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Vol. 27. Num. 6.November - December 2016Pages 263-316
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Vol. 27. Num. 6.November - December 2016Pages 263-316
Clinical Research
DOI: 10.1016/j.neucir.2016.02.004
Experience with “Fast track” postoperative care after deep brain stimulation surgery
Experiencia con el cuidado postoperatorio “Fast-Track” después de la cirugía de estimulación cerebral profunda
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Nuria Martína, Ricard Valeroa,
Corresponding author
rvalero@clinic.ub.es

Corresponding author.
, Paola Hurtadoa, Isabel Graciaa, Carla Fernándezb, Jordi Rumiàb, Francesc Valldeoriolac, Enrique J. Carreroa, Francisco Javier Terceroa, Nicolás de Rivaa, Neus Fàbregasa
a Anesthesiology Department, Hospital Clínic de Barcelona, Spain
b Neurosurgery Department, Hospital Clínic de Barcelona, Spain
c Neurology Department, Hospital Clínic de Barcelona, Spain
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Tables (3)
Table 1. Patient characteristics.
Table 2. Intraoperative complications.
Table 3. Postoperative complications.
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Abstract
Background

A 24-h-stay in the post-anesthesia care unit (PACU) is a common postoperative procedure after deep brain stimulation surgery (DBS).

Objective

We evaluated the impact of a fast-track (FT) postoperative care protocol.

Methods

An analysis was performed on all patients who underwent DBS in 2 periods: 2006, overnight monitored care (OMC group), and 2007–2013, FT care (FT group).

Results

The study included 19 patients in OMC and 95 patients in FT. Intraoperative complications occurred in 26.3% patients in OMC vs. 35.8% in FT. Post-operatively, one patient in OMC developed hemiparesis, and agitation in 2 patients. In FT, two patients with intraoperative hemiparesis were transferred to the ICU. While on the ward, 3 patients from the FT developed hemiparesis, two of them 48h after the procedure. Thirty eight percent of FT had an MRI scan, while the remaining 62% and all patients of OMC had a CT-scan performed on their transfer to the ward. One patient in OMC had a subthalamic hematoma. Two patients in FT had a pallidal hematoma, and 3 a bleeding along the electrode.

Conclusions

A FT discharge protocol is a safe postoperative care after DBS. There are a small percentage of complications after DBS, which mainly occur within the first 6h.

Keywords:
Deep brain stimulation
Parkinson's disease
Postoperative complications
Intracranial bleeding
Fast track
Postoperative care unit
Resumen
Introducción

La estancia durante 24h en una unidad de recuperación post-anestésica es una estrategia común de control post-operatorio después de la cirugía de estimulación cerebral profunda (DBS).

Objetivo

Evaluamos el impacto de un protocolo Fast-track (FT) en el cuidado postoperatorio.

Métodos

Analizamos todos los pacientes que se sometieron a cirugía DBS en 2 periodos: 2006, monitorización durante la noche (grupo OMC) y entre 2007 y 2013 (grupo FT).

Resultados

Incluimos 19 pacientes en el grupo OMC y 95 pacientes en el FT. Se registraron incidentes intraoperatorios en el 26,3% de pacientes del grupo OMC vs. 35,8% del grupo FT. Postoperatoriamente, un paciente en el grupo OMC desarrollo hemiparesia y 2 pacientes agitación. En el grupo FT, 2 pacientes con hemiparesia intraoperatoria fueron trasladados a la UCI. Durante su ingreso en planta, 3 pacientes del grupo FT desarrollaron hemiparesia, 2 de ellos 48h después del procedimiento. Al 38% del FT se les realizó una resonancia, mientras que al 62% restante y a todos los pacientes del grupo OMC se les realizó un escáner antes del traslado a sala: un paciente del grupo OMC tuvo un hematoma subtalámico; 2 pacientes del grupo FT tuvieron un hematoma en el pálido y 3, sangrado en el trayecto del electrodo.

Conclusiones

El protocolo FT es seguro después de la cirugía de DBS. Hay un pequeño porcentaje de complicaciones y la mayoría suceden en las primeras 6h.

