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The safety and feasibility of outpatient carotid endarterectomy
Clinical Neurology and Neurosurgery 114 (2012) 108–111
Contents lists available at SciVerse ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
The safety and feasibility of outpatient carotid endarterectomy夽 Curtis E. Doberstein, Marc A. Goldman, Jonathan A. Grossberg ∗ , Heather S. Spader Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States
a r t i c l e
i n f o
Article history: Received 13 June 2011 Received in revised form 1 August 2011 Accepted 20 September 2011 Available online 11 October 2011 Keywords: Carotid endarterectomy Outpatient surgery Same day discharge
a b s t r a c t Background: Carotid endarterectomy (CEA) is one of the most commonly performed and studied surgical procedures for extracranial ischemic disease. Objective: The authors reviewed the outcome of 39 consecutive carotid endarterectomy procedures performed by a single surgeon with emphasis on the safety of discharging patients the same day of the procedure. Methods: Retrospective analysis was performed over a two-year period on patients who were admitted as outpatients and underwent CEA. Following CEA, patients were observed for 4–6 h in the recovery room and Duplex ultrasonography was completed to assess the endarterectomy repair. Determination was then made whether patients could be safely discharged home. Results: Over a two year period, CEA was performed 39 times in 37 outpatients. Twenty-five patients (64%) were discharged within 6 h of surgery completion. The remaining 14 patients (36%) were admitted to the hospital for varying reasons. Six patients (43%) stayed either due to personal preference or the lack of supervision at home and six other patients (43%) stayed because of mild hemodynamic instability. Of the two remaining patients, one was admitted for chest pain and the other for a small wound hematoma. No patients developed postoperative neurologic deficits. Two-tailed Fisher test analysis of collected variables revealed that patients who had general anesthesia were more likely to be admitted (p < 0.02). Conclusion: Patients undergoing CEA can be safely discharged the same day after a brief period of postoperative observation. One factor that may predict the need for postoperative admission is the use of general anesthesia. © 2011 Elsevier B.V. All rights reserved.
1. Introduction
either the postoperative care unit or intensive care unit (ICU) [3–5]. In this study, we add to the literature about the safety of early discharge after CEA by describing our institutional experience over two years with discharging patients the same day of surgery.
Since its introduction in the 1950s, CEA has been increasingly performed and studied. In fact, following the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Artery Study (ACAS) in the 1990s, CEA became the standard of treatment for both symptomatic and asymptomatic carotid stenosis since the 1990s [1,2]. Few other surgical procedures have been as thoroughly scrutinized in the literature as CEA. In the past, postoperative management of patients undergoing CEA typically included overnight observation in an intensive care unit followed by several days inpatient observation on the hospital floor. Starting in the 1990s, however, hospitals reduced this length of stay with positive results. Hospitals achieved this through a variety of changes including proactive discharge planning, use of local and regional anesthesia and close postoperative monitoring in
2.2. Procedure
夽 Portions of this work were presented in poster form at the Congress of Neurological Surgeons Meeting, San Francisco, CA, 2010. ∗ Corresponding author. Tel.: +1 4014444000. E-mail address: [email protected] (J.A. Grossberg).
Prior to the day of surgery, all patients were given the option of undergoing the procedure with regional or general anesthesia. All procedures were performed by a single board certified neurovascular surgeon (CD). Continuous encephalographic (EEG) monitoring was used in all cases. During the operation, the carotid
0303-8467/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2011.09.011
2. Patients and methods 2.1. Patient population Charts were reviewed for all patients undergoing same day admission for elective CEA over twenty-four consecutive months. Thirty-nine CEAs were performed in 37 patients during this period. Patients who were hospitalized prior to their CEA were excluded from the study.
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111 Table 1 Criteria for same day discharge.
109
2.3. Data analysis All variables between the admitted and discharged groups were compared using a two-tailed Fisher test analysis to look for statistical significance.
