Abstract
Introduction:
To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm.
Methods:
An English language survey examined 138 areas of the perioperative care of aSAH patients. Reported practices were categorized as those reported by <20%, 21%–40%, 41%–60%, 61%–80%, and 81%–100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as intracluster correlation coefficient (ICC) and 95% confidence interval (CI).
Results:
48 hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥ 60 aSAH patients per year. Clinical practices reported by 81–100% of the hospitals included placement of an arterial catheter, pre-induction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6–8 ml/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high income and 10% in low/middle income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02–2.76) and between countries (ICC 0.44, 95% CI 0.00–0.68). The use of induced hypothermia for neuroprotection was low (2%). Prior to aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90–120 mmHg (30%), 90–140 mmHg (21%), and 90–160 mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle income countries).
Conclusions:
This global survey identifies differences in reported practices during the perioperative management of aSAH patients.
Keywords: ruptured, cerebral aneurysm, subarachnoid hemorrhage, practices, quality metrics, neuroprotection, adenosine, burst suppression
INTRODUCTION
Aneurysmal subarachnoid hemorrhage (aSAH) is a global health problem. In 2010, the crude worldwide aSAH incidence was 6.1 (95% confidence interval (CI), 4.9–7.5) per 100,000 person-years1. The management of aSAH includes early referral to a high-volume aSAH center (treating ≥60 aSAH/year) and early repair of the ruptured intracerebral aneurysm2,3. In 2005, the cost of aSAH to the United Kingdom (UK) National Health Service was GBP168.2 million annually4, while in 2014 the average cost of hospitalization for aSAH in the United States (US) was $82,000/patient5.
One of the principles of the management of aSAH is prevention of rebleeding by timely definitive treatment of the ruptured aneurysm. The perioperative anesthetic and intensive care unit (ICU) management of aSAH involve maintaining cerebral perfusion, preventing/managing intraoperative brain swelling, facilitating surgical exposure, neurophysiological monitoring and temporary clipping, optimizing systemic physiology and managing glycemia6, anticipating and managing crises (e.g., aneurysm rupture), facilitating timely, smooth emergence and neurologic assessment, and preventing postoperative pain and complications7. Prior research has demonstrated differences in the ICU management of aSAH8,9. A study by Hofman et al.10 also reported discrepancies between the available guidelines and clinical practice in aSAH treatment in Poland and highlighted that periprocedural management is poorly standardized.
This global survey aimed to describe reported practices in the perioperative management of aSAH patients who undergo microsurgical repair of a ruptured intracerebral aneurysm.
METHODS
This study was approved by the Institutional Review Board of the University of Washington (#00013475; June 17, 2022). The survey participants consented to publication of their responses deidentified at the institutional level.
Study design and study participants
A 240-question English-language electronic survey was conducted between June 18 and July 18, 2022 (Supplemental Digital Content 1: the global aSAH intraoperative practice survey).
The survey questionnaire explored the clinical setting, preoperative assessment and management (preoperative assessment, neurological examination, assessment for cardiac dysfunction, and hemodynamic targets), intraoperative management (monitoring, anesthetic technique, neuroprotective interventions, management of intraoperative rupture of an intracerebral aneurysm, and hemodynamic, oxygenation and ventilation targets), and quality metrics tracked, totaling 138 areas. Before being finalized, the survey underwent internal and external review by content experts in perioperative aSAH care.
The survey was implemented using the Research Electronic Data Capture (Redcap) system hosted by the University of Washington’s Institute of Translational Health Sciences Redcap electronic data capture tools11. Survey responders were deidentified for 18 Health Insurance Portability and Accountability Act identifiers. Study sites were identified from a list of neuroanesthesiolgy fellowship program directors listed on the Society for Neuroscience in Anesthesiology and Critical Care website (https://snacc.org/fellows-and-residents/fellowships). After contacting the program directors by email, a single point of contact was identified to provide hospital-specific data. A link to the survey was emailed to the hospital contact, followed by reminders at one-week intervals. Only one response per hospital was collected; data were deidentified at the hospital level. Some of the survey respondents were authors of this study.
