Predictors of ICU Admission Following Endoscopic Endonasal Skull Base Surgery

Introduction: Endoscopic endonasal skull base surgery encompasses a wide range of procedures. Transsphenoidal resection of pituitary tumors is one of the most common surgeries that utilizes this technique. These cases are high-risk procedures and patients are routinely admitted to the intensive care unit (ICU) postoperatively. This ensures detailed monitoring of patients postoperatively given the innate risk of possible neurologic decline and complications. ICU beds are a limited resource in the hospital setting. However, the ICU comprises 8%-30% of hospital budgets, representing a major economic burden for every hospital. While analyzing outcomes and costs during the COVID-19 pandemic, one study identified the median cost per day of ICU patients to be $2,902. Given the large proportion of cost, identifying patients who do not benefit from improved outcomes postoperatively in the ICU could play a large role in decreasing healthcare costs for patients and hospital systems. Therefore, the purpose of this study is to further investigate patient outcomes in the ICU following endoscopic endonasal skull base surgery and identify predictors or risk factors correlated to postoperative complications requiring ICU admission.

Methods: A retrospective analysis was performed of patients undergoing endoscopic endonasal resection of skull base tumors at a tertiary referral center from 2015 to 2022. Data collection focused on patient age, sex, past medical history or comorbidities, length of ICU stay, and stepdown unit stay. Operative data collected included primary surgery or revision surgery, CSF leak present intraoperatively, estimated blood loss (EBL), surgical duration, American Society of Anesthesiologist (ASA) physical health score, tumor pathology, tumor size. Postoperatively we looked at daily sodium levels and any complications. Postoperative complications included CSF leak, diabetes insipidus, intracranial hemorrhage, vision changes, meningitis, hydrocephalus, nosebleeds requiring nasal packing or nasal endoscopy.

Results: A total of 210 patients were included in this study. There were 218 cases performed in total with 8 revision cases included. A total of 108 of those were female with 110 males. Mean age was 53.4 years. Average length of ICU stay was 2.9 days with total length of stay at 5.3 days. Forty-seven patients (22%) were taking aspirin preoperatively.

Patients were chosen based on those who underwent endoscopic endonasal anterior skull base surgery in conjunction with the neurosurgical team. Masses excised included pituitary adenoma, meningioma, esthesioneuroblastoma, juvenile nasopharyngeal angiofibroma, craniopharyngioma, chordoma, encephalocele, Rathke's cleft cyst, epidermoid cyst, teratoma, astrocytoma, cholesterol granuloma, hypothalamic germinoma, and meningothelial hyperplasia.

Patients were excluded if pathology demonstrated metastatic cancer, patient underwent strict CSF leak repair without mass or lesion, or patient was undergoing surgery for acute or chronic sinusitis.

Hypertension and obesity were associated with increased length of stay in the ICU and increased postoperative complications.

Conclusion: While patients following endoscopic endonasal anterior skull base surgery are routinely admitted to the ICU, not all require intensive care and monitoring. This study identifies hypertension and obesity as risk factors leading to increase length of stay in the ICU and increased postoperative complications. These results can allow for stratification of patients to identify those requiring ICU care and better allocated hospital resources and improve patient care.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024