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J Neurosurg. 2018 Dec 1:1-9. doi: 10.3171/2018.7.JNS181226. [Epub ahead of print]

Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures.

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1University of Michigan Medical School; and.
Departments of2Neurology and.
3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan.


OBJECTIVEIt is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.METHODSThis retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.RESULTSOf the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.CONCLUSIONSInitiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.


CC = comfort care; EMERSE = Electronic Medical Record Search Engine; PGY = postgraduate year; SAH = subarachnoid hemorrhage; SST = surgical start time; cerebrovascular pathology; comfort care; complications; emergent neurosurgery; end-of-life care; outcomes; surgical start time; vascular disorders


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