Palabras clave:
Estimulación cerebral profunda
Enfermedad de Parkinson
Complicaciones post-operatorias
Sangrado intracraneal
Fast-track
Unidad de recuperación post-anestésica
Full Text
Introduction

Deep brain stimulation (DBS) surgery is a procedure that consists on the implantation of electrodes into subcortical brain structures for its electric neuromodulation. After the definition of the stereotactic coordinates for a specific brain target, most of the groups use intra-operative microelectrode recordings and macro/micro stimulation to refine the final electrode positioning and subsequently connect the therapeutic electrodes to a subcutaneous Internal Pulse Generator (IPG).1 DBS is used for the treatment of patients with neurological disorders as Parkinson's disease, dystonia, essential tremor, epilepsy, and certain psychiatric conditions.2

There are specific challenges and considerations in the anesthetic management of patients undergoing DBS insertion. They may present comorbidities related to the disease for which the DBS is indicated. There are also potential drug interactions and adverse effects between antiparkinsonian and anesthesia drugs.3 Moreover, the fact that patients are operated in “off” period may increase those risks due to severe hypokinesia.

Advances in neuroradiology and neurophysiology, that have allowed reaching a more accurate target anatomy for DBS procedures, together with the development of multiple channel microelectrodes that minimize the volume of brain parenchyma penetrated during microelectrode recording4 lead to a reduction of the surgical time and electrode tracks needed which may be promoting a reduction of morbidity.

Previous data from retrospective chart reviews have reported complication rates of 12–16%.1,5 Venous air embolism has been reported up to 4.5% of DBS procedures. Seizures during stimulations were recorded from 0.8% to 4.5% of the cases.1 Psychiatric problems, including depression or mania, have also been reported postoperatively in patients with subthalamic nucleus stimulation.6 Intracranial hemorrhage is the most severe complication and is reported to occur in 0.2–5% of patients.7–9 Risk factors for hemorrhage included hypertension, increasing age, Parkinson's disease as the surgical indication, ventricular involvement in the electrode placement trajectory and the use of microelectrode recording during implantation.10 The size of the hemorrhage varied from small and asymptomatic to severe intracranial hemorrhage resulting in significant and persistent neurological deficits or death.

The underlying disease, functional status, comorbidities and the possibility for severe postoperative complications may suggest for a postoperative overnight monitored care (OMC) of the patient. However, our reduced number of perioperative complications5 and our post anesthesia unit (PACU) resources prompted us to develop a “fast track” postoperative care program. It implies a 6-h monitoring period in the PACU followed by an imaging study (CT as a first option, MRI if necessary). If the patient did not present any radiological or clinical complication, an early discharge to the neurosurgical ward was established.

The aim of the present study is to analyze the impact and safety of this fast-track protocol for the DBS surgery postoperative care compared to a standard overnight postoperative care.

Patients and methods

We retrospectively analyzed all patients who underwent DBS in our institution between January 2006 and June 2013.

Anesthetic management

All patients were premedicated with 5mg diazepam administered orally 2h before starting the procedure. Intraoperative monitoring included electrocardiogram, oxygen saturation, end-tidal CO2, invasive blood pressure (S/5 Datex Ohmeda, Helsinki, Finland) and urinary catheter for hourly urinary output measure. Supplemental oxygen was delivered through nasal prongs with an outlet for end-tidal CO2 and respiratory rate monitoring. A peripheral vein (18G) and a peripherally inserted central venous catheter were placed for fluid infusion (0.9% Saline, Ringer or Ringer acetate).

A Leksell Series G stereotactic frame was applied under local anesthesia (infiltration of the scalp with 2% mepivacaine and 0.5% ropivacaine) and aligned with the midsagittal plane of the brain and the anterior commissural-posterior commissural line. Stereotactic CT was performed, and fused with a previously obtained MRI to define the anatomic target and the intra-cerebral trajectory. Multi-modality image fusion and trajectory planning was accomplished with the @Target software of the BrainLab system (@Target, BrainLAB, Heimstteten, Germany).

On arrival to the operating room, patients were placed in a semi recumbent position (20–30°). Compression stockings were already placed in their lower limbs and all contact areas were padded to comfort the patient.

Antibiotic prophylaxis was protocolyzed with intravenous ceftriaxone 2g before the incision and teicoplanin 400mg before placing the first electrode. Antiemetic prophylaxis with ondansetron (4mg) was also started at the beginning of the surgery.

Patients were sedated with propofol and/or remifentanil by means of a target controlled infusion pump (TCI) (Orchestra Infusion workstation, Primea base, Fresenius Vial, Bad Homburg v.d.H., Germany).11 Both drugs were titrated depending on the surgical moment and whether the patient cooperation was needed at each moment. On arrival of the patient to the operating room, the TCI was programmed to achieve a propofol plasma concentration of 1μgml−1 in 2-min duration and then maintained as required.12 Remifentanil was programmed to reach a target concentration between 0.5 and 1.5ngml−1. It was subsequently adjusted to achieve adequate sedation and spontaneous ventilation. Drugs infusion was maintained during the catheterizations but was discontinued when the head had to be fixed to the stereotactic surgical table. Right after that, it was restarted and maintained during the surgical approach.5,13 Sedation was suspended during neuronal microelectrode recordings, but in some cases a low dose of remifentanil was maintained for the patient to be comfortable. Intravenous pantoprazole 40mg and paracetamol 1g were also administered along the surgery.

In some cases the condition of the patient (e.g. severe dystonia) may require a total intravenous anesthesia with endotracheal intubation and mechanical ventilation (Primus, Dräger® Medical Hispania, Madrid). In such cases hypnosis depth was monitored with the bispectral index (BIS) (BIS module; S/5 Datex Ohmeda, Helsinki, Finland). Anesthesia was induced with propofol, fentanyl or remifentanil and rocuronium, and the anesthetic maintenance was performed with TCI propofol, TCI remifentanil and rocuronium bromide perfusion.

Surgical technique

In the operating room, a 14-mm burr hole was drilled at the intersection between the planned stereotactic trajectories and the cranial vault, and the dura opened widely for direct cortical visualization.14,15 A fibrin sealant (Tissucol Duo®, Baxter S.L., Spain) was used to minimize CSF loss and therefore pneumocephalus.

The whole procedure (electrodes and generator – IPG) was completed in a 2-staged procedure, with the IPG connected 2–3 days after the electrodes were inserted.

Postoperative management

All patients who underwent DBS surgery during 2006 were admitted to a surgical intensive care unit for overnight monitored care (OMC group). From 2007 to 2013, a “fast-track” postoperative care was established. In this group (FT group) all DBS patients were admitted after the surgical procedure to the post-anesthesia care unit just for the first 6h, following the same management as the other group during this shorter time, and then were early discharged to the neurosurgery ward.

All patients underwent postoperative MRI or CT scan before being transferred to the conventional hospital ward.

Variables

Variables recorded were age, sex, comorbidity, diagnosis, procedure, type of anesthesia, surgical time, postoperative care (including time and location), intra and postoperative complications, and immediate postoperative brain imaging.

Intraoperative and postoperative complications included all those requiring specific attention or treatment. We recorded the appearance of hemodynamic instability (hypotension: values below 20% of the patient's baseline value; hypertension: values higher than 20% of their baseline), cardiovascular events, respiratory complications, new onset neurological deficits and any surgical complication not specifically related to neurological patients. The risk of hemorrhagic complications described as a rate per implanted electrode15 was calculated.

Statistical analysis

Mean±standard deviation or absolute frequencies and percentages were used to describe quantitative and qualitative variables, respectively. Statistical analysis was done with Student t-test and Chi squared test when appropriate. All analyses were done with SPSS version 18 for windows (SPSS Inc., Chicago, IL) and a value of p<0.05 was considered to be statistically significant.

Results

A total of 114 patients were analyzed (40 women and 74 men), aged 56.5±14.2years. There were 19 patients in OMC group and 95 in the FT group. The demographic data, diagnose, type of procedure, anesthetic management and surgical time in both groups of patients are described in Table 1. There were no differences between the groups regarding any of these data.

Table 1.

Patient characteristics.

  OMC Group (2006)  FT Group (2007–2013) 
Number of patients [n]  19  95 
Sex (M/F) [n(%)]  10 (52%)–9 (48%)  64 (67%)–31 (33%) 
Age (years) [mean (range)]  55.9 (17–72)  56.6 (17–79) 
Diagnose [n(%)]     
Parkinson's disease  14 (74%)  66 (70%) 
Dystonia  4 (21%)  13 (14%) 
Essential tremor  1 (5%)  12 (13%) 
Huntington's Chorea  –  2 (2%) 
Epilepsy  –  1 (1%) 
Multiple sclerosis+Tremor  –  1 (1%) 
Procedure [n(%)]     
Unilateral  4 (21%)  10 (11%) 
Bilateral  15 (79%)  85 (89%) 
Anesthetic management [n(%)]     
General anesthesia  3 (16%)  10 (11%) 
Conscious sedation  15 (74%)  76 (80%) 
Both#  2 (10%)  9 (10%) 
Remifentanyl alone* 
Propofol+Remifentanyl  16  93 
Surgical time (hours) [mean±SD]  7.1±6.7±1.5 

OMC=overnight monitored care; FT=Fast track; M=male; F=female; #conscious sedation followed by general anesthesia for the Internal Pulse Generator implant. *p=0.008 between groups.

Intraoperative incidences are shown in Table 2. Arterial hypertension was the most frequent intraoperative complication (21% in OMC group vs. 29.5% in FT group). Two patients in the FT group developed a right hemiparesis during the procedure. But there were no statistically significant differences among the groups regarding the occurrence of intraoperative complications (Table 2).

Table 2.

Intraoperative complications.

  OMC GROUP (2006)  FT GROUP (2007–2013)  Total 
  n=19  n=95  n=114 
Arterial hypertension  4 (21%)  28 (29.5%)  32 (28.1%) 
Complete AVB  1 (5%)  –  1 (0.9%) 
Nausea  –  2 (2.1%)  2 (1.7%) 
Hemiparesisa  –  2 (2.1%)  2 (1.7%) 
Hypercapnia  –  1 (1.1%)  1 (0.9%) 
Arterial hypotension  –  1 (1.1%)  1 (0.9%) 
TOTAL  5 (26.3%)  34 (35.8%)  39 (34.2%) 

Data expressed as number of patients (percentage).

a

Those two patients were admitted in the ICU after the intervention. Both patients showed a left pallidal hematoma in the postoperative computerized tomography. (OMC=Overnight monitored care; FT=Fast track; n=number of patients; AVB=auriculoventricular blockade).

Patients of the OMC group spent 18.1±2.1h of postoperative monitored vigilance. Three out of the 19 patients (15.8%) developed a postoperative complication: one patient had a left hemiparesis and 2 patients presented agitation within the first 6h. The patient who suffered an intraoperative AV blockade remained in an intensive care unit (ICU) for 3 days (Table 3).

Table 3.

Postoperative complications.

GROUP    CT or MR findings 
OMC
(n=19) 
3 patients (15.8%)   
  Left hemiparesis  Right Thalamus hematoma 
  Agitation (2 patients)   
FT
(n=95) 
7 patients (7.4%)   
At the PACU:  Rigidity after awakening   
  Delayed awakening   
  Seizures   
At the ward:  Slight left hemiparesis (4/5)  Minimal bleeding along right electrode 
  Deep venous thrombosis   
  Right hemiparesis
(48h after surgery) 
Hematoma along left electrode 
  Agitation, bradipsychia and left spatial negligence
(5 days after surgery) 
Hematoma along right electrode 

(OMC=Overnight monitored care; FT=Fast track; n=number of patients; PACU: postanesthesia care unit).

As established, the Fast-track group patients only remained in the PACU for 6.1±4.0h. However, six patients had to remain in the PACU for more than 17h due to a delay in the attainment of the post-operative cranial imaging control. Both patients with the intraoperative hemiparesis were admitted to the ICU. In this Fast-track group, seven patients (7.4%) developed a postoperative complication (Table 3). Three patients showed new neurological findings: one slight left hemiparesis diagnosed in the first clinical exploration after being transferred to the conventional ward, one right hemiparesis 48h after the surgery, and one patient with agitation, bradipsychia and left spatial negligence (5 days after surgery). No significant differences were found in the rate of postoperative complications between groups (p=0.29).

All patients had an imaging control performed before they were transferred to the ward: all 19 patients in the OMC group underwent a CT scan, while only 59 (62.1%) of the patients in the FT group. An MRI was performed in the other 36 patients of the Fast-track group (37.9%). Radiological findings are described in Tables 2 and 3. Including both groups a total of six patients developed hemorrhagic complications (5.3%). The risk of hemorrhagic complications per implanted electrode15 was 2.8% globally in all our patients (2.9% in the OMC group and 2.8% in the FT group).

The patients who developed late neurological findings had a normal first CT-scan but showed a hematoma around the electrode when the CT-scan was repeated 2 and 5 days later, respectively. One of the aforementioned patients still presents a 4/5 left hemiparesis as a long-term stable deficit, while the other fully recovered his/her motor impairment.

Discussion

A Fast-track discharge protocol is a safe postoperative care after DBS. Our series includes mainly Parkinson's disease patients and out of the small percentage of serious perioperative events, most of them appeared within the first 6h. Only 2 patients developed a new focal deficit after 48h, not assessed intraoperatively or in the immediate postoperative period. A 24h admission to the ICU would have not prevented its occurrence.

Close monitoring in intensive care units during the first 24h after craniotomy is a common practice16 due to the potential severity of postoperative complications (13–27.5% rate of major complications after craniotomies)17 and the need for an early detection. However, an improvement of the surgical procedures together with a limited number of ICU beds and the need for cost-containment suggests for a review of the postoperative flows for neurosurgical patients. Stereotactic surgery is a minimally invasive neurosurgery with a low rate of postoperative complications for biopsy interventions18 and the same principles could apply to this functional neurosurgical procedure. Focusing on DBS surgery, Goodman et al. reported battery failures in 8.4% of the cases and postoperative confusion in 6.8% of 100 consecutive patients.19 Seijo et al.,20 analyzed 130 patients and found 2.2% of subthalamic electrode malposition. Other described complications were aborted procedures, misplaced leads, intracranial hemorrhage, seizures and hardware-related complications.

There are no studies on DBS surgery evaluating at which postoperative moment is the occurrence of complications more frequent. According to the literature reports, patients who underwent biopsy interventions present most complications within the first 6h after surgery.21–23 Retrospective studies show diverse results. Warnick et al. found that all cases of neurological deterioration occurred during the first 2h observation period and that no patient experimented delayed deficits.18 A prospective study by Bhardwaj and Bernstein23 concluded that 4h was a sufficient observation period after a stereotactic biopsy. However, the procedures of brain biopsies and DBS surgery have relevant differences that difficult its comparison. Our results suggest that it may be more cost-effective transferring these patients to their regular wards rather than monitor patients at low risk for complications. Further studies analyzing the cost-benefit of these postoperative protocols are needed.

Intraoperative arterial hypertension associates to a higher probability for postoperative hemorrhage.24,25 In our study, 21% of the patients in the OMC group and 30% of the patients in the fast track group needed intraoperative treatment for arterial hypertension, but none of them had postoperative bleeding complications. Hypertension was strictly defined and it was closely monitored (by means of continuous arterial pressure monitoring) and treated. That would explain why we did not find any relationship between the incidence of postoperative cerebral hemorrhage and hypertension.

Only three bleeding complications were detected with the postoperative imaging and that matched with the patients with neurological deficits in the intraoperative and immediate postoperative period. Criteria to indicate a CT or a MRI was not changed as it would have been done anyway to check the electrodes final location. The imaging was useful to assess the extent of the injury but did not change the management of the patients. Our rate of hemorrhagic complications is similar to the ones reported in the literature.15,26

One limitations of the study is that the two groups of patients were chronologically consecutive, so it is true that differences between groups could be related to a learning curve. However since our team started this procedure in 1995,5 we do not consider this a major concern for our results.

Conclusions

A fast track protocol could be a safe postoperative standard after DBS surgery. In our study most of the few serious perioperative events after DBS surgery appeared within the first 6h.

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Copyright © 2016. Sociedad Española de Neurocirugía
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