Postoperative surveillance in neurosurgical patients - usefulness of neurological assessment scores and bispectral index

Herrero, Silvia; Carrero, Enrique; Valero, Ricard; Rios, Jose; Fábregas, Neus

doi:10.1016/j.bjane.2015.09.003

Silvia Herrero ^** Corresponding author. E-mail:sherrern@clinic.ub.esE-mail:silviahn1505@gmail.com (S. Herrero).

Universidad de Barcelona, Hospital Clínic, Sala de Recuperación Pós-Anestésicos, Villarroel, Barcelona, Spain

Enrique Carrero

Universidad de Barcelona, Hospital Clínic, Servicio de Anestesiología, Villarroel, Barcelona, Spain

Ricard Valero

Universidad de Barcelona, Hospital Clínic, Servicio de Anestesiología, Villarroel, Barcelona, Spain

Jose Rios

Universitat Autònoma de Barcelona, Laboratório de Bioestatística e Epidemiologia, Barcelona, Spain

Hospital Clínic, IDIBAPS, Bioestadística y Plataforma de Gestión de Datos, Barcelona, Spain

Neus Fábregas

Universidad de Barcelona, Hospital Clínic, Servicio de Anestesiología, Villarroel, Barcelona, Spain

* Corresponding author. E-mail:sherrern@clinic.ub.esE-mail:silviahn1505@gmail.com (S. Herrero).

Conflicts interests

The authors declare no conflicts of interest.

Figures (3)
Tables (6)

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Figure 1
Chronogram of the study (PACU, post anesthesia care unit; T0, basal; Ta, admission to the PACU; T1 and T2, records in each nursing shift; Td, discharge to the neurosurgical ward; BIS, Bispectral Index; Scales, neurological scales applied; CT-MRI, computerized tomography-magnetic resonance imaging).

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Figure 2
Study flow chart (SICU, surgical intensive care unit; CSF, cerebrospinal fluid; BIS, bispectral index).

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Figure 3
Changes in bispectral index records during the postoperative period (Data expressed as median and interquartile range (bars). T0, basal; Ta, admission to the post-anesthesia care unit (PACU); T1 and T2, records in each nursing shift (only in CG); Td, discharge to the neurosurgical ward; BIS, Bispectral Index; SQI, signal quality index; EMG, electromyogram; CG, craniotomy group (closed symbols); NCG, non-craniotomy group (open symbols). *Significant differences compared to T0 value in each group).

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Table 1
Demographic and clinical characteristics of the subjects.

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Table 2
Alterations in the neurological evaluation scales and BIS in the post anesthesia care unit.

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Table 3
Postoperative neurological complications.

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Table 4
Analysis of concordance between alterations in neurological assessment scales or bis and occurrence of postoperative neurological complications in craniotomy group.

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Table 5
Significant odds ratio of altered neurological scales and BIS for the occurrence of postoperative neurological complications in craniotomy group.

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Pupil examination Assessment Score Pupil size (left/right) 1 mm 1 2 mm 2 3 mm 3 4 mm 4 5 mm 5 Pupil reaction (left/right) No reaction 0 Reacts 1 Pupil anisocoria, pupils of different size; pupil no reaction, a pupilthat does not contract when exposed to a bright light

Glasgow Coma Scale (GCS)4 Category Responses Score Eye opening Spontaneously 4 To speech 3 To pain 2 None 1 Verbal response Orientated 5 Confused 4 Inappropriate 3 Incomprehensible 2 None 1 Motor response Obeys commands 6 Localizes to pain 5 Withdraws from pain 4 Flexion to pain 3 Extension to pain 2 None 1 Maximum score 15

Ramsay Scale9 Level of activity Score Patient anxious and agitated or restless or both 1 Patient co-operative, orientated, and tranquil 2 Patient responds to commands only 3 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus 4 Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulust 5 Patient exhibits no response 6

Canadian Neurological Scale (CNS)10 Mentation Score Level of consciousness Alert 3.0 Drowsy 1.5 Orientation Oriented 1.0 Disoriented/NA 0.0 Speech Normal 1.0 Expressive deficit 0.5 Receptive deficit 0.0 Total: Section A1 Motor functions Weakness Score No comprehension deficit Face None 0.5 Present 0.0 None 1.5 Mild 1.0 Significant 0.5 Total 0.0 None 1.5 Mild 1.0 Significant 0.5 Total 0.0 None 1.5 Mild 1.0 Significant 0.5 Total 0.0 None 1.5 Mild 1.0 Significant 0.5 Total 0.0 Total: Section A2 Motor response Weakness Score Comprehension deficit Face Symmetrical 0.5 Asymmetrical 0.0 Arms Equal 1.5 Unequal 0.0 Legs Equal 1.5 Unequal 0.0 Total:

The Nursing Delirium Screening Scale (Nu-DESC)11 Symptom Score (0-2) I. Disorientation Verbal or behavioral manifestation of not being oriented to time or place or misperceiving persons in the environment II. Inappropriate behavior Behavior inappropriate to place and/or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when that is contraindicated, and the like. III. Inappropriate communication Communication inappropriate to place and/or for the person; e.g., incoherence, noncommunicativeness, nonsensical or unintelligible speech. IV. Illusions/hallucinations Seeing or hearing things that are not there; distortions of visual objects. V. Psychomotor retardation Delayed responsiveness, few or no spontaneous actions/words; e.g., when the patient is prodded, reaction is deferred and/or the patient is unarousable Total: Symptoms are rated from 0 to 2 based on the presence andintensity of each symptom.

Variable	Total (n = 116)	CG (n = 70)	NCG (n = 46)	p
Age, years, mean ± SD	54 ± 16.5	51.1 ± 16.5	58.5 ± 15.7	0.018
Sex, women, n (%)	69 (59.5)	43 (61.4)	26 (56.5)	0.6
ASA, n (%)				<0.001
ASA I	10 (8.6)	0 (0.0)	10 (21.7)	<0.001
ASA II	68 (58.6)	39 (56.7)	29 (63)	0.435
ASA III	38 (32.8)	31 (44.3)	7 (15.2)	0.001
Intervention, n (%)
Supratentorial		24 (34.3)
Transsphenoidal		20 (28.6)
Posterior fossa		12 (17.1)
Functional surgery		11 (15.7)
Other craniotomies		3 (4.3)
Lumbar microdiscectomy			16 (34.8)
Lumbar laminectomy			12 (26)
Spinal tumor			5 (10.9)
Cervical microdiscectomy			4 (8.7)
Brachial plexus surgery			4 (8.7)
Cervical laminectomy			3 (6.5)
Other			2 (4.4)
Intraop. Complications, n (%)	20 (17.2)	16 (22.9)	4 (8.7)	0.074
Hemodynamic instability	11 (9.5)	9 (12.9)	2 (4.3)	0.196
Bleeding	7 (6)	5 (7.1)	2 (4.3)	0.704
Anisocoria	2 (1.7)	2 (2.9)	0 (0)	0.522
Hypoxemia	1 (0.9)	1 (1.4)	0 (0)	1.000
Mortality	0 (0)	0 (0)	0 (0)	-

Group	Total time in the PACU, n (%)	T0, n (%)	Ta, n (%)	T1, n (%)	T2, n (%)	Td, n (%)	p ^a a p within group (time) comparison.
Pupils
CG (n = 70)	6 (8.6)	1 (1.4)	4 (5.7)	5 (8.6)	4 (9.8)	5 (7.2)	0.236
NCG (n = 46)	0 (0)	0 (0)	0 (0)			0 (0)
p ^b b p between group comparison.	0.080	0.423	0.154			0.155
GCS
CG (n = 70)	10 (14.3)	1 (1.4)	8 (11.6)	3 (5.2)	4 (9.8)	5 (7.2)	0.038
NCG (n = 46)	1 (2.2)	0 (0)	1 (2.2)			0 (0)	1.000
p ^b b p between group comparison.	0.048	0.418	0.083			0.082
Ramsay
CG (n = 70)	13 (18.6)	2 (2.9)	6 (8.6)	6 (10.3)	5 (12.2)	5 (7.2)	0.669
NCG (n = 46)	5 (10.9)	1 (2.2)	5 (10.9)			0 (0)	0.063
p ^b b p between group comparison.	0.305	0.821	0.751			0.082
CNS
CG (n = 70)	18 (25.7)	6 (8.6)	14 (20.3)	9 (15.8)	7 (17.1)	9 (13)	0.159
NCG (n = 46)	13 (28.3)	16 (34.8)	10 (21.7)			7 (15.2)	0.508
p ^b b p between group comparison.	0.831	<0.001	1.000			0.787
Nu-DESC
CG (n = 70)	10 (14.3)	6 (8.6)	7 (10)	7 (12.1)	6 (16.2)	5 (7.2)	0.186
NCG (n = 46)	1 (2.2)	2 (4.3)	1 (2.2)			0 (0)	1.000
p ^b b p between group comparison.	0.048	0.382	0.144			0.082
BIS
CG (n = 70)	16 (23.2)	0 (0)	2 (3)	2 (3.7)	3 (7.5)	0 (0)	0.162
NCG (n = 46)	1 (2.2)	0 (0)	0 (0)			0 (0)
p ^b b p between group comparison.	0.002	1.000	0.513			1.000
Pupils-GCS
CG (n = 70)	14 (20)	1 (1.4)	11 (15.9)	8 (13.8)	7 (17.1)	9 (18)	0.002
NCG (n = 46)	1 (2.2)	0 (0)	1 (2.2)			0 (0)	0.368
p ^b b p between group comparison.	0.008	1.000	0.026			0.011
Scales-BIS
CG (n = 70)	36 (51.4)	11 (15.7)	23 (34.3)	23 (42.6)	16 (43.2)	18 (27.7)	0.001
NCG (n = 46)	18 (39.1)	17 (37)	14 (30.4)			7 (15.6)	0.025
p ^b b p between group comparison.	0.254	0.014	0.689			0.168

