title: Elective endovascular treatment of unruptured intracranial aneurysms: a management case series of patient outcomes after institutional change to admit patients principally to postanesthesia care unit rather than to intensive care.
abstract: BACKGROUND
  Our intention in this case series was to review the postoperative care and neurologic outcomes of patients who had undergone elective endovascular treatment of unruptured intracranial aneurysms. The case series is unique managerially in that a progressively increasing percentage of patients were admitted to the postanesthesia care unit (PACU; 1:2 nurse-to-patient ratio) and subsequently to the neurosurgical ward (1:3 nurse-to-patient ratio) instead of directly to the intensive care unit (ICU; 1:1 nurse-to-patient ratio).
  
  
  METHODS
  A retrospective review was performed of 170 consecutive elective endovascular procedures to treat unruptured intracranial aneurysms between July 2009 and September 2012. Data included patient, aneurysm, procedural characteristics, and adverse events within 96 hours after the procedure. Rates of ICU admission and perioperative neurologic adverse events were compared over time.
  
  
  RESULTS
  Although direct ICU admission rates decreased over time (P < 0.0001) from 100% to 15%, perioperative neurologic event rates did not change (P = 0.79). Sixteen of 170 patients experienced perioperative neurologic events. The percentages of patients with neurologic events who died or had deficits that did not resolve before discharge were 38% (3 of 8) among patients directly admitted to the ICU versus 38% (3 of 8) among those first admitted to the PACU. Although the duration of anesthesia was greater among patients admitted to the ICU, duration was not useful in predicting decisions on the day of surgery for individual patients. The duration of anesthesia also was not meaningfully associated with information available preoperatively (i.e., for use when scheduling the case).
  
  
  CONCLUSIONS
  In centers in which PACU and ward care are comparable to those in this case series, in the absence of intraoperative events with the potential for ongoing cerebral ischemia, most patients undergoing elective endovascular treatment of unruptured cerebral aneurysms can be managed without direct ICU admission. Scheduling all these procedures by using the mean historical anesthesia duration is reasonable.
authors: From the Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa; Department of Biostatistics, The University of Iowa College of Public Health, Iowa City, Iowa; Division of Management Consulting, Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa; and Department of Neurosurgery, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa.
authors: Sarah H
authors: SH
authors: Eisen
authors: Bradley J
authors: BJ
authors: Hindman
authors: Emine O
authors: EO
authors: Bayman
authors: Franklin
authors: F
authors: Dexter
authors: David M
authors: DM
authors: Hasan
mesh_terms: D000368:Aged; D000761:Anesthesia Department, Hospital / Q000639:trends; D000762:Anesthesia Recovery Period; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000451:nursing / Q000639:trends; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000639:trends; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000451:nursing / Q000601:surgery*; D007484:Iowa; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000639:trends; D016528:Postanesthesia Nursing / Q000639:trends; D011182:Postoperative Care; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome