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Day care neurosurgery in India: Is it a possible reality or a far-fetched illusion? A neuroanesthesiologist's perspective
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.263216
Day care surgery, wherein an operated patient recovers after surgery and is fit to go home within a day or 24 h, is still in its infancy in India. It is a continually evolving concept performed in different specialties across the country. Recently, the complexity of procedures has increased with a wider range of patients now being considered suitable for daycare surgery. Appropriate accreditation, safe anesthesia protocols, and proper patient selection ensure a safe and an efficacious daycare surgery.[1] The primary aim of daycare surgery units is to facilitate early recovery of the patients so that they can return to their familiar “home” environment, with a possible reduction in the risk of thromboembolism and hospital-acquired infections.[1],[2] Daycare surgeries are believed to reduce the average unit cost of treatment by up to 70% as compared with inpatient surgery. Despite bearing 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hospital beds per 1,000 population in India are <35% of the world's average.[1] Given this scenario, the concept of daycare surgery is poised to revolutionize the medical care in India. The advancement in surgical skills, better imaging technology, advent of new anesthetic techniques, with advances in monitoring and perioperative care, have paved the way for the idea of establishment of day care surgery in neurosurgery.[1] The safety and feasibility of ambulatory neurosurgery can be fully realized with stringent protocols and coordination between the nursing, surgery, and anesthesia teams. Neurosurgery is a resource-intensive surgical specialty where a brain tumor surgery most often involves a craniotomy with invasive and noninvasive intraoperative monitoring and intensive postoperative management and can be done in a few selected cases. The use of minimally invasive approaches, image-guided navigation, retractor-less surgery, neuroprotective adjuvants, and ever-increasing dependence on perioperative neurophysiological monitoring has paved the way for the advent of daycare neurosurgery.[2],[3],[4] Selecting the patients appropriate for outpatient neurosurgery is of paramount importance. Success is reported in established western centers for day care surgery in neurosurgery for tumor excision or biopsy, where the lesion is intra-axial, supratentorial, and the duration of surgery is <4 h to allow for adequate postoperative monitoring in the postanesthetic care unit (PACU).[5] The criteria for outpatient lumbar surgery have been stated to include stable chronic comorbidities, a body mass index ≤42 kg/m 2, as well as clearance from a cardiologist for pre-existing cardiac conditions, determined either by stress test or echocardiogram.[6] Outpatient anterior cervical discectomy and fixation procedures are limited to the primary single level or the second level from C4/5 to C6/7.[7] The surgical time should be limited to <2 h. Patients with recent spine trauma or infection, or those requiring posterior cervical fusion should be excluded from the outpatient surgery protocol.[6],[7]
In India, the doctor: patient ratio is 1:1,800 and the hospital bed: patient ratio is 1:1,462. An estimated shortage of 42,000 beds exists in government hospitals, which cater to 60% of the country's' population.[8] The waiting period for most of the neurosurgical procedures in major institutions, which are the few centers of excellence in India, runs into months for hundreds and thousands of patients who are dependent on them. Most of them have brain lesions and cannot wait for a long time, hence such a long waiting period can cause irreparable damage resulting in functional and physical dependence.[2],[4] The aim of neurosurgery is not just to keep the patients alive but to return them to a functionally independent state. Daycare neurosurgery can enable a large number of patients with brain and spine pathologies to avail treatment early, thereby reducing their morbidity and mortality. Patients with malignant tumors can undergo an early surgical resection with faster follow-up chemo- or radiotherapeutic options, thereby increasing the 5-year survival. This can be achieved by decongesting the main surgical list and improving the bed availability by promoting patients presenting for minimally invasive surgeries and spine surgeries to undergo daycare neurosurgery. Patients whose pathology and medical condition warrant an in-patient setting will get the opportunity of an early treatment, and thus, this policy can result in better resource utilization.[2],[4] The duration of the postoperative stay for neurosurgical procedures depends on the type of surgery, the type of medical comorbidities present, a motivated surgeon-anesthesiologist team, the perioperative care, the patients' preference and their socioeconomic background, and the support systems available. With the advent of stereotactic biopsy, the scene was set for the introduction of daycare neurosurgery. The consensus on a “daycare neurosurgical procedure” will vary according to the expertise of individual neurosurgeons and anesthesiologists, and the support systems offered by the institutions.[2],[3],[4]