CG ( n = 70)
Number of patients (%) with neurological complications in the PACU
Total	16 (22.9)
Aphasia	4 (5.7)	Agitation	1 (1.4)
Anisocoria	3 (4.3)	Psychomotor retardation	1 (1.4)
Headache	2 (2.9)	Dysarthria	1 (1.4)
Hipoesthesia	2 (2.9)	Nonconvulsive seizures	1 (1.4)
Cranial nerve palsy	2 (2.9)	Hemiplegia	1 (1.4)
Low level of consciousness	1 (1.4)	Paresis	1 (1.4)
Hallucination	1 (1.4)	Trigeminal neuralgia	1 (1.4)
Anxiety	1 (1.4)
Number of patients (%) with neurological complications in the ward
Total	18 (25.7)
Cranial nerve palsy	5 (7.1)	Bradypsychia	1 (1.4)
Headache	4 (5.7)	Dystonia	1 (1.4)
Aphasia	4 (5.7)	Alexia	1 (1.4)
CSF fistula	4 (5.7)	Right-hemisphere Synd.	1 (1.4)
Seizures	2 (2.9)	Psychiatric decompensation	1 (1.4)
Number of patients (%) with neurological complications by CT-MRI
Total	9 (12.9)
Pneumocephalus mass effect	7 (10)	Infection	1 (1.4)
Hematoma mass effect	1 (1.4)
NCG (n = 46)
Number of patients (%) with neurological complications in the PACU
Total	0 (0)
Number of patients (%) with neurological complications in the in the ward
Total	5 (10.9)
Lumbosciatalgia	2 (4.3)	Unstable gait	1 (2.2)
Paraplegia	1 (2.2)	Disorientation	1 (2.2)
Number of patients (%) with neurological complications by CT-MRI
Total	2 (4.3)
Spinal cord compression	2 (4.3)

	Complications in the PACU		Complications in the ward		Complications diagnosed by CT-MRI
	Kappa	p	Kappa	p	Kappa	p
Pupils	0.169	0.098	0.044	0.655	0.000	0.250
GCS	0.440	<0.001	0.213	0.058	0.399	0.006
Ramsay	0.263	0.027	0.136	0.244	0.143	0.326
CNS	0.379	0.001	0.177	0.138	0.530	<0.001
Nu-DESC	0.347	0.003	0.213	0.058	0.175	0.229
BIS	0.349	0.004	0.220	0.066	0.108	0.460
Pupils-GCS	0.407	0.001	0.274	0.020	0.240	0.097
Scales-BIS	0.381	<0.001	0.155	0.133	0.161	0.132

Time	Diagnosis of neurological complication	Odds ratio	95% CI	p
Pupils
Ta	PACU	12.23	1.18-127.36	0.036
GCS
Ta	PACU	7.58	1.57-36.53	0.012
Td	Ward	15.69	1.61-152.55	0.018
Td	CT-MRI	18.00	1.60-202.95	0.019
Ta, T1, T2 and Td	CT-MRI	9.33	1.59-54.58	0.013
CNS
Ta	PACU	5.11	1.44-18.16	0.012
Td	Ward	8.91	1.92-41.24	0.005
Ta	CT-MRI	10.31	1.93-59.05	0.006
Td	CT-MRI	9.07	1.55-53.07	0.014
Ta, T1, T2 and Td	CT-MRI	18.67	3.09-112.61	0.001
Pupils-GCS
Ta	PACU	9.53	2.31-39.39	0.002
Td	Ward	8.91	1.92-41.24	0.005
Ta, T1, T2 and Td	Ward	4.09	1.19-14.11	0.026
Scales-BIS
Ta	PACU	7.15	2.07-24.69	0.002
Ta	Ward	3.40	1.06-10.88	0.039
Ta	CT-MRI	5.78	1.19-28.04	0.030

Pupil examination
Assessment		Score
Pupil size (left/right)	1 mm	1
	2 mm	2
	3 mm	3
	4 mm	4
	5 mm	5
Pupil reaction (left/right)	No reaction	0
	Reacts	1

Glasgow Coma Scale (GCS)⁴4 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81-4.
Category	Responses	Score
Eye opening	Spontaneously	4
	To speech	3
	To pain	2
	None	1
Verbal response	Orientated	5
	Confused	4
	Inappropriate	3
	Incomprehensible	2
	None	1
Motor response	Obeys commands	6
	Localizes to pain	5
	Withdraws from pain	4
	Flexion to pain	3
	Extension to pain	2
	None	1
Maximum score		15

Ramsay Scale⁹9 Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974;2:656-9.
Level of activity	Score
Patient anxious and agitated or restless or both	1
Patient co-operative, orientated, and tranquil	2
Patient responds to commands only	3
Patient exhibits brisk response to light glabellar tap or loud auditory stimulus	4
Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulust	5
Patient exhibits no response	6

Canadian Neurological Scale (CNS)¹⁰10 Côté R, Battista RN, Wolfson C, et al. The Canadian Neurological Scale: validation and reliability assessment. Neurology. 1989;39:638-43.
Mentation			Score
Level of consciousness	Alert		3.0
	Drowsy		1.5
Orientation	Oriented		1.0
	Disoriented/NA		0.0
Speech	Normal		1.0
	Expressive deficit		0.5
	Receptive deficit		0.0
	Total:
Section A1	Motor functions	Weakness	Score
No comprehension deficit	Face	None	0.5
		Present	0.0
		None	1.5
		Mild	1.0
		Significant	0.5
		Total	0.0
		None	1.5
		Mild	1.0
		Significant	0.5
		Total	0.0
		None	1.5
		Mild	1.0
		Significant	0.5
		Total	0.0
		None	1.5
		Mild	1.0
		Significant	0.5
		Total	0.0
		Total:
Section A2	Motor response	Weakness	Score
Comprehension deficit	Face	Symmetrical	0.5
		Asymmetrical	0.0
	Arms	Equal	1.5
		Unequal	0.0
	Legs	Equal	1.5
		Unequal	0.0
		Total:

The Nursing Delirium Screening Scale (Nu-DESC)¹¹11 Gaudreau JD, Gagnon P, Harel F, et al. Fast, systematic, and continuous delirium assessment in hospitalized patients: the Nursing Delirium Screening Scale. J Pain Symptom Manag. 2005;29:368-75.
Symptom	Score (0-2)
I. Disorientation Verbal or behavioral manifestation of not being oriented to time or place or misperceiving persons in the environment
II. Inappropriate behavior Behavior inappropriate to place and/or for the person; e.g., pulling at tubes or dressings, attempting to get out of bed when that is contraindicated, and the like.
III. Inappropriate communication Communication inappropriate to place and/or for the person; e.g., incoherence, noncommunicativeness, nonsensical or unintelligible speech.
IV. Illusions/hallucinations Seeing or hearing things that are not there; distortions of visual objects.
V. Psychomotor retardation Delayed responsiveness, few or no spontaneous actions/words; e.g., when the patient is prodded, reaction is deferred and/or the patient is unarousable
	Total:

[1] * Corresponding author. E-mail:sherrern@clinic.ub.esE-mail:silviahn1505@gmail.com (S. Herrero).

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Postoperative surveillance in neurosurgical patients - usefulness of neurological assessment scores and bispectral index

Abstract

Background and objectives:

Methods:

Results:

Conclusions: