Demonstrating the Value of Routine Anesthesiologist Involvement in Acute Stroke Care: A Retrospective Chart Review

Abstract

Introduction: The value of routine involvement of anesthesiologists during endovascular thrombectomy (EVT) for acute ischemic stroke has not been clearly demonstrated. At some institutions, anesthesiologists are involved only as needed, while at other institutions, anesthesiologists are involved from the beginning for every EVT. Methods: We retrospectively analyzed the workflow, intraprocedural variables and complications, and outcomes in acute ischemic stroke patients undergoing EVT at a comprehensive stroke center after implementation of routine involvement of an anesthesia team and compared this cohort with patients who received care from sedation-trained nurses working under the supervision of neurointerventionalists with the involvement of anesthesiologists on an as-needed basis. Results: Routine involvement of anesthesiologists was associated with improved workflow performance measures, including decreased median door-to-arterial puncture time (68 min; interquartile range (IQR), 15.5–94.5 min vs. 81 min; IQR, 53–104 min; P=0.001), in-room to arterial puncture time (11 min; IQR, 8–14 min vs. 15 min; IQR, 9–21 min; P<0.0001), and procedure time (51 min; IQR, 40–64 min vs. 60 min; IQR, 40–88.5 min; P=0.007). It was also associated with a nonsignificant trend towards lower rates of desaturation events (8.2% vs. 3.4%; P=0.082) and lower rates of conversion to general anesthesia (1.7% vs. 0%; P=0.160). Ninety-day modified Rankin scores were similar regardless of provider type. Conclusion: Implementation of routine involvement of an anesthesia team during EVT was not associated with improved outcomes but was associated with improved efficiency and greater adherence to guidelines-based physiological parameters, supporting the routine involvement of anesthesiologists during EVT.

Answering the Call: The Case for Anesthesiologist-led Care for All Stroke Thrombectomies

“…The first concern has been dispelled by multiple randomized trials, including 2 recent multi-center studies, which demonstrated that outcomes, when MT was performed with GA, were at least as good as those performed with conscious sedation (CS). 1,2 The second concern is addressed by McCusker et al 3 in this issue of the Journal of Neurosurgical Anesthesiology. The authors reported the results of their systematically planned transition from the involvement of anesthesia teams on an "as-needed" basis to routine anesthesia involvement during MT, which showed that routine involvement of anesthesiologists decreased variability and improved 2 key time metrics-in-room to arterial puncture times and procedure times (Fig.…”

“…More recent evidence has suggested that it may be associated with a reduced risk for unfavorable outcomes in patients undergoing surgical clipping compared with endovascular treatment of the ruptured aneurysm but with an increased frequency of adverse effects in patients who received dexamethasone compared with those who did not. 3 A potential role for corticosteroids in patients with traumatic brain injury ended with the publication of the CRASH trial in 2004. 4 This large, randomized controlled trial demonstrated a 3.15% increase in the absolute risk of mortality at 2 weeks in patients receiving methylprednisolone compared with placebo, leading the authors to conclude that corticosteroids should not be routinely used in traumatic brain injury.…”

“…* P <0.01 compared with times for sedation-trained nurses and anesthesia as and when needed. Adapted from McCusker et al 3 PRN, as and when needed . Adaptations are themselves works protected by copyright.…”

“…In a recent report of a standardized sedation protocol administered by neurointensivists, 12.5% of patients required emergency intubation, with a number needed to harm of 4 for both disability and death 6 . An anesthesiology team present from the beginning of MT is well-positioned to convert to GA promptly and safely if required. Improved efficiency and timeliness of care: While induction of GA inherently takes longer than the initiation of CS, the overall efficiency and timeliness can be improved when anesthesiologists are involved routinely during MT rather than sporadically, as shown by McCusker et al 3 Similar improvements also occurred at a British hospital with the transition to dedicated anesthesia involvement for all MTs 7 Consistent workflows and familiarity with stroke care: Routine involvement of anesthesiologists in MTs allows mobilization of anesthesia teams during patient evaluation and treatment decision-making, which enhances overall workflow and teamwork and reduces door-to-puncture times 8 .…”

“… Consistent workflows and familiarity with stroke care: Routine involvement of anesthesiologists in MTs allows mobilization of anesthesia teams during patient evaluation and treatment decision-making, which enhances overall workflow and teamwork and reduces door-to-puncture times 8 . Familiarity of anesthesia teams with acute stroke care also enhances their performance, as exemplified by the reduction in intraprocedural hypotension with routine anesthesiology involvement compared with the subgroup of patients who received anesthetic care on an as-needed basis in the study by McCusker et al 3 Optimization of hemodynamic management: Ischemic stroke patients frequently demonstrate periprocedural hemodynamic perturbations with both GA and CS, which are associated with neurological worsening. Randomized trials using anesthesia teams in both GA and CS arms demonstrated the feasibility of strict hemodynamic control in expert hands.…”