ࡱ> a bjbjzz .P\P\^r r :::NNN8<Nvl\\\j>+k+k+k+k+k+k$^nqfOk:::"Ok0l3'3'3'8j3'j3'3'` ")f T-~# b:jFl0vlGbzqI$zqt)fzq:)f\>,3'$\\\OkOk%T\\\vlzq\\\\\\\\\r > : Policy #: Issued: Reviewed: January 2017Revised:January 2017Section:  Aneurysmal Subarachnoid Hemorrhage Management Guidelines Purpose: To provide guidance in the management of the Aneurysmal Subarachnoid Hemorrhage patient Application: For all potential Aneurysmal Subarachnoid Hemorrhage patients presenting at Boston Medical Center Exceptions: None Disclaimer This document is meant to serve as a guide for the care of patients with aneurysmal subarachnoid hemorrhage (SAH) and not as a substitute for clinical judgment at the level of the individual patient. It is recognized that not all suggestions contained in this document will be appropriate for all patients. This document was created as a collaborative effort between the Neurointerventional Service, Neurosurgery, Vascular Neurology, and Neurocritical Care. It has been reviewed and approved by all of these groups as of January 2017. Alert Appropriate Services Neurology Resident pages Stroke Fellow (#1620), Neurointerventional Service (#COIL/2645), Neurosurgery (#7000 on HARRISON AVENUE CAMPUS) immediately Stroke Fellow pages Neurocritical Care attending on-call (#7999) Initial Diagnostic Evaluation Imaging CT head, non-contrast (If non-diagnostic, should be followed by LP) CT angiogram of head and/or conventional angiogram at discretion of Neurointerventionalist and Neurosurgeon Digital substraction angiography (DSA) is recommended to delineate the anatomy of the aneurysm and determine patient candidacy for coiling vs clipping. This is preferentially done on Menino (direct transfer from the Menino ER to Menino angio suite). Chest X-ray EKG Labs: Chem7, Mg, CBC, INR, PTT, troponin, ABG (for patients with evidence of respiratory compromise and/or diminished level of arousal) Acute Resuscitation and Stabilization Airway, Breathing Provide supplemental oxygen to keep SpO2>95% (PaO2>80mmHg if ABG has been done) Intubate for inadequate airway protection, hypoventilation, or refractory hypoxemia Circulation Keep SBP<140mmHg Initiate treatment of hypertension with intermittent doses of labetalol (10mg IV Q5-10 minutes; increase dose to 20 and then 40mg IV Q15minutes as needed; hold for HR<65) or hydralazine (10mg IV Q20 minutes; increase dose to 20mg IV Q20 minutes as needed). If the above is inadequate or if >3 prn doses are required per hour, change to nicardipine IV continuous infusion. Start at 5mg/hour and titrate up to a maximum dose of 15mg/hour. Nicardipine is the preferred agent as it provides smoother blood pressure control than labetalol or sodium nitroprusside and does not increase intracranial pressure like sodium nitroprusside. If hypotensive (i.e. MAP<60 mmHg; a rare occurrence) place central venous line place arterial line volume resuscitate with normal saline use norepinephrine or phenylephrine as needed to maintain MAP 65-80 mmHg Consider early use of inotropic agents (milrinone or dobutamine) if acute neurogenic cardiac failure is suspected. Poor response to fluids and pressors Diffuse ST-segment and T-wave changes on EKG Emergent transthoracic echocardiogram (TTE) showing global hypokinesis of the left ventricle with EFd"35% Neurologic: The initial clinical severity of aSAH should be determined rapidly by use of Hunt and Hess.. Early external ventricular drain (EVD) placement by neurosurgery Consider for Hunt and Hess grade IV and V patients. Consider for any patient with any depression in level of arousal or hydrocephalus on CT Treat seizures if they have occurred Ativan 2-4 mg IV STAT prn seizure Phenytoin Load: fosphenytoin 15-20mg/kg IV x 1 Maintenance: phenytoin 100mg IV Q8h; check trough level after 5th dose OR Levetiracetam Load: 1-2g IV x 1 Maintenance: 500-1000mg IV q12h Attending Neurointerventionalist (Dr. Nguyen) and Attending Neurosurgeon (Dr. Cronk or Dr. Holsapple) discuss coiling vs clipping of the aneurysm and provide recommendation to the patient and/or their family. Microsurgical clipping may receive increased consideration in pts presenting with large intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling may receive increase consideration in the elderly (>70 years of age), in those presenting with poor grade aSAH (WFNS IV/V), and in those with aneurysms of the basilar apex. Stenting of a ruptured aneurysm is associated with increased morbidity and mortality and should only be considered when less risky options have been excluded. Re-rupture prophylaxis for patients with planned delayed aneurysm treatment Factors associated with aneurysm rebleeding include; longer time to aneurysm treatment, worse neurological status on admission, initial loss of consciousness, previous sentinel headaches (severe headaches lasting >1 hr that do not lead to the diagnosis of aSAH), larger aneurysm size and possibly systolic blood pressure >160 mmHg. Consider antifibrinolytics Tranexamic acid 1g IV loading dose followed by 1g IV q6h beginning 2h after the loading dose or aminocaproic acid can be used. If antifibrinolytics are used, they should be started at admission and continued until 72 hours or aneurysm is secured, whichever is shorter. Stop medication 2 hours pre-procedure. Patients treated with antifibrinolytic therapy should have close screening for deep venous thrombosis Contraindications Ischemic EKG changes Elevated troponin levels Signs or symptoms of DVT, PE, or other thromboembolic disease History of coronary artery disease, DVT, PE, or other thromboembolic disease MUST discuss with the attending physician who will be securing the aneurysm before using Discontinue once aneurysm has been secured or after 48h, whichever occurs first. After aneurysm repair, cerebrovascular imaging with catheter angiogram should be performed to identify remnants or recurrence of the aneurysm that may require treatment IV fluids: Normal saline at 1-1.5cc/kg/ Admit Attending Coiled patient: Dr. Nguyen or Neurocritical Care Attending Clipped patient: Dr. Cronk or Dr. Holsapple Non-aneurysmal or untreated SAH: Neurocritical Care Location: Harrison Avenue Campus, SICU if plan for coil on Menino. Once stable, patient may transfer to 3West East Newton Campus, SICU. East Newton Campus SICU if plan for clip If unsure whether the patient will be coiled vs clipped, default location is Harrison Avenue Campus, SICU under Neurocritical Care Attending. Co-managing team: i. Surgical/Anesthesia critical care Initial Plan by Systems Neurologic Activity Pre-securing Bed rest with HOB e" 30 degrees EVD Typically open at 15 cmH2O Hooked up to collection system and ICP monitor Please instruct nurse to check and chart ICP from EVD Q1h ICP is typically measured after EVD has been clamped for 2 minutes Call ICU and neurology residents for ICP>20 mmHg or CPP<60 mmHg Q1h nursing neuro checks; call ICU and neurology residents for any changes Neuroprotection Oral Nimodipine should be administered to all patients with aSAH from day of admission through hospital day 21. Nimodipine 60mg PO Q4h, hold for SBP<100 If SBP <120, may give as 30mg PO Q2h. If hypotension persists, nimodipine may be discontinued and needs to be documented in the chart Statins Continue for all patients taking one as an outpatient Vasospasm surveillance Baseline transcranial Doppler (TCD) exam should be performed by the end of the third hospital day Thereafter, obtain TCDs daily in a.m. or as determined by NCC staff Thresholds of mean blood flow velocities <120 cm/s for absence and>200 cm/s and/or MCA/ICA ratio>6 for presence are reasonable. Digital subtraction angiography (DSA) is the gold standard for detection of vasospasm. Seizures Prophylaxis: The use of prophylactic anticonvulsants may be considered prior to securing of aneurysm. If anticonvulsant prophylaxis is used, a short course (3-7 days) is recommended. Long-term seizure prophylaxis for patients without evidence of seizure is not recommended and has been associated with worsened cognitive outcomes. Continuous EEG monitoring should be considered in patients with poor-grade SAH who fail to improve or who have neurological deterioration of undetermined etiology. Treatment: Ativan 2-4mg IV STAT prn seizure and call neurology and ICU resident Phenytoin Load: fosphenytoin 15-20mg/kg IV x 1 Maintenance: phenytoin 100mg IV Q8h; check trough level after 5th dose OR Levetiracetam Load: 1-2g IV x 1 Maintenance: 500-1000mg IV q12h Analgesia avoid higher tier drugs in drowsy patients Tier 1: Acetaminophen 650-1000mg PO/PR Q6h prn headache Tier 2: Acetaminophen 1000mg PO/PR Q6h prn headache AND either tramadol 25-50mg PO Q4h prn headache > 4/10 OR codeine 30-60mg PO Q4h prn headache > 4/10 Tier 3: Acetaminophen 1000mg PO/PR Q6h prn headache AND either oxycodone OR hydrocodone 5mg PO Q6h prn headache > 4/10 Tier 4: Fentanyl 12.5-25mcg IV Q30min-2h OR Dilaudid 0.2-0.4mg IV Q3-4h prn pain > 4/10 OR Morphine 2-4mg IV Q1h prn Temperature control Acetaminophen 650-1000mg PO Q6h; hold for temp<100 (total acetaminophen dose must not exceed 4g in 24h) In select cases, Arctic Sun cooling may be used per Neurocritical Care (NCC) attending Cardiovascular Arterial line for continuous BP monitoring should be considered in the following patient groups Intubated patients Patients receiving a continuous infusion of an antihypertensive agent Patients with hemodynamic instability Patients with active vasospasm Pre-securing: keep SBP<140mmHg to decrease the likelihood of re-bleeding Initiate treatment of hypertension with intermittent doses of labetalol (10mg IV Q15minutes; increase dose to 20 and then 40mg IV Q15minutes as needed; hold for HR<65) or hydralazine (5-10mg IV Q20 minutes; increase dose to 15-20mg IV Q20 minutes as needed). If the above is inadequate or if >2 prn doses are required per hour, change to nicardipine IV continuous infusion. Start at 5mg/hour and titrate up to a maximum dose of 15mg/hour. Outpatient antihypertensives Stop all in hypotensive patients For normo- or hypertensive patients Continue beta-blocker at 50% of outpatient dose Stop all other antihypertensives If hypotension occurs, consider central venous line placement and evaluate for sepsis, MI, neurogenic cardiac failure, and PE with appropriate imaging, cultures, EKG, TTE, and cardiac enzymes Serial serum troponin I measurement Q8h x 3 or until a peak value is identified Obtain a baseline TTE on hospital days 1-3 for patients with any of the following risks for vasospasm Elevated mean arterial pressure on hospital admission (>110mmHg) Poor Hunt-Hess grade (e"3) Modified Fisher grade e"2 Respiratory Oxygenation goals: SpO2>95% (PaO2>80mmHg for patients monitored with ABGs) Ventilation goal: PaCO2 37-42 mmHg Place arterial line and check ABGs on all mechanically ventilated patients Intubate for inadequate airway protection, hypoventilation, or refractory hypoxemia Initial ventilator settings will vary, but in uncomplicated situations should begin with AC or SIMV mode with a TV of 7-8cc/kg ideal body weight, rate 8-10 per minute, FiO2 40%, pressure support of 5-10cmH2O and PEEP of 5cmH2O Renal Consider placing a Foley/condom catheter or Purewick (female incontinence device) for optimal recording of urine output This is especially important for patients with Hunt & Hess grade e"3, patients with significant disorders of sodium and/or volume homeostasis, and patients in whom accurate urine outputs cannot be recorded using other methods Not needed in Hunt & Hess grades 1 and 2 patients who are cooperative with urinating in a urinal or bedpan for measurement Evaluate the need for the catheter daily and remove once no longer necessary to decrease risk of UTI Keep patient euvolemic; avoid hypovolemia. Intravascular volume status is best determined by vigilant fluid management. IV fluids: normal saline at 1-1.5cc/kg/h, then adjust for the following goals Keep 24h I/O 500-1000cc positive on days 1 and 2. Thereafter, keep I/O even. Keep CVP (when available) 8-10 mmHg Adjust fluid administration as needed according to patient-specific co-morbidities such as CHF, neurogenic pulmonary edema, ARDS, renal failure Maintenance fluids with normal saline. The addition of 20mEq/L of KCl can be considered DO NOT give any of the following hypotonic maintenance fluids D5W NS or D5 NS 1/2NS or D5 1/2NS Check electrolytes (including Mg), BUN, Cr daily Watch carefully for sodium abnormalities, hyponatremia is associated with the onset of sonographic and clinical vasospasm. In addition to abnormal absolute values, changes in serum sodium concentration of e"5mEq/L/24h should prompt STAT re-checking of the serum sodium level and attending physician notification Hyponatremia (Na <135 mEq/L or rapidly falling Na) SIADH (euvolemic, normal urine output) Restrict PO/NGT intake of free water If patient is eating and drinking, write the following order: No free water by mouth. All PO fluid intake must be in the form of V8 or double-concentrated Gatorade mixed from powder If the patient is receiving tube feeds, give only the minimum flushes that are needed to keep the tube patent in the form of normal saline (instead of water) and change solution to Nutren 2.0 3% saline (if Na <130 mEq/L) Rate dependent upon degree of hyponatremia and volume status Must be given through central line or PICC Consider NaCl 1g tabs; 1-2 tabs PO/NGT BID-QID Demeclocycline 300-600mg PO/NGT BID (monitor renal function carefully) Cerebral salt wasting (euvolemic or hypovolemic; moderate-high urine output) fludrocortisone 0.1-0.2mg PO/NGT BID Normal saline to match urine output If serum sodium < 130mEq/L, use 3% saline Rate dependent upon degree of hyponatremia and volume status Must be given through central line or PICC Hypernatremia Central diabetes insipidus (high urine output; inappropriately dilute urine) If urine output is >300cc/h for two or more consecutive hours, check urine osmolality (Uosm), urine specific gravity (Uspec grav), and serum sodium If Uosm d"200mosmol/kg or Uspec grav < 1.005 and serum sodium is rising, diagnosis = CDI Treatment Replace estimated volume deficit (often multiple liters) with normal saline boluses Replace ongoing volume loss with IV normal saline 1cc:1cc of urine output DDAVP 2-4mcg IV x 1 If not CDI and patient is asymptomatic, do not treat unless sodium is >155mEq/L. Then treat very conservatively to prevent a further rise in rather than to actively reduce the serum sodium Follow serum sodium levels at least Q6h when an abnormal serum sodium level is detected. Hypomagnesemia should be avoided, but also inducing hypermagnesemia is not recommended. Replace magnesium daily with IV magnesium sulfate for goal serum level >2 Gastrointestinal Nutrition Pre-securing NPO except medications Avoid NGT placement Nausea Tier 1: Ondansetron 4mg IV Q8h Tier 2: Ondansetron 4mg IV Q6h Tier 3: Add and stagger with ondansetron: Metoclopromide 10mg IV Q8h or Q6h OR Proclorperazine 5-10mg IV Q6h Hematologic Serial CBC while in ICU (measures should be taken to minimize blood loss from blood drawing) Consider PRBC transfusion for Hgb<8g/dL (higher hemoglobin concentrations may be appropriate for patients at risk for DCI) Infectious disease Aggressive control of fever to a target of normothermia by use of standard or advanced temperature modulating systems is reasonable in the acute phase of aSAH. Evaluate for infection when temp > 101 Common infections: pneumonia (aspiration, VAP), UTI, EVD-associated ventriculitis, central line-associated bacteremia Chest X-ray; sputum GS, cx, sensitivities; UA, cx, sensitivities; Blood cx If EVD has been in place for e"72h, send CSF from drain for cell count with differential, glucose, Gram stain, cx, Fever can be non-infectious due to the presence of subarachnoid and/or intraventricular blood, but this may only be assumed when all possible causes of infection have been conclusively excluded. This usually requires multiple sets of cultures Work-up for noninfectious causes of fever with 4 limb Doppler ultrasound should be performed. Endocrine: Goal blood glucose between 120 and 180mg/dL Hypoglycemia (serum glucose<80 mg/dl) should be avoided. If serum glucose is <150 on admission POC glucose check Q6h Sliding scale regular insulin Change to IV insulin infusion if sliding scale does not consistently keep glucose in 120-180mg/dL range If e"150 on admission IV insulin infusion titrated to maintain glucose 120-180mg/dL If <60 at any time, give 1 amp of D50 and call ICU HO ICU Prophylaxis Peptic ulcer prophylaxis for all patients who are on mechanical ventilation, vasopressors, or are not receiving enteral nutrition Pantoprazole 40mg PO/IV Qday OR Famotidine 20mg PO/IV BID (H2 antagonists can rarely cause drowsiness, confusion, and delirium) Constipation prophylaxis Colace 100mg PO BID Senna 2 tabs PO QHS prn no BM for 24h Dulcolax 10mg PR prn no BM for 48h Thromboprophylaxis If pharmacologic prophylaxis is contraindicated, document reason in the chart. Pre-securing Lower extremity sequential compression immediately upon admission. The use of LMWH or unfractioned heparin for prophylaxis should be withheld in patients with unprotected aneurysms and expected to undergo surgery. Unfractionated heparin or LWMH should be used 24 hours after securing of an aneurysm. Changes after aneurysm is secured (clipped or coiled) Neurologic Activity Early mobilization is the goal, discuss level of activity with attending. Nursing neurologic checks (while in ICU) Q1h for the duration of ICU admission for clipped patients Q1h for the first 72h of admission for coiled patients After 72h Continue Q1h neuro checks for patients with abnormal neurologic exams Consider lengthening intervals at night for patients with a consistently normal neurologic exam and low risk for vasospasm: Q1h while awake and Q2-4h while asleep Check with attending before lengthening neuro check intervals Call ICU and neurology residents for any changes Seizure treatment/prophylaxis Discontinue seizure prophylaxis in all patients who have been secured and who have not had seizures Continue AED treatment in those patients who have had a seizure CVEEG monitoring should be employed in all patients with transient events suspicious for seizure. Cardiovascular Treat only very severe hypertension. Treating lesser degrees of hypertension might increase the risk of delayed ischemic deficits. Discontinue all pre-securing antihypertensives (including prn orders) with the exception of outpatient beta-blockers, which should be further decreased to 25% of outpatient