Benefits of routine ICU avoidance following stereo-electroencephalography

Stereo-electroencephalography (SEEG) is a minimally invasive surgical technique for seizure localization in patients with refractory epilepsy. Acute postimplantation care varies, with many centers choosing routine postoperative ICU monitoring before transfer to an epilepsy monitoring unit (EMU). In this study, the authors aimed to describe their institutional experience implementing an ICU bypass guideline for pediatric patients, and to evaluate the safety and benefits of the bypass guideline, while comparing patient characteristics and outcomes before and after guideline implementation.

All SEEG surgeries performed from November 2015 to April 2024 at a single institution were retrospectively reviewed. The center historically admitted all patients to the ICU for the first 24 hours following SEEG. A guideline allowing bypass of initial ICU care for pediatric patients at low risk was instituted in September 2021.

A total of 142 children (74 female, mean age 12.6 ± 5.6 years) underwent 149 SEEG surgeries; in all 85 surgeries before guideline implementation, patients were admitted to the ICU, while there were 54 of 64 surgeries (84.3%) in which the patient bypassed the ICU and was admitted to the EMU after guideline implementation. Five patients underwent surgery both before and after the guideline was implemented. Patients excluded from ICU bypass had respiratory (n = 2), behavioral (n = 1), neurological (n = 1), or combined (n = 1) concerns. The before and after guideline implementation groups had similar preoperative medical comorbidities, with patients in 42 procedures overall having neurological (excluding epilepsy, 20.8%, p = 0.16), cardiac (6.7%, p = 0.1), or pulmonary (9.4%, p = 0.27) comorbidities. Patients who underwent SEEG placement before and after guideline implementation did not differ in demographic characteristics (p ≥ 0.05). The overall mean age was 12.6 years, median American Society of Anesthesiologist class was III, mean number of electrodes implanted was 14.4, mean hospital length of stay (LOS) was 11 days, and mean duration of leads in place was 8 days. The overall rate of seizure detection was 98%, rate of unplanned head imaging in the first 24 hours after implantation was 5.4%, and rate of ICU transfer in the first 24 hours after implantation was 4%. No patients who underwent SEEG after guideline implementation required subsequent ICU transfer or experienced symptomatic intracranial hemorrhage, hardware dislodgment, or unplanned surgery in the first 24 hours after SEEG. After implementation of the ICU bypass guideline, the mean ICU LOS decreased (0.6 vs 1.08 days, p < 0.005), which reduced resource utilization and saved a mean of $2690 per SEEG surgery.

After a guideline was implemented to identify patients undergoing SEEG who could bypass the ICU immediately after SEEG implantation, resource utilization was reduced without compromising patient safety or clinical outcomes.