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