Systolic blood pressure: 100–150 mmHg Heart rate: 50–100 bpm Pulse oximetry > 90% on room air No additional clinical complaints
3. Results was cross-clamped only during the endarterectomy and repair. There was no limit in the duration of cross-clamp time, but this time was minimized as much as possible. When EEG or clinical exam changes occurred after clamping, a vascular shunt was used to restore flow to the brain during the repair. The arteriotomy was closed primarily without a patch and a post-operative drain was not used. A routine postoperative carotid Duplex ultrasound was performed by a certified registered vascular technician (RVT) in the recovery room to assess the arteriotomy repair. Patients were subsequently observed in the recovery room for a minimum of 4 h and then discharged home if the following conditions were met: systolic blood pressure between 100 and 150 mmHg, heart rate between 50 and 100 bpm, pulse-oximetry greater than 90%, and no clinical complaints or complications requiring further hospital observation (Table 1). Patients were admitted if they did not meet the above criteria, due to personal preference, or lack of supervision at home for the first postoperative night. The final decision on whether to admit or discharge the patient was performed by attending surgeon. All patients were seen in follow-up in the outpatient clinic within two weeks of surgery.
Thirty-nine elective, outpatient CEAs were performed on 37 patients from January 2004 to December 2005. Twenty-five patients (64%) were discharged the same day, fourteen patients (36%) were admitted to the hospital for various reasons. The patient characteristics and reasons for admission are summarized in Table 2. The mean age was seventy for the admitted group and sixty-eight for the discharged group. Twelve (86%) of patients in the admitted group had left CEA, while fourteen patients (56%) in the discharged group had left CEA. Nine (64%) of patients in the admitted group were symptomatic, while eleven (44%) in the discharged group were symptomatic. All of the patients in the admitted group had 70–99% stenosis while twenty-two (88%) of those discharged had 70–99% stenosis. Five patients (36%) in the admitted group had general endotracheal anesthesia (GETA) whereas one patient (4%) had GETA in the discharged group. Two shunts were used, with one patient subsequently being admitted. The results are summarized in Table 3. There were no perioperative cerebrovascular accidents (CVA) or transient ischemic attacks (TIA). Of the patients admitted, six patients (43%) stayed either due to lack of supervision at home, or due to personal preference. Another
Table 2 Patient characteristics and reasons for admission. Age
Side
Intra-op shunt
Anesthesia
Reason for admission
Length of stay
Symptomatic vs. asymptomatic
% Stenosis
Complications
74 80 67 70 80 69 79 61 61 65 61 64 59 79 76 41 70 62 67 63 65 81 81 47 61 62 78 74 78 58 84 83 58 59 76 71 75 70 76
L L R L R L R L L L R R L L L L L R R L L L L L R L L L R L R L R L R L L R L
Yes No No No No No Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No
GETA Local Local Local Local Local Local Local Local Local GETA Local GETA GETA Local GETA Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local GETA Local Local
SBP > 160
8d
HR < 50 bpm
24 h
BP > 160 No supervision Decided to stay Decided to stay
24 h 24 h 24 h 24 h
No supervision SBP < 100
24 h 24 h
SBP > 160 Decided to stay
24 h 24 h
Decided to stay
24 h
Neck swelling
24 h
SBP < 100 Chest pain
24 h 24 h
S A S A A A S A S A A S S S S S A A A A S S S S S A A S S A S A A S S A A S A
70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99
Wound hematoma None None none None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None
110
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111
Table 3 Characteristics of patients admitted and discharged same day after endarterectomy.
Number Average age Side Symptoms Shunt Anesthesia Grade
Admitted
Discharged
Total
14 70 L: 12 S: 9 Yes: 1 GETA: 5 70–99%: 14
25 68.2 L: 14 S: 11 Yes: 1 GETA: 1 70–99%: 22
39 68.8 L: 26 S: 20 Yes: 2 GETA 6 70–99%: 36
R: 2 A: 5 No: 13 Regional: 9 50–69%: 0
R: 11 A: 14 No: 24 Regional: 24 50–69%: 3
R: 13 A: 19 No: 37 Regional: 33 50–69%: 3
Legend: L: left; R: right; S: symptomatic; A: asymptomatic.
