News and Opinions

“No-ICU-Unless” Policy for Tumor Craniotomy

Mark ter Laan and Ronald HMA Bartels

During postoperative outpatient visits of oncology patients, we
often ask how they have experienced the perioperative period.
Most are surprised by the fact that everything went so well and that
they could leave the hospital a couple of days after surgery. The
only thing that had bothered them was the stay in the intensive
care unit (ICU). They experienced a noisy, busy, and stressful
environment that contributed to disturbed sleep. These patient
testimonials have generated 2 important questions: 1) Why are we
still surprised that patients are dismissed after a tumor craniotomy
within 2 or 3 days and 2) if the ICU stay is so stressful, do we still
need this?
Brain surgery used to be extremely risky with high morbidity
and mortality. This has improved since the introduction of peri-
operative corticosteroid use and further with advancements made
in anesthesiologic and surgical techniques. Nevertheless, we seem
to uphold the idea of a “risky business.” Maybe the devastating
effects of eventual complications overshadow the enormous
decrease in complication rates. The psychologic impact of this
kind of surgery certainly affects doctors and, especially, patients
and their relatives’ expectations regarding risks. The psychologic
burden will not be decreased by a standard admission to the ICU
but should be managed by listening to the fears and worries of our
patients. Empathetic doctors and nurses can manage expectations
and are of utmost importance to decrease the psychologic impact
associated with any kind of brain surgery.
Therefore we asked ourselves: Do we need intensive post-
operative care after tumor craniotomy as a default for all patients?
As described in our recent publication,1 we set out to check some
600 recent tumor cases for serious complications and hardly found
any. In 1 of the complicated cases, postoperative hematoma did not
occur until day 2, when the patient was already readmitted to the
normal neurosurgical ward. The low incidence of serious
complications in combination with the realization that they occur
after postoperative day 1 as well reinforced our doubt for the
need for standard ICU admission after tumor craniotomy. We
have introduced a “no-ICU-unless” policy and compared length
of stay, costs, patient satisfaction, and complications with 1 year
before introduction. We have shown that patients were satisfied
with this changed postoperative regimen. Furthermore,
complications were not increased and costs were reduced.
One could question which criteria should be used to select
patients who should and who should not have intensive moni-
toring postoperatively. Possibly randomized trials, prospective
registries, or other studies could help identify these criteria more
specifically. On the basis of our findings, it is unlikely that others
will show that standard postoperative ICU admittance for all tu-
mor craniotomy cases will be either significantly safer or more
cost-effective. Therefore we propose not to wait for further studies
on this matter but rather to adopt the pragmatic approach of our
“no-ICU-unless” policy. In short, this means that patients with a
supratentorial craniotomy do not need ICU admission unless high
blood loss or long (>6 hours) surgery is anticipated by the surgeon
or unless anesthesiologists find the need for extra monitoring
based on American Society of Anesthesiologists score or
functional status. We do recommend involving nursing staff in
changing perioperative regimen and increasing check-ups and
monitoring possibilities in the ward for the first 6 hours. We
hypothesize that such a policy would suit other patients
(infratentorial lesions) as well.
We live in a time where we need to be more and more conscious
about the costs of health care. The concept of “just to be on the
safe side” does not seem to suit this era. As we have shown,
patient satisfaction can be improved and costs can be reduced
without increasing complication rates. To recognize these kinds of
opportunities, we should reconsider habits based on concepts that
are no longer valid. A skeptical and open-minded attitude toward
everything we have become used to do is paramount in order to be
able to recognize and change these habits.

REFERENCE
1. Ter Laan M, Roelofs S, Van Huet I, Adang EMM,
Bartels RHMA. Selective intensive care unit
admission after adult supratentorial tumor
craniotomy: complications, length of stay, and
costs. Neurosurgery. 2020;86:E54-E59.
Department of Neurosurgery, Radboud University Medical
Center, Nijmegen, The Netherlands
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.
https://doi.org/10.1016/j.wneu.2020.01.099

406 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.01.099