a. Patient factors The patients of American Society of Anesthesiologists (ASA) physical status I-III are preferred. The patient's social situation should be suitable for ensuring an early discharge.[9] The presence of a difficult intubation and/or bag mask ventilation, cardiovascular disease, pulmonary insufficiency, obstructive sleep apnea, susceptibility to anesthetic or analgesic medications, and difficult positioning make the patient ineligible for day care surgery.[10] The p atient comorbidities that preclude an early discharge following a craniotomy include uncontrolled seizures, altered neurological status or decreased cognitive function, and psychological factors.[9] The patient and the primary caregiver should be convinced regarding the effectiveness of outpatient surgery and a responsible adult caregiver should be available to escort the patient home and observe him/her overnight. Patients may elect to stay in a hotel close to a hospital, if need be, so that they can reach the emergency department early.[9] The patients should be educated on the benefits of outpatient surgery, including the comfort and privacy of familiar surroundings, as well as the potential reduced risk of nosocomial infections and thromboembolism. The patients and their family can be reassured that if there are any changes during the hospital course of the patient, then the possibility of the conversion of their status to an inpatient one will always be available. Patient information booklets and appropriate communications related to daycare neurosurgery are fundamental to the effective implementation of day care surgery.[10] Patient counseling and motivation play an important role in boosting the confidence of the patient and the family members.[2],[10],[11] b. Manpower The skill, commitment, and expertise of the operating surgeon and the anesthesiologist are of paramount importance in achieving successful and safe daycare neurosurgery. The operating team (neurosurgeon, neuroanesthesiologist, nursing personnel) should make the safety of the patient as the primary goal and have a good communication and coordination among themselves. Dedicated neuroanesthesiologists, who understand the nuances of awake craniotomy and are aware of the immediate postoperative complications, should be involved in both patient selection and discharge decisions. The standardization of techniques, protocols, and the appropriate discharge criteria will prevent mishaps in the effective implementation of daycare surgery.[9],[11] c. Protocol for discharge Following a craniotomy, the patients should be kept for a minimum of 2 h in the post-anesthesia care unit (PACU), followed by at least 4 h in the step down unit. In the PACU, the patients' neurological status and cardiorespiratory vitals are monitored. Blood pressure is optimized to <160/90 mmHg with titrated labetalol boluses, if required.[5] Invasive catheters, including arterial and urinary, should be discontinued. Pain and nausea are aggressively treated with analgesics and antiemetics. At 4 h, the patient should undergo a computed tomography (CT) scan to rule out complications. Patients should attempt to void and drink clear fluids. Antiemetics and oral analgesics are given.[11] The neurosurgeon and neuroanesthesiologist should assess the patient after 6 h for fitness for discharge, neurological status, and control of nausea and pain.[5],[11] d. Infrastructure It is desirable to have a separate group or subgroup for daycare surgery with its own administrative infrastructure to manage the patient flow and scheduling.[6] There should be dedicated neurosurgical and neuroanesthesiology consultants, staff, and operation theaters. This will help in appropriate patient selection, preoperative optimization, and preparation prior to the surgery. Also, there should a system for streamlined admission on the day of surgery without any time lag, rapid transfer of patients to the theater, and postoperative care areas.[10],[11],[12] The readmission procedure should be seamless as there can be a need for urgent readmission, which can arise commonly in neurosurgical procedures.
Most centers which are successfully conducting day neurosurgeries have performed either stereotactic brain tumor biopsies or small craniotomies for resections of tumors such as gliomas and metastases. The surgery has typically lasted <2 h, with less opioid consumption and blood loss <300 mL, requiring only standard monitoring and no invasive lines.[10],[11] Their data on postoperative complications should be assessed carefully before applying them to our practice. Western institutional guidelines for an early discharge following stereotactic brain biopsy requires the absence of intraoperative hemorrhage, new postoperative deficit, and clot on a postoperative CT scan within 1–3 h prior to discharge. They found that all complications occurred within 6 h. Early studies quoted a complication rate of 2.6% and a same-day discharge rate of 97.4%.[13] The first case series depicting the UK experience with day surgery brain biopsy reported a 90% success rate for discharge within 6 h, with the patient's preference being the most predominant reason for an unplanned admission.[14] Complications that may preclude an early discharge following the craniotomy for tumor removal include an intraoperative seizure, venous air embolism, transient or permanent neurologic deficits, nausea and vomiting, cognitive deficits, hyperglycemia, hemorrhage, and hyponatremia.[9],[11],[15] The healthcare team will need to have a low threshold for the conversion of the patient's status to an inpatient one. A streamlined readmission process is mandatory, which will facilitate the quick return of patients to the hospital if the need arises, so that they can be managed optimally. This process can be limited in our large volume centers due to bed unavailability. An early discharge should be a consequence of good patient care and not a primary end point.[12] Most of the daycare neurosurgeries, especially the minimally invasive cranial surgeries, are conducted as awake craniotomies.[16],[17] In awake craniotomy, the patient will be awake or under minimal sedation though the procedure. Thus, the need for anaesthesia and the incidence of residual anesthetic effects and their side effects in the postoperative period are very minimal, resulting in an early mobilization and a shorter hospital stay. Patients undergoing awake craniotomy should be cooperative, motivated, and be able to lie supine.[17] Good communication is fundamental to the success of awake craniotomy, which is hindered largely by the diverse languages and educational levels present in India. Subtle neurological signs of cerebral edema and other complications in the early phase can be picked up more reliably by a trained person rather than an attendant, given the fact that the input from the patient may be largely absent due to their altered neurological state. Due to a large number of patients being illiterate and from a low socioeconomic strata, this can be even more challenging. Most of the Indian patients tend to become uncomfortable if they are not attended to by the surgical team in the postoperative period. Such patients may even experience discomfort and stress at home after a surgery. Pain after discharge remains the most common compliant after neurosurgery. Pain after discharge affects sleep, delays an early mobilization, and thus impairs an early return to normal function and work, negating the advantages gained by undergoing daycare neurosurgery.[18] Most neurosurgical patients require opioid-based analgesia in the postoperative period. Opioid analgesia-related side effects, such as sedation and respiratory depression, can result in readmission after discharge in the immediate postoperative period. Acute severe postoperative pain is, in itself, a risk factor for the development of chronic persistent postsurgical pain. The option of using nonsteroidal anti-inflammatory drugs (NSAIDS) as part of the multimodal approach in neurosurgical patients is a risky one, considering the risk of intracranial bleeding in this subset of patients.[19] Even though Indian anesthesiologists are highly skilled, their services are limited by the lack of suitable infrastructure and availability of certain pharmacological agents. The review of literature reveals that most of the western centers, which practice daycare neurosurgeries use ultra-short acting opioid, remifentanil, which helps them to maintain a good analgesia in the perioperative period without any long-lasting adverse effects developing in the postoperative period. Majority of Indian centers still depend on morphine for their perioperative analgesia and a selected few have access to fentanyl, which is a shorter acting agent.[5],[13] Most of the western centers use intraoperative neuromonitoring, such as somatosensory-evoked potential, motor evoked potential, as well as intraoperative neuronavigation and intraoperative magnetic resonance imaging to provide faster and safer surgeries with an improved outcome. Though these are available in a select few centers in India, their routine use as a part of institutional protocol is yet to be implemented. Postoperative nausea and vomiting (PONV) is distressing to patients and may lead to prolonged hospital stay and unanticipated hospital readmission.[16] After discharge, patients undergoing daycare surgeries do not have access to fast-acting parenteral antiemetics and monitored care as in hospitals. Nausea and vomiting can also be a presentation of raised intracranial pressure in postoperative neurosurgical patients, which, if not detected early, can result in a disastrous outcome.[20],[21] In a prospective and observational study involving 188 patients admitted to the intensive care unit (ICU) after brain tumor surgery, 31% of the patients presented with at least one complication (25% with PONV, and 16% with neurological complications) justifying the postoperative stay for an early detection of these entities.[20] Cerebral edema usually begins within 5 h after the surgery and peaks at 48–72 h. The extent of edema is influenced by the amount of direct brain manipulation, the duration and force of retraction, and the degree of bipolar coagulation used intraoperatively. Postoperative cerebral edema can be asymptomatic or may manifest clinically with a decreased level of alertness, exacerbation of focal deficits, or seizures.[21],[22] Having a complication at home is different from having the same in a controlled environment of a hospital and the delay in identifying or managing it can even cost a life. Tabulation of the results of various studies published on daycare neurosurgery does cite a complication rate of 18% in one of the studies.[14] Day care neurosurgery for spinal and neurosurgical procedures do have medicolegal hurdles. The majority of Indian patients who come to large centers arrive from peripheral areas and from a poor socioeconomic background. The family members are given instructions on diet, ambulation, and appropriate medications for managing pain and nausea. They are advised on how to identify a seizure, a new onset neurological deficit, and given the contact number of a nurse, who will either address further concerns at home or facilitate their return to the emergency. Some western centers which conduct an outpatient craniotomy and brain biopsy had a home care nurse visit the patients on the evening of the surgery, whereas in others, a nurse routinely made a call at the patients' home to monitor their progress.[13],[14] The feasibility of such an extended care is impractical in the current Indian scenario. Discharging the patients on the same evening of surgery may not be feasible considering the travel, overcrowding, and sanitation at home. A traveling time to the surgical center of >1 h is a contraindication for daycare surgery.[9] Lack of insurance coverage by insurance companies for neurosurgical cases without overnight admission in the current situation can be a major deterrent for the patients to opt for daycare neurosurgery.[18] Insurance reimbursements to hospitals for procedures performed are substantially higher in cases that include an approved overnight stay. Lack of a dedicated daycare surgery outpatient department, lack of wards with additional trained workforce to facilitate the prompt admission, as well as a sound readmission policy and discharge process is a problem. Centers which currently practice daycare neurosurgery have trained dedicated transfer teams and ambulances that are appropriately equipped to respond to an emergency situation arising in the postoperative period.[13],[23],[24] The medicolegal issues that may arise out of a catastrophe will prevent the surgeons from performing neurosurgeries under day care procedures. Meticulous scrutiny is needed to make sure that the patient is genuinely fit for day care surgery. Clear and legible documentation at all levels, along with good communication, form the cornerstone of avoiding medicolegal issues in an ambulatory or day care setting.
We propose that a safe and practical way to initiate day care neurosurgery in India would be to implement the fast-tracking and an early discharge of minimally invasive neurosurgical cases within 1–2 days in the postoperative period, and then determine whether this could be replicated in the outpatient setting. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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