dose as tolerated by the heart rate Treat hypertension only If end-organ damage is occurring (angina, CHF, PRES, renal failure) OR If SBP is >180 mmHg for >2 consecutive hours In this case, discuss with stroke fellow/NCC staff before treating Goal of treatment is to bring BP to a level just below that at which end organ damage is occurring or is at high risk to occur Gastrointestinal Swallow evaluation Bedside swallow evaluation by neurology housestaff or nursing MUST be completed and documented prior to ANY PO intake (including medications or medications crushed in applesauce/pudding) in ALL patients Those who pass and who have a normal level of arousal, normal articulation, normal language function, and no facial weakness may be started on an oral diet Those who fail must not be given ANY PO intake, including medications Formal swallow evaluation for all patients with depressed level of arousal, dysarthria, facial weakness, or dysphagia on bedside testing MUST be completed. NGT should be placed in all patients who cannot be fed orally Nutrition Patients who are eating should be fed a normal diet. Low salt diets should not be ordered (to avoid exacerbation of hyponatremia) unless there is a clear indication (i.e. severe CHF or liver disease) Early enteral nutrition by NGT (within 72h of admission) should be strongly considered in patients who cannot eat. Prophylaxis Heparin 5000U SC Q8h once aneurysm is secured Begin 12h after coiling or clipping unless otherwise indicated by the neurointerventionalist / operating neurosurgeon Incentive spirometry Q1h for cooperative, non-intubated patients Rehabilitation Physical and occupational therapy consult 24-96h after aneurysm is secured, depending upon the patients condition. After discharge, it is reasonable to refer patients with aSAH for a comprehensive evaluation including cognitive, behavioral, and psychosocial assessments. Management of Vasospasm/Delayed Cerebral Ischemia (DCI) Patients are at highest risk for vasospasm between days 7 10 following aneurysm rupture. Vasospasm risk seems to resolve after 21 days post-rupture. The Modified Fisher Score at admission is helpful in determining the risk of developing clinical vasospasm and delayed cerebral ischemia. ii. As above, pt. at high risk for developing vasospasm are closely monitoring in the ICU with q1h neuro checks. TCDs should be employed by day 3 and daily afterwards to assist with identification of patients at risk for vasospasm. If clinical neurologic changes are suggestive of DCI and screening (via TCDs) shows vasospasm, medical therapy should be started. If uncertainty exists, consideration should be given for CTA vs. conventional angiography. iii. First line medical therapy aims at improving cerebral perfusion to an at risk vascular territory: Volume fluid boluses should be given to raise BP into target range, mindful that the aim is to keep pt. euvolemic and not hypervolemic. Pressure induced hypertension should be employed with goals to augment blood pressure in a stepwise fashion with close clinical assessment to identify a MAP threshold at which pt. symptoms improve. If a patient with DCI is unresponsive or under-responsive to medical therapy, or a contraindication exists to hypertensive therapy (i.e. ongoing cardiac ischemia) patients should be considered for endovascular therapy (cerebral angioplasty and/or selective intra-arterial vasodilator treatment). Neurointerventional team should be notified early. Outpatient Follow-up: All coiled patients require follow-up with Dr. Nguyen within 1-2 months post discharge. 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Responsibility: MD, RN, Radiologist, radiology tech, Lab, Pharmacy Forms: tPA consent, tPA information sheet, IR consent Other Related Policies: IA Stroke Protocol, References: Critical Care Management of Patients Following Aneursymal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Societys Multidisciplinary Consensus Conference. Neurocrit. Care 2011 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. AHA/ASA Guideline. Stroke 2012. McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, Albuquerque FC.The Barrow Ruptured Aneurysm Trial. J Neurosurg 2012;116(1):135-44. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005;366(9488):809-17. Molyneux A1, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. Liu-Deryke et al. A comparison of nicardipine and labetalol for acute hypertension management following stroke. Neurocrit Care 2008International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002 Oct 26;360(9342):1267-74. 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