Republished: Society for Neuroscience in Anesthesiology and Critical Care Expert Consensus Statement: Anesthetic Management of Endovascular Treatment for Acute Ischemic Stroke*

Abstract

Abstract-Literature on the anesthetic management of endovascular treatment of acute ischemic stroke (AIS) is limited.Anesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Thus, the Society of Neuroscience in Anesthesiology and Critical Care (SNACC) created a task force to provide expert consensus recommendations on anesthetic management of endovascular treatment of AIS. The task force conducted a systematic literature review (up to August 2012). Because of the limited number of research articles relating to this subject, the task force solicited opinions from experts in this area. The task force created a draft consensus statement based on the available data. Classes of recommendations and levels of evidence were assigned to articles specifically addressing anesthetic management during endovascular treatment of stroke using the standard American Heart Association evidence rating scheme. The draft consensus statement was reviewed by the Task Force, SNACC Executive Committee and representatives of Society of NeuroInterventional Surgery (SNIS) and Neurocritical Care Society (NCS) reaching consensus on the final document. For this consensus statement the anesthetic management of endovascular treatment of AIS was subdivided into 12 topics. Each topic includes a summary of available data followed by recommendations. This consensus statement is intended for use by individuals involved in the care of patients with acute ischemic stroke, such as anesthesiologists, interventional neuroradiologists, neurologists, neurointensivists and neurosurgeons.

Clinical Impact of Ventilation Duration in Patients with Stroke Undergoing Interventional Treatment under General Anesthesia: The Shorter the Better?

“…However, data from the literature and a more elaborate interpretation of our results imply that ventilation duration may nevertheless have an impact on clinical outcome. 8,9,21,23 A more thorough insight into our data shows that the missing significance at early and late cutoffs may be partly attributed to the non-normal distribution of our data. In fact, 33 of 42 (78.6%) patients with favorable functional outcome were ventilated for Յ24 hours and only 3 of 42 (7.1%) patients with favorable clinical outcome were ventilated for Ͼ1 week.…”

“…Hence, our results support the hypothesis that shorter ventilation times are associated with lower pneumonia rates and a more favorable clinical outcome. [21][22][23] When we investigated the influence of ventilation times via various cutoffs, multivariate analyses indicated that longer ventilation times resulted in higher pneumonia rates, regardless of the time of cutoff (Online Table 2). However, multivariate analysis also indicated that longer ventilation times per se had no independent impact on unfavorable functional outcome (P Ն .075).…”

“…21,24 Thus, we always attempt to extubate patients immediately after the procedure to reduce the risk of pneumonia and to assess an early neurologic status. 23 However, sometimes extubation may be delayed due to medical (eg, dysphagia, low pharyngeal muscle tone, and impaired cooperation or level of consciousness; see the "Materials and Methods" section for further extubation criteria) or nonmedical reasons (eg, reduced staff capacities due to other medical emergencies). Therefore, we investigated whether delayed extubation (outside the angiography suite) was associated with a higher pneumonia rate and a less favorable clinical outcome.…”

Anesthetic Care for Acute Ischemic Stroke: Facts and Aspirations

“…In addition to hemodynamic and time delay issues, there are other compelling reasons why MAC might be preferred over GA. For one, neuro-interventionalists and anesthesiologists would be able to monitor neurological status throughout the procedure, potentially allowing them to more quickly detect complications such as hemorrhage or allowing the procedure to be terminated after neurologic improvement rather than angiographic recanalization. Secondly, MAC avoids hazards associated with intubation and mechanical ventilation, including the placement of a patient on a socalled 'critical care treatment pathway' (22). Finally, MAC typically involves low-dose propofol or other intravenous anesthetic infusions.…”

“…GA remains preferable in patients who cannot protect their airway and MAC is preferable in patients who can protect their airway and are cooperative (class IIa, level B evidence) (22). If GA is chosen for all patients at a given institution based on the preference of the neuro-interventionalists, the patients should be extubated as soon as possible following the procedure.…”