Statistical analysis
Survey participant characteristics were presented as a descriptive analysis, with results reported as counts and percentages. Reported practices were categorized amongst 138 different areas of perioperative care into five groups based on Cohen’s kappa reporting: 81–100%, 61–80%, 41–60%, 21–40%, and <20%12 based on responses received from participating hospitals. Variation between Worldbank country-income level groups (stratified as high-income (HI) or low/middle-income (LMIC)) and between countries was presented as intracluster correlation coefficients (ICC) for each variable in a mixed model that treated clusters as random effects13,14. Since the study sample was small, the mean ICC and 95% CI (2.5th and 97.5th percentiles of the bootstrap estimates’ distribution) from 1000 bootstrap samples were reported15. RStudio version 1.55416 (package ICC) was used for statistical analysis.
RESULTS
The study sample comprised 48 hospitals (survey response rate 48/75, 64%) representing 14 countries. The number of hospital responses from each of these 14 countries was: US, 11; India, 11; Ethiopia, 5; Canada, 3; France, 2; Turkey, 2; and one hospital each from Brazil, China, Finland, Germany, Italy, Spain, and the UK (Table 1). Forty-five (94%) of the responding hospitals were academic medical centers, 35 (73%) had a bed capacity ≥ 600, 35 (71%) were comprehensive stroke centers, and 33 (69%) admitted ≥ 60 aSAH patients annually. Of the 27 HI-country hospitals, 11 (41%) were located in the US. The majority of hospitals (34, 71%) reported that aSAH patients were admitted to a dedicated neurocritical care unit.
Table 1.
Global subarachnoid hemorrhage study participating center characteristics stratified by Worldbank country-income level
| Characteristic |
Overall sample (n = 148) | HI countries (n=27) | LMIC countries (n=21) | Variation between HI & LMIC country* | Variation between country* |
|---|---|---|---|---|---|
| Presence of an aSAH pathway for perioperative care | 17 (35%) | 11 (41%) | 6 (29%) | 0 (0.00–0.11) | 0 (0.00–0.29) |
| Bed-size of hospital > 600 beds | 35 (73%) | 17 (63%) | 18 (86%) | 0.04(0.00–0.21) | 0.08 (0.00–0.54) |
| Comprehensive stroke center | 34 (71%) | 22 (82%) | 12 (57%) | 0.04 (0.00–0.23) | 0.12 (0.00–0.61) |
| Admit ≥ 60 aSAH cases/year | 33 (69%) | 20 (74%) | 13 (62%) | 0 (0.00–0.10) | 0.66 (0.00–0.97) |
| Admitted to dedicated neurocritical care unit | 34 (71%) | 20 (74%) | 14 (67%) | 0 (0.00–0.10) | 0.97 (0.61–0.99) |
| Dedicated neurointerventional suite | 39 (81%) | 25 (93%) | 14 (67%) | 0.14 (0.00–0.61) | 0.67 (0.00–0.99) |
| Presence of hybrid operating room | 11 (23%) | 9 (33%) | 2 (10%) | 0.08 (0.00–0.52) | 0.27 (0.00–0.82) |
| aSAH patients managed only by neuroanesthesiologists | 21 (44%) | 10 (37%) | 11 (53%) | 0 (0.00–0.08) | 0.97 (0.42–0.99) |
Data presented as number (%) or *intracluster correlation coefficient (95% confidence interval)
Notes: Because the random intercept model did not estimate variance components from sample data, the mean ICC and percentile 95% CI from 1000 bootstrap samples are reported.
Interpretation: The ICC reflects the variability in outcomes within and between Worldbank Country-income hospitals or countries. ICC values close to 1 imply that clustering within country-income group or countries is similar. ICC values close to 0 imply that clustering within country-income group or countries differs.
Example: The ICC for a dedicated neurointerventional suite by Worldbank country-income group is 0.138, implying that the variation between HI and LMIC countries is 13.8% and the variation is 86.2% within HI and LMIC hospitals. The ICC country-level variation for the same parameter is 26.7%, implying that 26.7% is between country variation and 73.3% is within country variation.
aSAH, aneurysmal subarachnoid hemorrhage; CI, confidence interval; HI, high income; ICC, intracluster correlation coefficient; LMIC, low/middle income
Institutional characteristics related to aSAH care
The characteristics of participating centers stratified by Worldbank country-income level are shown in Table 1. The majority of hospitals (39, 81%) reported the presence of a dedicated neuro-interventional suite. Eleven (23%) hospitals reported the presence of a hybrid operating room where a microsurgical and endovascular repair could be carried out. In 18 (38%) hospitals, an operating room was kept available as a backup when a neuro-interventional case was ongoing. A little over half of hospitals (28, 54%) reported that microsurgical aneurysm repair was performed 24/7. When asked whether microsurgical or endovascular repair is preferred at their institutions, 34 (71%) hospitals reported that the decision to perform a microsurgical or endovascular repair is made with consideration of the patient’s clinical condition and aneurysm characteristics and after a discussion between the attending neurosurgeon and interventionalist.
