December 2017 #PRSJournalClub Wrap-Up: “Is ICU Care Necessary After Cranial Vault Remodeling?”

by Ara A. Salibian, MD (@AraSalibianMD)
Resident Physician
Hansjörg Wyss Department of Plastic Surgery
NYU School of Medicine

The December #PRSJournalClub featured an excellent study in this month’s @PRSJournal entitled “Is Postoperative Intensive Care Unit Care Necessary following Cranial Vault Remodeling for Sagittal Synostosis?” in a special “Craniofacial Masters Edition” of the award-winning #PRSJournalClub. The study analyzed outcomes, hospital length of stay and cost among a large cohort of patients who underwent cranial vault remodeling for saggital synostosis with direct admission to a general hospital ward instead of standard initial transfer to an intensive care unit (ICU). On December 17th and 18th, @PRSJournal hosted a fantastic discussion with study authors Dr. Erik M. Wofswinkel (@DrEWolfswinkel) and Dr. Mark M. Urata (@urata_mark) from the Division of Plastic and Reconstructive Surgery and the Department of Neurological Surgery at the University of Southern California, Keck School of Medicine and Children’s Hospital of Los Angeles.

Click here to read the study as well as view this month’s comprehensive collection of #PRSJournalClub articles.

Patients that undergo correction of saggital synostosis are often initially admitted to an ICU despite a reduction in complications secondary to advances in the perioperative care of these patients. Prior studies have provided conflicting viewpoints on whether ICU care is really needed after these procedures. As the standard protocol of the authors in this study is to admit patients directly to a general ward after correction of saggital synostosis, they set out to determine if there were any differences in outcomes and cost among patients admitted directly to a ward instead of an ICU.

Wolfswinkel et al. performed a 6-year retrospective review of all patients undergoing cranial vault remodeling for correction of saggital synostosis at a single pediatric institution. All procedures involved occipital reduction with temporal widening under a single craniofacial/neurosurgical team; however, those with prior significant medical comorbidities that may necessitate ICU admission were excluded from the study. The authors analyzed patient demographics and outcomes including blood loss, transfusions, complications, length of stay, mortality and need for ICU admission.

The standard protocol for postoperative care after correction of saggital synostosis included admission to a general medical/surgical ward with a 1:3 patient-to-nursing ratio and in-house pediatric resident coverage. Patients received steroids, antibiotics, anti-histamines and as-needed pain medications, and were transfused for a hematocrit less than 21 or if symptomatic. Clears were started on postoperative day 0, the urinary catheter was removed on postoperative day 1, dressing on postoperative day 2 and the patient was discharged on postoperative day 3 to 4.

One-hundred ten patients were included the study, of which 98 patients (89%) were directly admitted to the general ward and 12 patients (11%) were initially admitted to the ICU for reasons including airway management, prematurity, and metabolic derangements, among others. There were no major adverse events among patients admitted directly to the ward and no patients required transfer to the ICU. Five patients required transfusion in the immediate postoperative period and four patients had minor late postoperative complications. Patients that were initially admitted to the ICU were found to have a total hospital length of stay of 4.4 days compared to 3.6 days in the direct ward admission group. Using the calculated hospital bed cost per day, the authors found the total cost per patient for the entire hospital stay to be $39,435 for the direct ICU admission group and $20,406 for the direct general ward admission group. The authors demonstrate that in the appropriate clinical care setting, patients undergoing correction of saggital synostosis can receive postoperative care on an individual basis, with the majority of patients treated without admission to an intensive care unit.

The article was discussed on this month’s #PRSJournalClub podcast with special guest moderator Dr. Jeffrey A. Fearon, MD, Director of the Craniofacial Center in Dallas, Texas, and Associate Editor of @PRSJournal. As usual, he was joined by PRS Resident Ambassadors Chad Purnell (@ChadPurnellMD), Jordan Frey (@JordanFreyMD), and M. Shuja Shafqat (@shujashafqatmd). The panel shared a great discussion on topics including the need for special training amongst nurses and staff taking care of cranial vault remodeling patients, as well as the decision-making process behind determining level of care needs. The panelists also discussed the generalizability of the authors’ protocol to other institutions as well as other types of cranial vault remodeling. Great ideas were brought up by all discussants including Dr. Fearon’s important point on always being aware of a patient’s clinical status during surgery and subsequently pacing the procedure appropriately to ensure safety. Click the link below to listen to this enlightening podcast.

On December 17th and 18th, the PRS journal hosted a fantastic interactive #PRSJournalClub discussion on Twitter!  Over the two days, Dr. Urata and Dr. Wofswinkel answered many excellent questions posed by plastic surgeons around the world and described several important points on the postoperative care of cranial vault remodeling patients. Noteworthy topics included the importance of counseling patients’ parents on postoperative care protocols and what to expect after surgery with regards to the level of care and length of stay. The discussions also addressed expanding similar protocols to other saggital cranial vault remodeling techniques as well as correction of other types of craniosynostosis. The authors also detailed their protocols for transfusion as well as criteria for direct admission to an intensive care unit.

Check out some of the great discussions from the weekend below! 











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