six patients (43%) stayed for hemodynamic lability defined as systolic blood pressure either less than 100 mmHg or greater than 160 mmHg, or sustained heart rate less than 50. Of the two remaining patients, one was admitted for chest pain and the other for hypertension and a small wound hematoma that was managed with observation, and subsequently diminished in size. Thirteen of the fourteen (93%) patients admitted to the hospital were discharged within 24 h. One patient, who developed a wound hematoma secondary to hypertension, had an admission for eight days, as this patient had significant pre-existing comorbid medical problems and needed prolonged work with rehabilitation services prior to discharge. Two-tailed Fisher test analysis was performed on all the above-mentioned variables and local anesthesia was the only statistically significant variable that correlates with same day discharge (p < 0.02). 4. Discussion Over the past several years, postoperative length of stay for patients undergoing carotid endarterectomy has shortened. Where patients once expected to be admitted the night before for angiography and then stay two–seven days postoperatively, patients now are routinely admitted the same day and discharged the day after surgery [3,5–10]. The rationale for longer stays was predicated upon the assumption that this resulted in decreased morbidity and mortality for a group of patients who have a significant number of comorbidities. Starting in the 1990s, however, studies started showing that ICU stays were not necessary. One study by Collier showed that only ten percent of 186 patients needed ICU monitoring with an overall neurologic event rate of 1.6% [4]. Then other studies like the retrospective study by Sheehan and Baker showed that in a review of 773 patients, less than 0.4% of patients had a complication occurring between 8 and 24 h after operation [7]. This study showed that careful monitoring can catch most complications within 8 h of surgery. Another study by Angevine et al. showed no obvious association between the rate of complications and length of stay [3]. Angevine and others also established the safety of discharging patients after postoperative day one [5,9,10]. However, the authors argued for patients to be monitored in an ICU, not the floor, for optimal patient care and quick discharge [3]. After reviewing the literature regarding early discharge and the benefits to the patient and the health care system, Sheehan and Greisler published a study showing the initial success of sameevening discharges. This study established that close monitoring for 8 h, appropriate scheduling, and good patient education resulted in a same-day discharge rate of around 32%, with no adverse events for the group of patients who were discharged home the same day [8]. In our series, we add to the literature about same day discharges and provide details about the measures we took to facilitate these discharges in a safe manner. We anticipated complications to occur with hemodynamic lability, and, as a result, we established strict criteria that needed to be met prior to discharge from the
recovery room. These criteria included a systolic blood pressure between 100 mmHg and 150 mmHg, a heart rate between 50 and 100 bpm, pulse-oximetry greater than 90%, and the lack of clinical complaints. In addition, Duplex ultrasonography was completed to assure patency and lack of abnormalities at the arteriotomy site. We felt comfortable with discharge from the recovery room after 4 h for those patients who met the above criteria and had a normal ultrasound. In our study, we also found that patients who underwent GETA were statistically more likely to not be discharged. There has been a large discussion in the literature about the benefits of performing a CEA under local or regional anesthetic as opposed to GETA [11–16]. A large meta-analysis comparing 5000 non-randomized endarterectomies found that the risk of CVA or death with local anesthesia was significantly less than that that of general anesthesia [16]. In a large multi-center study by Halm et al., of 1972 CEA, the use of local anesthesia reduced the riskadjusted odds of stroke or death compared to GETA [17]. These results were further corroborated by Love, who found that significantly more deaths associated with CVA occurred with general anesthesia [15]. However, the largest trial to date, the general anesthesia versus local anesthesia for carotid surgery (GALA) study, was a multi-center, randomized controlled trial of 3526 patients that showed that there is no statistically significant difference in patient outcomes between general and local anesthesia for carotid surgery [18]. It should be noted that many patients undergoing CEA have significant cardiovascular comorbidities including hypertension, coronary artery disease, and congestive heart failure. Although this study did not account for these comorbidities, the authors believe that careful postoperative monitoring in the recovery room that demonstrates clinical and hemodynamic stability could be the determining factor for safe same day discharge. In fact, a study by Posner et al., looked at risk factors that correlated with the need for vasoactive medications and it found that preoperative comorbidities like blood pressure medications, hypertension, symptomatic presentation and intraoperative use of vasoactive medications did not correlate with the use of vasoactive medications postoperatively [19]. From this study, he concluded that patients who were hemodynamically stable were safe for same day discharge from the recovery room, and our experiences with thirty nine patients corroborates this finding [19]. 5. Conclusions Patients undergoing CEA can be safely discharged from the recovery room the same day following surgery provided they have had sufficient postoperative observation over a 4-h period, have demonstrated clinical and hemodynamic stability throughout this brief postoperative course, and have some type of supervision at home the night of surgery. In addition, Doppler ultrasonography can help assess the arteriotomy repair prior to discharge. Those patients who do not fulfill discharge criteria should be admitted overnight for observation. Our study also found that the only
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111
statistically significant predictive factor for same day discharge was the use of regional anesthesia. Financial disclosure None. References [1] North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade stenosis. N Engl J Med 1991;325:445–53. [2] Executive Committee for ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–8. [3] Angevine PD, Choudhri TF, Huang J, Quest DO, Solomon RA, Mohr JP, et al. Significant reductions in length of stay after carotid endarterectomy can be safely accomplished without modifying either anesthetic technique or postoperative ICU monitoring. Stroke 1999;11:2341–6. [4] Collier PE. Are one-day admissions for carotid endarterectomy feasible? Am J Surg 1995;170:140–3. [5] Friedman SG, Tortolani AJ. Reduced length of stay following carotid endarterectomy under general anesthesia. Am J Surg 1995;170:235–6. [6] Luna G, Adye B. Cost-effective carotid endarterectomy. Am J Surg 1995;169:516–8. [7] Sheehan MK, Baker WH, Littooy FN, Mansour MA, Kang SS. Timing of postcarotid complications: a guide to safe discharge planning. J Vasc Surg 2001;34:13–6. [8] Sheehan MK, Greisler HP, Littooy FN, Baker WH. Same-evening discharge after carotid endarterectomy: our initial experience. J Vasc Surg 2004;39:575–7.
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[9] Cikrit DF, Larson DM, Sawchuk AP, Lalka SG, Shafique S, Dalsing MC. Short-stay carotid endarterectomy in a tertiary-care Veterans Administration hospital. Am J Surg 2004;188:544–8. [10] Kaufman JL, Frank D, Rhee SW, Berman JA, Friedmann P. Feasibility and safety of 1-day postoperative hospitalization for carotid endartectomy. Arch Surg 1996;131:751–5. [11] Aleksic M, Huff W, Hoppmann B, Heckenkamp J, Pukrop R, Brunkwall J. Cognitive function remains unchanged after endarterectomy of unilateral internal carotid artery stenosis under local anaesthesia. Eur J Vasc Endovasc Surg 2006;31:616–21. [12] Bhattathiri PS, Ramakrishnan Y, Vivar RA, Bell K, Bullock RE, Mitchell P, et al. Effect of awake carotid endarterectomy under local anaesthesia on perioperative blood pressure: blood pressure is normalised when carotid stenosis is treated under local anaesthesia. Acta Neurochir 2005;147:839–45. [13] Hakl M, Michalek P, Sevcik P, Pavlikova J, Stern M. Regional anaesthesia for carotid endarterectomy: an audit over 10 years. Br J Anaesth 2007;99:415–20. [14] Lawrence PF, Alves JC, Jicha D, Bhirangi K, Dobrin PB. Incidence, timing, and causes of cerebral ischemia during carotid endarterectomy with regional anesthesia. J Vasc Surg 1998;27:329–37. [15] Love A, Hollyoak MA. Carotid endarterectomy and local anaesthesia: reducing the disasters. Cardiovasc Surg 2000;8:429–35. [16] Tangkanakul C, Counsell C, Warlow C. Local versus general anesthesia in carotid endarterectomy: a systematic review of the evidence. Eur J Vasc Surg 1997;13:491–9. [17] Halm EA, Hannan EL, Rojas M, Tuhrim S, Riles TS, Rockman CB, et al. Clinical and operative predictors of outcomes of carotid endarterectomy. J Vasc Surg 2005;42:420–8. [18] Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008;372:2132–42. [19] Posner SR, Boxer L, Upchurch Jr GR, Stanley JC, Henke PR. Uncomplicated carotid endarterectomy: factors contributing to blood pressure instability precluding safe early discharge. Vascular 2004;12:278–84.