Anesthesia personnel who routinely manage aSAH patients
Care of aSAH patients was provided by anesthesia residents (18, 38%), certified nurse anesthetists (10, 21%), anesthesia assistants (13, 21%) or neuroanesthesiolgy fellows (7, 15%), all under the supervision of an attending anesthesiologist. Seven hospitals (15%) reported that an attending anesthesiologist provided solo care for aSAH patients. Twenty-one hospitals (43%) reported that aSAH patients received care only from neuroanesthesiologists, while the remainder (57%) reported that care was provided by a mix of neuro- and non-neuroanesthesiologists (Table 1).
Reported clinical practices
The areas of clinical practice reported by 81–100% of hospitals are shown in Table 2. Amongst these areas, variation amongst Worldbank country-income level groups was highest for the use of an arterial catheter (ICC 0.55; 95% CI, 0.00–0.83); between-country variation was highest for placement of an arterial catheter (ICC 0.99, 95% 0.96–0.99) and for review of a 12-lead electrocardiogram (ICC 0.83, 95% CI 0–0.99).
Table 2.
Perioperative care areas reported by 81–100% of participating hospitals stratified by Worldbank country-income level
| Overall sample | HI country hospital | LMIC country hospital | Variation between Worldbank category* | Variation between country* | |
|---|---|---|---|---|---|
| Preoperative assessment | |||||
| Preoperative neurological examination | 96% | 100% | 90% | 0.11 (0.00–0.32) | 0.68 (0.00–0.99) |
| 12-lead electrocardiogram | 94% | 100% | 86% | 0.321 (0.00–0.62) | 0.83 (0.00–0.99) |
| Hemodynamic monitoring | |||||
| Invasive arterial catheter | 90% | 100% | 80% | 0.55 (0.00–0.83) | 0.99 (0.96–0.99) |
| Induction of general anesthesia | |||||
| Use of neuromuscular blocking agent | 97% | 93% | 100% | 0 (0.00–0.32) | 0.34 (0.00–0.99) |
| Laboratory workup | |||||
| Pre-induction blood type and screen | 95% | 100% | 90% | 0.33 (0.00–0.65) | 0.28 (0.00–0.99) |
| Intraoperative hemoglobin/hematocrit | 89% | 82% | 95% | 0 (0.00–0.16) | 0 (0.00–0.61) |
| Pre-induction blood type and cross-match | 86% | 77% | 94% | 0 (0.00–0.16) | 0.31(0.00–0.98) |
| Intraoperative electrolyte panel | 83% | 81% | 85% | 0 (0.00–0.16) | 0.04 (0.00–0.57) |
Data presented as percentage of hospitals reporting the perioperative care area or *intracluster correlation coefficient (95% confidence interval)
Notes: Because the random intercept model did not estimate variance components from sample data, the mean ICC and percentile 95% confidence interval from 1000 bootstrap samples are reported.
Interpretation: ICC: reflects the variability in outcomes within and between Worldbank Country-income hospitals or countries. Values close to 1 imply that clustering within country-income or countries is similar. Values close to 0 imply that clustering within country-income or countries differs.
ICC, intraclass correlation coefficient; MAP, mean arterial pressure; PCO2, partial pressure of carbon-dioxide; PO2, partial pressure of oxygen; SBP, systolic blood pressure
The areas of clinical practice reported by 21–80% of the hospitals are shown in Table 3. Of note, variation was observed between Worldbank country-income level groups regarding trending intracranial pressure (ICC, 0.68; 95% CI, 0.00–0.95), followed by monitoring core temperature using a bladder catheter (ICC, 0.61; 95% CI, 0.00–0.88). The highest variation between countries was in the use of fentanyl for analgesia (ICC, 0.98; 95% CI, 0.60–0.99).
Table 3.
