Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma.

Abstract

Enhanced recovery programs may be especially useful in patients with chronic subdural hematoma or hygroma (cSDH), who frequently exhibit frailty and multimorbidity. We aim to evaluate the real-world safety and effectiveness of an enhanced recovery protocol in this population. From a prospective registry, burr hole evacuations for cSDH carried out under the protocol (including early thromboprophylaxis, no flat bed rest, early mobilization without drain clamping, and early resumption of antithrombotic medication) were extracted, along with those procedures carried out within the past year before protocol change. Propensity score-based matching was carried out. A range of clinical and imaging outcomes were analyzed, including modified Rankin Scale as effectiveness and Clavien-Dindo adverse event grading as safety primary end points. Per group, 91 procedures were analyzed. At discharge, there was no significant difference in the modified Rankin Scale among the standard and enhanced recovery groups (1 [1; 2] vs 1 [1; 3], P = .552), or in Clavien-Dindo adverse event grading classifications of adverse events (P = .282) or occurrence of any adverse events (15.4% vs 20.9%, P = .442). There were no significant differences in time to drain removal (2.00 [2.00; 2.00] vs 2.00 [1.25; 2.00] days, P = .058), time from procedure to discharge (4.0 [3.0; 6.0] vs 4.0 [3.0; 6.0] days, P = .201), or total hospital length of stay (6.0 [5.0; 9.0] vs 5.0 [4.0; 8.0] days, P = .113). All-cause mortality was similar in both groups (8.8% vs 4.4%, P = .289), as was discharge disposition (P = .192). Other clinical and imaging outcomes were similar too (all P > .05). In a matched cohort study comparing perioperative standard of care with a novel enhanced recovery protocol focusing on evidence-based drainage, mobilization, and thromboprophylaxis regimens as well as changes to the standardized reuptake of oral anticoagulants and antiaggregants, no differences in safety or effectiveness were observed after burr hole evacuation of cSDH.