Contents lists available at SciVerse ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
The safety and feasibility of outpatient carotid endarterectomy夽 Curtis E. Doberstein, Marc A. Goldman, Jonathan A. Grossberg ∗ , Heather S. Spader Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, United States
a r t i c l e
i n f o
Article history: Received 13 June 2011 Received in revised form 1 August 2011 Accepted 20 September 2011 Available online 11 October 2011 Keywords: Carotid endarterectomy Outpatient surgery Same day discharge
a b s t r a c t Background: Carotid endarterectomy (CEA) is one of the most commonly performed and studied surgical procedures for extracranial ischemic disease. Objective: The authors reviewed the outcome of 39 consecutive carotid endarterectomy procedures performed by a single surgeon with emphasis on the safety of discharging patients the same day of the procedure. Methods: Retrospective analysis was performed over a two-year period on patients who were admitted as outpatients and underwent CEA. Following CEA, patients were observed for 4–6 h in the recovery room and Duplex ultrasonography was completed to assess the endarterectomy repair. Determination was then made whether patients could be safely discharged home. Results: Over a two year period, CEA was performed 39 times in 37 outpatients. Twenty-five patients (64%) were discharged within 6 h of surgery completion. The remaining 14 patients (36%) were admitted to the hospital for varying reasons. Six patients (43%) stayed either due to personal preference or the lack of supervision at home and six other patients (43%) stayed because of mild hemodynamic instability. Of the two remaining patients, one was admitted for chest pain and the other for a small wound hematoma. No patients developed postoperative neurologic deficits. Two-tailed Fisher test analysis of collected variables revealed that patients who had general anesthesia were more likely to be admitted (p < 0.02). Conclusion: Patients undergoing CEA can be safely discharged the same day after a brief period of postoperative observation. One factor that may predict the need for postoperative admission is the use of general anesthesia. © 2011 Elsevier B.V. All rights reserved.
1. Introduction
either the postoperative care unit or intensive care unit (ICU) [3–5]. In this study, we add to the literature about the safety of early discharge after CEA by describing our institutional experience over two years with discharging patients the same day of surgery.
Since its introduction in the 1950s, CEA has been increasingly performed and studied. In fact, following the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Artery Study (ACAS) in the 1990s, CEA became the standard of treatment for both symptomatic and asymptomatic carotid stenosis since the 1990s [1,2]. Few other surgical procedures have been as thoroughly scrutinized in the literature as CEA. In the past, postoperative management of patients undergoing CEA typically included overnight observation in an intensive care unit followed by several days inpatient observation on the hospital floor. Starting in the 1990s, however, hospitals reduced this length of stay with positive results. Hospitals achieved this through a variety of changes including proactive discharge planning, use of local and regional anesthesia and close postoperative monitoring in
2.2. Procedure
夽 Portions of this work were presented in poster form at the Congress of Neurological Surgeons Meeting, San Francisco, CA, 2010. ∗ Corresponding author. Tel.: +1 4014444000. E-mail address: [email protected] (J.A. Grossberg).
Prior to the day of surgery, all patients were given the option of undergoing the procedure with regional or general anesthesia. All procedures were performed by a single board certified neurovascular surgeon (CD). Continuous encephalographic (EEG) monitoring was used in all cases. During the operation, the carotid
0303-8467/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2011.09.011
2. Patients and methods 2.1. Patient population Charts were reviewed for all patients undergoing same day admission for elective CEA over twenty-four consecutive months. Thirty-nine CEAs were performed in 37 patients during this period. Patients who were hospitalized prior to their CEA were excluded from the study.
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111 Table 1 Criteria for same day discharge.
109
2.3. Data analysis All variables between the admitted and discharged groups were compared using a two-tailed Fisher test analysis to look for statistical significance.
Systolic blood pressure: 100–150 mmHg Heart rate: 50–100 bpm Pulse oximetry > 90% on room air No additional clinical complaints
3. Results was cross-clamped only during the endarterectomy and repair. There was no limit in the duration of cross-clamp time, but this time was minimized as much as possible. When EEG or clinical exam changes occurred after clamping, a vascular shunt was used to restore flow to the brain during the repair. The arteriotomy was closed primarily without a patch and a post-operative drain was not used. A routine postoperative carotid Duplex ultrasound was performed by a certified registered vascular technician (RVT) in the recovery room to assess the arteriotomy repair. Patients were subsequently observed in the recovery room for a minimum of 4 h and then discharged home if the following conditions were met: systolic blood pressure between 100 and 150 mmHg, heart rate between 50 and 100 bpm, pulse-oximetry greater than 90%, and no clinical complaints or complications requiring further hospital observation (Table 1). Patients were admitted if they did not meet the above criteria, due to personal preference, or lack of supervision at home for the first postoperative night. The final decision on whether to admit or discharge the patient was performed by attending surgeon. All patients were seen in follow-up in the outpatient clinic within two weeks of surgery.
Thirty-nine elective, outpatient CEAs were performed on 37 patients from January 2004 to December 2005. Twenty-five patients (64%) were discharged the same day, fourteen patients (36%) were admitted to the hospital for various reasons. The patient characteristics and reasons for admission are summarized in Table 2. The mean age was seventy for the admitted group and sixty-eight for the discharged group. Twelve (86%) of patients in the admitted group had left CEA, while fourteen patients (56%) in the discharged group had left CEA. Nine (64%) of patients in the admitted group were symptomatic, while eleven (44%) in the discharged group were symptomatic. All of the patients in the admitted group had 70–99% stenosis while twenty-two (88%) of those discharged had 70–99% stenosis. Five patients (36%) in the admitted group had general endotracheal anesthesia (GETA) whereas one patient (4%) had GETA in the discharged group. Two shunts were used, with one patient subsequently being admitted. The results are summarized in Table 3. There were no perioperative cerebrovascular accidents (CVA) or transient ischemic attacks (TIA). Of the patients admitted, six patients (43%) stayed either due to lack of supervision at home, or due to personal preference. Another
Table 2 Patient characteristics and reasons for admission. Age
Side
Intra-op shunt
Anesthesia
Reason for admission
Length of stay
Symptomatic vs. asymptomatic
% Stenosis
Complications
74 80 67 70 80 69 79 61 61 65 61 64 59 79 76 41 70 62 67 63 65 81 81 47 61 62 78 74 78 58 84 83 58 59 76 71 75 70 76
L L R L R L R L L L R R L L L L L R R L L L L L R L L L R L R L R L R L L R L
Yes No No No No No Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No
GETA Local Local Local Local Local Local Local Local Local GETA Local GETA GETA Local GETA Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local Local GETA Local Local
SBP > 160
8d
HR < 50 bpm
24 h
BP > 160 No supervision Decided to stay Decided to stay
24 h 24 h 24 h 24 h
No supervision SBP < 100
24 h 24 h
SBP > 160 Decided to stay
24 h 24 h
Decided to stay
24 h
Neck swelling
24 h
SBP < 100 Chest pain
24 h 24 h
S A S A A A S A S A A S S S S S A A A A S S S S S A A S S A S A A S S A A S A
70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 70–99 50–69 70–99 70–99 70–99 70–99
Wound hematoma None None none None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None None
110
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111
Table 3 Characteristics of patients admitted and discharged same day after endarterectomy.
Number Average age Side Symptoms Shunt Anesthesia Grade
Admitted
Discharged
Total
14 70 L: 12 S: 9 Yes: 1 GETA: 5 70–99%: 14
25 68.2 L: 14 S: 11 Yes: 1 GETA: 1 70–99%: 22
39 68.8 L: 26 S: 20 Yes: 2 GETA 6 70–99%: 36
R: 2 A: 5 No: 13 Regional: 9 50–69%: 0
R: 11 A: 14 No: 24 Regional: 24 50–69%: 3
R: 13 A: 19 No: 37 Regional: 33 50–69%: 3
Legend: L: left; R: right; S: symptomatic; A: asymptomatic.