Perioperative care areas reported by 21–80% of the participating hospitals and stratified by Worldbank country-income level
| % of hospitals reporting a particular practice | Overall sample | HI country hospital | LMIC country hospital | Variation between Worldbank category* | Variation between country* | |
|---|---|---|---|---|---|---|
| Preoperative assessment | ||||||
| Hunt and Hess grading | 61–80% | 79% | 85% | 71% | 0 (0.00–0.33) | 0.65 (0.00–0.97) |
| World Federation of Neurological Surgeons grading | 61–80% | 77% | 78% | 76% | 0 (0.00–0.33) | 0.67 (0.00–0.99) |
| Intracranial pressure trends | 21–40% | 31% | 52% | 5% | 0.68 (0.00–0.95) | 0.76 (0.00–0.99) |
| Cardiac troponin | 21–40% | 27% | 41% | 10% | 0.15 (0.00–0.51) | 0.24 (0.00–0.73) |
| Hemodynamic monitoring and arterial/venous access | ||||||
| SBP-based blood pressure target | 61–80% | 69% | 62% | 76% | 0 (0.00–0.08) | 0.28 (0.00–0.79) |
| MAP-based blood pressure target | 41–60% | 55% | 50% | 59% | 0 (0.00–0.08) | 0 (0.00–0.29) |
| Pulse pressure variation | 41–60% | 44% | 46% | 42% | 0 (0.00–0.11) | 0.61 (0.00–0.99) |
| Central venous catheter | 21–40% | 38% | 15% | 60% | 0.21(0.00–0.52) | 0.65 (0.00–0.98) |
| Pre-induction arterial catheter | 21–40% | 32% | 44% | 20% | 0.05 (0.00–0.19) | 0.50 (0.00–0.97) |
| SBP variation | 21–40% | 22% | 19% | 24% | 0 (0.00–0.17) | 0.05 (0.00–0.62) |
| Induction of anesthesia | ||||||
| Propofol | 61–80% | 65% | 70% | 60% | 0 (0.00–0.10) | 0 (0.00–0.33) |
| Fentanyl | 41–60% | 54% | 37% | 70% | 0 (0.00–0.09) | 0.23 (0.00–0.65) |
| Intravenous lidocaine | 41–60% | 47% | 48% | 45% | 0 (0.00–0.08) | 0 (0.00–0.27) |
| Maintenance of anesthesia | ||||||
| Total intravenous anesthesia only | 21–40% | 26% | 22% | 30% | 0 (0.00–0.14) | 0 (0.00–0.38) |
| Inhalational anesthetic only | 21–40% | 26% | 7% | 45% | 0.24 (0.00–0.68) | 0.31 (0.00–0.97) |
| Analgesia | ||||||
| Fentanyl | 21–40% | 34% | 7% | 60% | 0.36 (0.00–0.78) | 0.98 (0.60–0.99) |
| Remifentanil | 21–40% | 27% | 44% | 10% | 0.19 (0.00–0.61) | 0.69 (0.00–0.99) |
| Intravenous acetaminophen | 21–40% | 26% | 11% | 40% | 0.10 (0.00–0.37) | 0.60 (0.00–0.99) |
| Any scalp block placed in the perioperative period | 21–40% | 25% | 4% | 45% | 0.37 (0.00–0.78) | 0.32 (0.00–0.96) |
| Laboratory workup | ||||||
| Laboratory workup | 61–80% | 78% | 70% | 85% | 0 (0.00–0.12) | 0 (0.00–0.46) |
| Arterial blood gas | 61–80% | 75% | 74% | 75% | 0 (0.00–0.11) | 0.68 (0.00–0.99) |
| Blood glucose | 61–80% | 75% | 74% | 75% | 0 (0.00–0.11) | 0.37 (0.00–0.97) |
| International normalized ratio | 61–80% | 74% | 63% | 85% | 0 (0.00–0.12) | 0.16 (0.00–0.71) |
| Prothrombin time | 61–80% | 71% | 56% | 85% | 0.05 (0.00–0.20) | 0.17 (0.00–0.64) |
| Partial thromboplastin time | 61–80% | 67% | 63% | 70% | 0 (0.00–0.11) | 0 (0.00–0.27) |
| Lactate levels | 61–80% | 65% | 63% | 66% | 0 (0.00–0.10) | 0.46 (0.00–0.93) |
| Fluid management | ||||||
| 25% albumin | 61–80% | 71% | 81% | 60% | NA | NA |
| Balanced salt solution | 41–60% | 58% | 56% | 60% | 0 (0.00–0.08) | 0.10 (0.00–0.51) |
| Normal saline | 21–40% | 36% | 15% | 57% | 0.21 (0.00–0.57) | 0.22 (0.00–0.70) |
| Neurophysiological monitoring | ||||||
| Neurophysiologists interpret neurophysiological monitoring | 61–80% | 76% | 89% | 62% | 0.10 (0.00–0.36) | 0.69 (0.00–0.99) |
| Intraoperative neurophysiological monitoring | 21–40% | 26% | 41% | 10% | 0.15 (0.02–2.76) | 0.44 (0.00–0.68) |
| Electroencephalogram | 21–40% | 24% | 37% | 10% | 0.12 (0.03–2.06) | 0.44 (0.00–0.48) |
| Somatosensory evoked potentials | 21–40% | 21% | 37% | 5% | 0.26 (0.01–3.85) | 0.51 (0.00–0.49) |
| Anti-epileptic prophylaxis | ||||||
| Anti-epileptic prophylaxis | 21–40% | 40% | 44% | 35% | 0 (0.00–0.21) | 0.11 (0.11–1.06) |
| Levetiracetam | 21–40% | 29% | 41% | 14% | 0.07 (0.05–1.91) | 0.57 (0.00–0.35) |
| Phenytoin | 21–40% | 21% | 7% | 38% | 0.43 (0.00–0.82) | 0.13 (0.05–0.54) |
| Temperature monitoring | ||||||
| Target temperature > 35°C | 41–60% | 52% | 48% | 55% | 0 (0.00–0.10) | 0.25 (0.00–0.73) |
| Some temperature monitoring | 41–60% | 50% | 62% | 38% | 0.15 (0.00–0.56) | 0.28 (0.00–0.98) |
| Esophageal temperature | 41–60% | 50% | 75% | 25% | 0.01 (0.00–0.14) | 0 (0.00–0.35) |
| Nasopharyngeal temperature | 41–60% | 50% | 21% | 78% | 0.23 (0.00–0.66) | 0.73 (0.00–0.99) |
| Bladder temperature | 41–60% | 50% | 100% | 0% | 0.61 (0.00–0.88) | 0.98 (0.51–0.99) |
| Skin temperature | 41–60% | 50% | 0% | 100% | 0.46 (0.00–0.76) | 0.86 (0.00–0.99) |
| Target temperature > 36 °C | 21–40% | 37% | 48% | 25% | 0.03 (0.00–0.17) | 0.18 (0.00–0.63) |
| Osmotherapy | ||||||
| Mannitol | 41–60% | 49% | 33% | 64% | 0.05 (0.00–0.21) | 0 (0.00–0.25) |
| Any osmolar agent (mannitol/hypertonic saline) | 21–40% | 33% | 26% | 40% | 0 (0.00–0.10) | 0.06 (0.00–0.50) |
| Neuroprotection during temporary clipping | ||||||
| Provide neuroprotection | 41–60% | 52% | 56% | 47% | 0.06 (0.00–0.45) | 0 (0.00–0.08) |
| Maintain MAP >100 mmHg | 41–60% | 46% | 44% | 47% | NA | NA |
| Propofol for burst suppression | 41–60% | 44% | 56% | 31% | 0.04 (0.00–0.22) | 0.15 (0.00–0.60) |
| Induced hypertension | 21–40% | 37% | 37% | 37% | 0 (0.00–0.09) | 0 (0.00–0.26) |
| Maintain SBP 120–140 mmHg | 21–40% | 33% | 19% | 47% | 0.04 (0.00–0.22) | 0.26 (0.00–0.85) |
| Maintain MAP 81–100 mmHg | 21–40% | 32% | 26% | 37% | 0 (0.00–0.12) | 0 (0.00–0.35) |
| Maintain SBP 141–160 mmHg | 21–40% | 24% | 11% | 36% | 0.06 (0.00–0.33) | 0.29 (0.00–0.97) |
| Maintain MAP 60–80 mmHg | 21–40% | 24% | 15% | 32% | 0 (0.00–0.11) | 0.01(0.00–0.56) |
| Burst suppression | 21–40% | 23% | 41% | 5% | 0.29 (0.00–0.70) | 0.51 (0.00–0.99) |
| Oxygenation & ventilation | ||||||
| Delivered tidal volume 6–8 ml ideal body weight | 61–80% | 80% | 81% | 78% | 0 (0.00–0.14) | 0 (0.00–0.43) |
| PO2 91–150 mmHg | 61–80% | 61% | 59% | 63% | 0 (0.00–0.08) | 0.04 (0.00–0.36) |
| PaCO2 31–35 mmHg | 21–40% | 37% | 26% | 47% | 0 (0.00–0.08) | 0.32 (0.00–0.86) |
| PaCO2 36–40 mmHg | 21–40% | 24% | 26% | 21% | 0 (0.00–0.12) | 0(0.00–0.31) |
| Intraprocedural re-bleed management | ||||||
| Adenosine available in operating room | 21–40% | 40% | 58% | 22% | 0.14 (0.00–0.42) | 0.19 (0.00–0.67) |
| Adenosine dose 0.1–0.3 mg/kg | 21–40% | 24% | 31% | 17% | 0 (0.00–0.14) | 0 (0.00–0.39) |
| MAP reduction to 60 mmHg | 21–40% | 23% | 12% | 33% | 0.02 (0.00–0.21) | 0 (0.00–0.48) |
| Pre-securement blood pressure targets | ||||||
| Maintain MAP 60–80 mmHg | 21–40% | 35% | 35% | 35% | 0 (0.00–0.13) | 0 (0.00–0.35) |
| Maintain SBP 90–120 mmHg | 21–40% | 30% | 31% | 29% | 0 (0.00–0.13) | 0 (0.00–0.43) |
| Maintain MAP 60–100 mmHg | 21–40% | 24% | 19% | 29% | 0 (0.00–0.15) | 0 (0.00–0.47) |
| Maintain SBP 90–140 mmHg | 21–40% | 21% | 23% | 18% | 0 (0.00–0.17) | 0.01 (0.00–0.53) |
| Post-securement blood pressure targets | ||||||
| Maintain MAP 60–80 mmHg | 21–40% | 31% | 27% | 35% | 0 (0.00–0.10) | 0 (0.00–0.38) |
| Maintain SBP 90–120 mmHg | 21–40% | 28% | 27% | 29% | 0 (0.00–0.11) | 0 (0.00–0.40) |
| Maintain SBP 90–140 mmHg | 21–40% | 28% | 27% | 29% | 0 (0.00–0.15) | 0 (0.00–0.41) |
| Quality metrics | ||||||
| Intensive care unit length of stay | 41–60% | 51% | 60% | 41% | 0 (0.00–0.27) | 0 (0.00–0.69) |
| Re-bleed of aneurysm | 41–60% | 50% | 50% | 50% | 0.01(0.00–0.15) | 0.21 (0.00–0.73) |
| Glucose targets | 41–60% | 50% | 57% | 43% | 0 (0.00–0.093) | 0 (0.00–0.34) |
| Patient movement | 41–60% | 50% | 36% | 64% | 0.06 (0.00–0.35) | 0.12 (0.00–0.67) |
| Stroke after microsurgical repair | 41–60% | 50% | 56% | 44% | 0 (0.00–0.11) | 0.38 (0.00–0.97) |
| Postoperative mortality | 41–60% | 50% | 62% | 38% | 0 (0.00–0.27) | 0 (0.00–0.73) |
| Hemodynamic target adherence | 41–60% | 50% | 44% | 55% | 0.04 (0.00–0.21) | 0.17 (0.00–0.68) |
| Perioperative hypothermia | 41–60% | 50% | 67% | 33% | 0 (0.00–0.12) | 0 (0.00–0.42) |
| Postoperative reintubation | 41–60% | 50% | 54% | 46% | 0 (0.00–0.095) | 0.71 (0.00–0.98) |
| Hospital length of stay | 41–60% | 50% | 58% | 42% | 0 (0.00–0.27) | 0 (0.00–0.57) |
| Delayed cerebral ischemia | 41–60% | 50% | 56% | 44% | 0 (0.00–0.11) | 0.07 (0.00–0.53) |
| Venous thromboembolism | 41–60% | 50% | 58% | 42% | 0 (0.00–0.11) | 0.45 (0.00–0.97) |
| Postoperative pulmonary complications | 41–60% | 50% | 50% | 50% | 0.01 (0.00–0.13) | 0.68(0.00–0.99) |
| EVD-associated adverse events | 41–60% | 50% | 54% | 46% | 0 (0.00–0.11) | 0.14 (0.00–0.69) |
| Education | ||||||
| SNACC cognitive aids available in operating room | 41–60% | 50% | 78% | 21% | 0.13(0.00–0.40) | 0.35 (0.00–0.97) |
| Intraoperative crisis management for trainees | 41–60% | 50% | 67% | 33% | 0 (0.00–0.12) | 0.70 (0.00–0.99) |
| Intraoperative crisis management for non-neuroanesthesiologists | 41–60% | 50% | 60% | 40% | 0 (0.00–0.11) | 0.37 (0.00–0.96) |
Data presented as percentage or *intracluster correlation coefficient (95% confidence interval)
Notes: Because the random intercept model did not estimate variance components from sample data, the mean ICC and percentile 95% confidence interval from 1000 bootstrap samples are reported.
Interpretation: ICC: reflects the variability in outcomes within and between Worldbank Country-income hospitals or countries. Values close to 1 imply that clustering within country-income or countries is similar. Values close to 0 imply that clustering within country-income or countries differs.
ICC, intracluster correlation coefficient; EVD, external ventricular drain; MAP, mean arterial pressure; N/A, not available (overall reported use was 5% or lower so ICC not calculated for these data elements); PaCO2, partial pressure of carbon-dioxide; PaO2, partial pressure of oxygen; SBP, systolic blood pressure; SNACC, Society for Neuroscience in Anesthesiology and Critical Care
There were reported variations in hemodynamic targets and monitoring. Prior to aneurysm securement, institutions variably maintained SBP between 90–120 mmHg (30%), 90–140 mmHg (21%), or between 90–160 mmHg (5%). There was also variation between countries regarding placement of central venous access catheters (ICC, 0.65; 95% CI, 0.00–0.98) and use of pulse pressure variation for hemodynamic monitoring (ICC, 0.61; 95 CI%, 0.00–0.99).
Oxygenation and ventilation management also varied, including between Worldbank country-income group in maintaining PaCO2 between 25–30 mmHg (ICC, 0.22; 95% CI, 0.00–0.55) and between countries in maintaining PaO2 between 60–90 mmHg (ICC, 0.22; 95% CI, 0.00–0.88).
Overall, intraoperative neurophysiological monitoring (IONM) use was reported by 26% of hospitals; IONM was used by 41% of hospitals in HI countries and by 10% in LMIC countries. Variation in IONM was observed between Worldbank country-income group (ICC, 0.15; 95% CI, 0.02–2.76) and also between countries (ICC, 0.44; 95% CI, 0.00–0.68). Specifically, variation between countries was noted for interpretation of IONM by neurophysiologists (ICC, 0.69; 95% CI, 0.00–0.99) and use of motor evoked potential monitoring (ICC, 0.68; 95% CI, 0.00–0.03).
There was variable use of neuroprotective strategies during temporary clipping. Induced hypertension use was reported by 37% of hospitals (equally distributed amongst HI and LMIC groups). Regarding electroencephalographic burst suppression, there was variation between Worldbank country-income regions (ICC, 0.29; 95% CI, 0.00–0.70) and between countries (ICC, 0.51; 95% CI, 0.00–0.99). The reported use of induced hypothermia was rare (2%). Other areas of perioperative care reported by < 20% of participating hospitals are presented in Supplemental Digital Content 2.
The management of intraoperative aneurysm rupture was also variable, including between Worldbank country-income groups regarding adenosine dosing (ranging from 0.31–0.45 mg/kg) to manage intraoperative aneurysm rupture (ICC, 0.22; 95% CI, 0.00–0.58).
Between-country variation in reported quality metrics was highest for tracking postoperative pulmonary complications (ICC, 0.68; 95% CI, 0.00–0.99). Finally, in terms of education, there was between-country variation in the use of intraoperative crisis management for anesthesiology trainees (ICC, 0.70; 95% CI, 0.00–0.99).
DISCUSSION
We conducted a global survey to describe institutional practices regarding the perioperative management of aSAH patients undergoing microsurgical repair of a ruptured intracerebral aneurysm. The main findings of the survey were: 1) reported variation in the majority of areas of care practices during the perioperative management of aSAH patients, and 2) reported variation in practices between/within Worldbank country-income groups and also between/within countries where participating hospitals are located.
This study found variation in the perioperative care of aSAH patients undergoing microsurgical repair of a ruptured intracerebral aneurysm. This finding is not surprising given the lack of high-quality, evidence-based recommendations regarding such perioperative care practices and dependence upon locally-based practices. The variability in perioperative care observed in our survey complements previous publications demonstrating variability in the ICU management of aSAH8,9,10.
The areas of perioperative care with practice variation were many. They included preoperative assessment/preparation, choice of anesthetic agents for induction and maintenance of general anesthesia, analgesia use, laboratory workup, anti-epileptic prophylaxis, osmotherapy, hemodynamic, neurophysiological and temperature monitoring, hemodynamic support and fluid management, oxygenation and ventilation management, neuroprotection during temporary clipping, management of intraoperative bleeding, quality metrics, and education. Areas reported by 81–100% of the hospitals, such as placement of an invasive arterial catheter or type or screening or cross-matching for blood, may not necessarily reflect the specific management of cerebral aneurysm cases but, instead, reflect general principles of preoperative preparation and intraoperative management. In addition, the variation between Worldbank country-income groups and between countries may reflect the availability of technology and institutional biases toward specific practice patterns. For example, variation was reported in the use of IONM not only between countries but also within countries; thus, IONM may not be used in all academic centers, even in HI countries. Similarly, the reported use of anesthetic agents (volatile vs. intravenous) may be aligned with local institutional practice and may also depend upon the use of IONM. This may imply institutional biases regarding locally preferred technique versus what is supported by evidence17–20.
Reported clinical practices and their alignment with available evidence deserve some discussion. Our survey results indicate that hypothermia is not routinely used for neuroprotection which may be due to the results of the IHAST21 clinical trial, and is also aligned with aSAH guidelines2 which state that induced hypothermia during aneurysm surgery is not routinely recommended but that it may be a reasonable option in selected cases (Class III; Level of Evidence B). While our survey found that SBP was reportedly maintained below 160 mmHg based on the aSAH guidelines,2 there was variation in the range of SBP targets used (90–120 mmHg vs. 90–140 mmHg vs. 90–160mmHg); this not something that is clearly defined in aSAH guidelines which, instead, recommend that minimizing the degree and duration of intraoperative hypotension during aneurysm surgery is probably indicated (Class IIa; Level of Evidence B). Similarly, the variation in practices regarding neuroprotection during temporary clipping appear to follow the recommendations that there are insufficient data on pharmacological strategies or induced hypertension during temporary vessel occlusion to make specific recommendations, but that there are instances when their use may be considered reasonable (Class IIb; Level of Evidence C).
This study has some limitations as well as strengths. The limitations are typical of survey-based reporting in that clinical practices are at risk for under- or over-reporting of events based on prevalent institutional biases. This study did not correlate practices with clinical outcomes; thus, it is hard to draw inferences based on the responses received. The study sample was primarily from academic medical centers and may not represent clinical care practices globally. In addition, many of the reported clinical practices do not necessarily represent evidence-based best practices and should not be taken as the standard of care in all components. Some of the study respondents were authors of this manuscript which could also introduce bias. Finally, the study did not specify nor characterize the training which distinguishes a neuroanesthesiologist. The strengths of the survey are that it was a comprehensive review of many aspects of the perioperative care of aSAH patients, and also an attempt to explore a 360-degree view of the perioperative care that may be provided to aSAH patients at the participating hospitals worldwide, As such, it provides a global perspective on this issue.
CONCLUSIONS
This global survey identified differences in reported practices during the perioperative management of aSAH patients. These differences highlight opportunities for future research and the unmet need for evidence-based recommendations that may guide clinical care.
Supplementary Material
Disclosures:
Author AL reports salary support from LifeCenter Northwest.
Author AU reports K08NS125038 grant awarded by the National Institute of Neurological Disorders and Stroke (NINDS) and a grant from the Brain Aneurysm foundation. The remaining authors have no financial disclosures to report.
Footnotes
SUPPLEMENTARY MATERIAL
Supplementary digital content 1
Global-SAH survey questionnaire.
SDC 1.PDF
Supplementary digital content 2
Perioperative care areas reported by < 20% of participating hospitals and stratified by Worldbank country-income level.
R3_Revised_SDC_2.PDF
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