,
staffing patterns, and intraoperative procedures. It cannot
be uniformly transposed to all neurosurgical units.
Nevertheless, we strongly encourage medical teams to
conduct a similar evaluation in their own centers to define
the best strategy for neurosurgical patients. Secondly, the
design of this study was observational to identify the
incidence and timing of postoperative complications, as
well as to observe complications related to intraoperative
factors. Further investigation to assess the discriminative
strength of the model as a decision-making tool is
obviously required. In particular, the theoretical inci-
dence of 2.5% complications found in patients with
successful tracheal extubation and no intraoperative
factors must be assessed in a large cohort. Thirdly, our
study population size is relatively small (306 patients)
although being comparable with other studies.10,14,16 It
should be kept in mind that the incidence of major
neurologic complications after elective craniotomy is low,
that gives more difficult for the determination of strong
predictors. A prospective validation of the present results
will require a larger group of patients. Fourthly, we did
not assess emergency brain surgery in this study. For
emergency cases, the postoperative strategy is primarily
dictated by the severity of the preoperative neurologic
status and the intensity of care during surgery.3
In conclusion, a small proportion of patients deve-
lop severe postoperative complications after elective brain
surgery, most of which occur during awakening in the
operating room or in the PACU. In patients subjected to
an attempt to awake and extubate in the operating room,
the success of tracheal extubation is a strongly associated
with uneventful postoperative period. Providing further
prospective validation, patients with immediate, success-
ful tracheal extubation with a surgical duration of less
r 2011 Lippincott Williams & Wilkins
Complications After Elective Neurosurgery
than 4 hours in a nonlateral surgical position could safely
bypass ICU, staying in the PACU for monitoring instead
before being discharged to the neurosurgical ward.
REFERENCES
1. Kelly DF. Neurosurgical postoperative care. Neurosurg Clin N Am.
1994;5:789–810.
2. Bruder NJ. Awakening management after neurosurgery for
intracranial tumours. Curr Opin Anaesthesiol. 2002;15:477–482.
3. Weissman C, Klein N. Who receives postoperative intensive and
intermediate care? J Clin Anesth. 2008;20:263–270.
4. Sirio CA, Martich GD. Who goes to the ICU postoperatively?
Chest. 1999;115:125S–129S.
5. Palmer JD, Sparrow OC, Iannotti F. Postoperative hematoma:
a 5-year survey and identification of avoidable risk factors.
Neurosurgery. 1994;35:1061–1064.
6. Taylor WA, Thomas NW, Wellings JA, et al. Timing of post-
operative intracranial hematoma development and implications for
the best use of neurosurgical intensive care. J Neurosurg. 1995;82:
48–50.
7. Basali A, Mascha EJ, Kalfas I, et al. Relation between perioperative
hypertension and intracranial hemorrhage after craniotomy.
Anesthesiology. 2000;93:48–54.
8. Zetterling M, Ronne-Engstrom E. High intraoperative blood loss
may be a risk factor for postoperative hematoma. J Neurosurg
Anesthesiol. 2004;16:151–155.
9. Kvam DA, Loftus CM, Copeland B, et al. Seizures during the
immediate postoperative period. Neurosurgery. 1983;12:14–17.
10. Gerlach R, Raabe A, Scharrer I, et al. Post-operative hematoma
after surgery for intracranial meningiomas: causes, avoidable risk
factors and clinical outcome. Neurol Res. 2004;26:61–66.
11. Fabregas N, Bruder N. Recovery and neurological evaluation. Best
Pract Res Clin Anaesthesiol. 2007;21:431–447.
12. Knaus WA, Draper E, Lawrence DE, et al. Neurosurgical
admissions to the intensive care unit: intensive monitoring versus
intensive therapy. Neurosurgery. 1981;8:438–442.
13. Zimmerman JE, Junker CD, Becker RB, et al. Neurological
intensive care admissions: identifying candidates for intermediate
care and the services they receive. Neurosurgery. 1998;42:91–101.
14. Beauregard CL, Friedman WA. Routine use of postoperative ICU
care for elective craniotomy: a cost-benefit analysis. Surg Neurol.
2003;60:483–489.
15. Manninen PH, Raman SK, Boyle K, et al. Early postoperative
complications following neurosurgical procedures. Can J Anaesth.
1999;46:7–14.
16. Magni G, La Rosa I, Gimignani S, et al. Early postoperative
complications after intracranial surgery: comparison between total
intravenous and balanced anesthesia. J Neurosurg Anesthesiol. 2007;
19:229–234.
17. Niskanen M, Koivisto T, Rinne J, et al. Complications and
postoperative care in patients undergoing treatment for unruptured
intracranial aneurysms. J Neurosurg Anesthesiol. 2005;17:100–105.
18. Hwang SL, Lin CL, Lee KS, et al. Factors influencing seizures in
adult patients with supratentorial astrocytic tumors. Acta Neurochir
(Wien). 2004;146:589–594.
19. Ziai WC, Varelas PN, Zeger SL, et al. Neurologic intensive care
resource use after brain tumor surgery: an analysis of indications
and alternative strategies. Crit Care Med. 2003;31:2782–2787.
20. Bruder N, Stordeur JM, Ravussin P, et al. Metabolic and
hemodynamic changes during recovery and tracheal extubation in
neurosurgical patients: immediate versus delayed recovery. Anesth
Analg. 1999;89:674–678.
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