Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)—part 2

Abstract

Background Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts’ recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. Methods A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. Results A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. Conclusions This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician’s decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.

A Survey on Monitoring and Management of Cerebral Vasospasm and Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: The Mantra Study

“…8 CTA was the most frequently used modality to confirm the presence of cerebral vasospasm as the cause of DNDs related to DCI, in agreement with the recommendations of several consensus conferences. 13,14 Transcranial Doppler/cerebral ultrasound is the most frequently used diagnostic tool for cerebral vasospasm in comatose aSAH patients or in aSAH patients unable to tolerate an interruption in sedation (e.g., those with intracranial hypertension). Neurological examination is also commonly used in comatose aSAH patients or in aSAH patients unable to tolerate an interruption in sedation; this approach is logical and reasonable in the former scenario but unreliable in the latter scenario.…”

“…Respondents mainly utilized induced hypertension as the first step in the management of DCI related to vasospasm and intra-arterial procedures as the second step; this approach follows recommendations in several guidelines. 9,10,13,14 However, data are lacking regarding the optimal timing of intra-arterial procedures, particularly in patients receiving vasopressors for DCI related to vasospasm; little is known whether intra-arterial procedures should be performed before, at the same time as, or after failure of vasopressor therapy. Noradrenaline was the most used vasopressor.…”

Ventilator-associated pneumonia in neurocritically ill patients: insights from the ENIO international prospective observational study

“…This may be due to the fact that current guidelines suggest that patients with SAH are managed trying to keep them awake as much as possible to early detected a possible clinical deterioration (i.e., vasospasm) through assessment of sequential neurological examinations during ICU stay. This may impact on earlier extubation and reduced days of mechanical ventilation, thus decreasing the risk of developing VAP [ 25 – 27 ]. In our cohort, we observed that only 3% of patients with ischemic stroke developed VAP, which is lower than reported in previous studies (4–57%) [ 28 ].…”

Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage

“…The mortality rates of our patients on days 30 th and 90 th after ictus were also lower than rates reported in previous studies (22–25% and 25–29%, respectively) [ 38 , 39 ]. These findings might be due to several advances in the past decades in the medical diagnosis and care of patients with aneurysmal SAH, including medical advances, new systems of standardized care in neurocritical care units, and new surgical and endovascular techniques for aneurysmal SAH [ 4 , 40 ]. Additionally, as unique to patients with aneurysmal SAH in Vietnam, many are not transferred to a central hospital and are relegated to death in the local hospitals as well as dying outside of the hospital [ 41 ].…”