Return to the operating room
Return to the operating room (ROR) has been put forth by the National Quality Forum and the American College of Surgeons as a surgical quality indicator. However, current quality metrics fail to consider the nature and etiology of the ROR.
To provide a comprehensive description of all reoperations after neurosurgical procedures and assess the validity of ROR as a quality measure in neurosurgery.
We retrospectively analyzed all neurosurgical procedures performed in a high-volume, tertiary care academic medical center between June 1, 2014 and December 31, 2016. Based on a system constructed and validated at our institution, we classified RORs into (a) unplanned related, (b) planned return due to complications, © planned-staged return, or (d) unrelated return.
A total of 9200 unique neurosurgical cases were identified, of which 788 had an ROR within 45 d (8.6%). Median time to ROR (interquartile range) was 9 d (4-15). Specifically, 4.2% were planned-staged returns, 3.4% were unplanned related, 0.3% were unrelated, and 0.6% were planned because of previous complications. Cranial procedures had the highest unplanned ROR rate (4.2%), followed by spinal (2.8%) and peripheral nerve (0.4%). The most common reason for an unplanned ROR was wound complication/surgical site infection (34.3%), followed by hematoma evacuation (13.9%) and cerebrospinal fluid (CSF) leak (11.3%).
Unplanned RORs were relatively rare and most commonly associated with wound complication, postoperative hematoma, and CSF leak. To better reflect surgical quality, ROR metrics should indicate whether the return was planned or unrelated 1).
Results of recent studies and clinical reasoning argue that repetitive neurological examination and surveillance is key for detection of complications with the need for return to the operating room (OR). Early termination of anesthesia and early extubation is, of course, mandatory for a thorough neurological examination. Today most neurosurgical patients are awakened directly postoperatively in the OR for clinical assessment. Still, some institutions—at least within Europe—prefer a delayed extubation with parameter focused monitoring on the intensive care unit (ICU) over an early extubation in the OR with clinical-neurological monitoring of the awakened patient. The concerns for latter strategy may originate from a fear of too much cardiopulmonary and metabolic distress to the just trephined patient caused by an immediate (“forced”) awakening and extubation with potential sequelae (e.g. postoperative hemorrhage, brain swelling). No evidence from prospective studies exist to support these assumptions.
Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention 2).