POST-OPERATIVE INTENSIVE CARE UNIT ADMISSION FOR ELECTIVE BRAIN TUMOUR SURGERIES: A NIGERIAN NEUROSURGICAL UNIT EXPERIENCE

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O.O. Agboola¹, O.O. Idowu², J.A. Balogun.^1,3

1. Department of Neurological Surgery, University College Hospital, Ibadan.
2. Department of Anaesthesia, College of Medicine, University of Ibadan, Ibadan.
3. Department of Surgery, College of Medicine, University of Ibadan, Ibadan.

Abstract

Background: Patients, post elective brain tumour surgeries, are usually admitted into the Intensive Care Unit (ICU) for quick identification of life-threatening complications or for elective ventilation. The Covid-19 pandemic exerted additional strain on the limited ICU spaces. This study was to probe the need for ICU admission following
elective surgery for brain tumour in our environment on the background of enormous constraints.

Methods: Data was collected prospectively from patients who had elective brain tumour surgery over 12-months at the University College Hospital, Ibadan. Data included the indications for ICU admission and outcome. Chi-square test and Student t-test were used for analysis at  < 0.05.

Results: There were 56 patients with a mean age of 44.6 years and M:F ratio of 1:1. 61.8% of the patients were admitted into the ICU for observation. Patients who had open surgeries were 2 times more likely to be admitted (p<0.01; OR = 2.2, CI: 2.0 – 36.8) than those who had endoscopic surgeries. Awake craniotomy patients did not require ICU care compared with the 63% of the patients who had General Anaesthesia + Endo Tracheal Tube (GA+ETT). Patients with skull base and posterior fossa tumours were more likely to be admitted into the ICU (p=0.036). Of the 34 patients admitted into the ICU, 11(19.6%) had prolonged ICU stay and were 2 times more likely to die compared with those with short admissions (p<0.01; OR = 2.5, CI: 2.29 – 70.02).

Conclusion: Observation is the main reason patients are admitted into the ICU. The endoscopic and awake surgery approaches appear to preclude the need for ICU admission, thus capable of cutting costs.

Keywords: Brain tumour, Covid-19 craniotomy, Intensive care unit, Nigeria.

Introduction

The post-operative care of patients, following electivev surgery for brain tumours, has traditionally been in the Intensive Care Unit (ICU).¹ This is usually to allow for close observation and swift identification of immediate post-op complications or planned elective ventilation.² A period of 24 – 48hours or more depending on the amount of peritumoral oedema preoperative was recommended for the observation of these patients.³ This philosophy is now being challenged as the need to cut the cost of care is becoming more inevitable.⁴ The situation in Low- or Middle-Income Countries (LMICS), which includes our practice setting, is even more precarious because of limited ICU beds,⁵ which when available, are expensive, with the cost of care in the ICU multiple folds of the general ward costs. Any need for ventilatory support further multiplies this cost of care.⁶

The cost of neurosurgical care generally has been described as the most expensive for a medical specialty⁷ thus imposing varying significant burden on individuals, families and the nation’s economy, especially in countries that practice some form of socialised health care system. In developing economies such as Nigeria with less than 5% of the population enrolled in the National Health Insurance Authority (NHIA),⁸ ‘out of pocket’ payment by patients for healthcare is the predominant form of healthcare financing, which raises a significant challenge to both the access of neurosurgical care and the promptness of such access. The government funded health insurance scheme in Nigeria, the NHIA, does not cover most of the neurosurgical cost of care, with patients having to provide counterpart funding to offset some of the costs which includes Intensive Care Unit (ICU) fees, and only a small proportion of Nigerians have access to private health insurance schemes.^{9, 10}

The evolution of Covid-19 virus pandemic had a major negative impact on the availability of ICU beds worldwide^11-14. There was an increased demand for ventilators with up to 9 – 11% of Covid-19 patients requiring ventilatory support.^15-17 This without doubt, further stifled the availability of the ICU facilities for the care of patients with other pathologies. Consequently, those patients deemed to require the use of the ICU following elective procedures such as for brain tumour surgery could not get spaces; sometimes resulting in the cancellation of scheduled cases.¹ Thus, this is stimulating a re-think in the way these patients are managed in the light of these occurrences.^{18, 19}

We therefore set out to study the indications for ICU admission post elective surgery for brain tumours, and identify the factors that determine prolonged ICU stay and the effect of ICU care on outcome.

MATERIALS AND METHODS
Ethical Considerations
Ethical approval was obtained from the University of Ibadan/University College Hospital ethics review committee with the reference number UI/EC/19/ 0374.

Study Setting
The study was carried out at the University College Hospital (UCH), Ibadan; a 900-bedded tertiary health care centre, in southwestern Nigeria. It is a major referral centre for brain tumour care in Nigeria, particularly in the southern part of the country. The hospital is equipped with a 12-bedded general intensive care unit, with ventilators. There is no dedicated neurosurgery ICU or neurosurgery bed.

The patients with brain tumours are usually first seen in the Neurosurgical out-patient clinic, where they are evaluated, subsequently optimised for surgery and then admitted to the ward, usually a few days to their proposed surgery. The study included all patients who had elective brain tumour surgery over a 12-month period starting from February 2020, which included periods of service disruption due to the Covid-19 lockdown, operative room slowing and industrial action by resident doctors.

Data Collection Procedure
Data was collected using a proforma pre-designed for the study. The details obtained included the patients’ socio-demographic data, the clinical diagnosis, tumour location, the surgical approach, type of anaesthesia, surgery and anaesthesia duration, intra-operative blood loss and blood transfusion up till 24hours post-op, details of ICU admission, histologic diagnosis, and re-admission into the ICU. Peri-operative anaesthetic managements were documented, these include, analgesia which were essentially opioid-based.
Induction and maintenance of anaesthesia were mostly done with propofol and dexmedetomidine while local anaesthetics and dexmedetomidine were used for local infiltration for awake craniotomy. All the vital signs and other intra-operative findings were documented and this trend continued with those admitted to the ICU until they were discharged.