six patients (43%) stayed for hemodynamic lability defined as systolic blood pressure either less than 100 mmHg or greater than 160 mmHg, or sustained heart rate less than 50. Of the two remaining patients, one was admitted for chest pain and the other for hypertension and a small wound hematoma that was managed with observation, and subsequently diminished in size. Thirteen of the fourteen (93%) patients admitted to the hospital were discharged within 24 h. One patient, who developed a wound hematoma secondary to hypertension, had an admission for eight days, as this patient had significant pre-existing comorbid medical problems and needed prolonged work with rehabilitation services prior to discharge. Two-tailed Fisher test analysis was performed on all the above-mentioned variables and local anesthesia was the only statistically significant variable that correlates with same day discharge (p < 0.02). 4. Discussion Over the past several years, postoperative length of stay for patients undergoing carotid endarterectomy has shortened. Where patients once expected to be admitted the night before for angiography and then stay two–seven days postoperatively, patients now are routinely admitted the same day and discharged the day after surgery [3,5–10]. The rationale for longer stays was predicated upon the assumption that this resulted in decreased morbidity and mortality for a group of patients who have a significant number of comorbidities. Starting in the 1990s, however, studies started showing that ICU stays were not necessary. One study by Collier showed that only ten percent of 186 patients needed ICU monitoring with an overall neurologic event rate of 1.6% [4]. Then other studies like the retrospective study by Sheehan and Baker showed that in a review of 773 patients, less than 0.4% of patients had a complication occurring between 8 and 24 h after operation [7]. This study showed that careful monitoring can catch most complications within 8 h of surgery. Another study by Angevine et al. showed no obvious association between the rate of complications and length of stay [3]. Angevine and others also established the safety of discharging patients after postoperative day one [5,9,10]. However, the authors argued for patients to be monitored in an ICU, not the floor, for optimal patient care and quick discharge [3]. After reviewing the literature regarding early discharge and the benefits to the patient and the health care system, Sheehan and Greisler published a study showing the initial success of sameevening discharges. This study established that close monitoring for 8 h, appropriate scheduling, and good patient education resulted in a same-day discharge rate of around 32%, with no adverse events for the group of patients who were discharged home the same day [8]. In our series, we add to the literature about same day discharges and provide details about the measures we took to facilitate these discharges in a safe manner. We anticipated complications to occur with hemodynamic lability, and, as a result, we established strict criteria that needed to be met prior to discharge from the
recovery room. These criteria included a systolic blood pressure between 100 mmHg and 150 mmHg, a heart rate between 50 and 100 bpm, pulse-oximetry greater than 90%, and the lack of clinical complaints. In addition, Duplex ultrasonography was completed to assure patency and lack of abnormalities at the arteriotomy site. We felt comfortable with discharge from the recovery room after 4 h for those patients who met the above criteria and had a normal ultrasound. In our study, we also found that patients who underwent GETA were statistically more likely to not be discharged. There has been a large discussion in the literature about the benefits of performing a CEA under local or regional anesthetic as opposed to GETA [11–16]. A large meta-analysis comparing 5000 non-randomized endarterectomies found that the risk of CVA or death with local anesthesia was significantly less than that that of general anesthesia [16]. In a large multi-center study by Halm et al., of 1972 CEA, the use of local anesthesia reduced the riskadjusted odds of stroke or death compared to GETA [17]. These results were further corroborated by Love, who found that significantly more deaths associated with CVA occurred with general anesthesia [15]. However, the largest trial to date, the general anesthesia versus local anesthesia for carotid surgery (GALA) study, was a multi-center, randomized controlled trial of 3526 patients that showed that there is no statistically significant difference in patient outcomes between general and local anesthesia for carotid surgery [18]. It should be noted that many patients undergoing CEA have significant cardiovascular comorbidities including hypertension, coronary artery disease, and congestive heart failure. Although this study did not account for these comorbidities, the authors believe that careful postoperative monitoring in the recovery room that demonstrates clinical and hemodynamic stability could be the determining factor for safe same day discharge. In fact, a study by Posner et al., looked at risk factors that correlated with the need for vasoactive medications and it found that preoperative comorbidities like blood pressure medications, hypertension, symptomatic presentation and intraoperative use of vasoactive medications did not correlate with the use of vasoactive medications postoperatively [19]. From this study, he concluded that patients who were hemodynamically stable were safe for same day discharge from the recovery room, and our experiences with thirty nine patients corroborates this finding [19]. 5. Conclusions Patients undergoing CEA can be safely discharged from the recovery room the same day following surgery provided they have had sufficient postoperative observation over a 4-h period, have demonstrated clinical and hemodynamic stability throughout this brief postoperative course, and have some type of supervision at home the night of surgery. In addition, Doppler ultrasonography can help assess the arteriotomy repair prior to discharge. Those patients who do not fulfill discharge criteria should be admitted overnight for observation. Our study also found that the only
C.E. Doberstein et al. / Clinical Neurology and Neurosurgery 114 (2012) 108–111
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