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October 14, 2006
9:00 AM - 11:00 AM
Room Hall E, Area B
Patient Population and Outcome Is No Different in Elective Versus Non-Elective Craniotomy for Tumor
Manyat Nantha-Aree, M.D., Ling Elizabeth, M.D., F.R.C.P.C., M.S., Afisi S. Ismaila, M.S., B.S.
Dept. of Anesthesia, McMaster University, Hamilton, Ontario, Canada
Introduction: In-hospital mortality may be higher and emergency room treatment may be worse on weekends compared to those admitted on a weekday.1,2 The reduction in clinical staff and/or their lack of experience may explain the shortfall in clinical care.3 The outcome of craniotomy for tumor resection performed electively versus non-electively after hours has not been examined. Is is unknown if patients operated on after hours are sicker than electively booked cases, and if morbidity is any different between these two populations.

Objective: To compare the pre- and postoperative morbidity and patient population in elective versus non-elective (after hours) craniotomy for tumor resection.

Methods: This study was approved by the Research Ethics Board. A retrospective chart review via the intranet health sciences network (SOVERA and Meditech) was conducted on all consecutive patients undergoing elective and urgent (after hours and weekends) craniotomy for tumor from January 1 to October 31 2004 at one institution. Data sheets were made a priori and in consultation with a statistician. There were no exclusion criteria.

Analysis: A statistician performed all statistical tests. Categorical data were analyzed using Pearson X2, Fisher's exact test and test for equality of proportions. Continuous data were tested using ANOVA and LSD for post-hoc analysis.

Results: Five neurosurgeons performed 161 cranotiomy's, of which 125 (78%) were done electively (during weekday), 16 (10 %) after hours on a weekday, and 20 (12%) on a weekend. Patient population for elective versus non-elective craniotomy did not differ in terms of preoperative comorbidity (angina, hypertension, asthma, diabetes, TIA, CVA, renal failure, seizures), GCS < 10, or demographics. Significantly more (62 versus 29%) ASA 4 status (p=0.009) were done after hours on a weekday than during elective time. Significantly more Priority 2 cases (surgery within 8 hours) were booked after hours on weekdays (25%) (p=0.006) and weekends (30%)(p=0.00) versus weekday time (3%). No difference was seen in intraoperative blood loss (p=0.43) or transfusion of packed red cells (p=0.63) between elective versus non-elective cases. The rate of transfer postoperatively to PACU, PACU awaiting ICU transfer, or directly to ICU was the same in all groups (p= 0.29), despite the proportion of patients still intubated postoperatively was higher in the weekend group (8/12) compared to weekday cases (20/125) (p=0.03). Morbidity (infection, neurological deficit, intracranial bleed, myocardial infarction) or mortality was no different between any of the groups.

Conclusions: In our institution, patients presenting for craniotomy for tumor resection after hours are no different clinically than scheduled elective patients. Anesthesiologists and neurosurgeons subjectively classify after hours patients as presenting with greater morbidity, as evidenced by the significantly greater number of ASA 4 status and Priority 2 booking codes. Outcomes were no different, however the sample size was small. These after hour cases may reflect inappropriate use of operating room time. Conversely, it may reflect the lack of resources to manage these cases more appropriately during daytime hours.

1. N Engl J Med 2001;345(9):663-8

2. Stroke 1996;27:398-400

3. CMAJ 1997;157:889-96.

Anesthesiology 2006; 105: A54