Mechanical Ventilation, Sedation and Neuromonitoring of Patients with Aneurysmal Subarachnoid Hemorrhage in Germany: Results of a Nationwide Survey

Abstract

Objective: Current evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) focus primarily on timing, modality and technique of aneurysm occlusion, and on prevention and treatment of delayed cerebral ischemia. Significant aspects of management in the intensive care unit (ICU) during the later course of aSAH such as ventilation and sedation (VST) remain unaddressed. aSAH patients present unique challenges not accounted for in general ICU recommendations and guidelines, which is why we attempted to further characterize ICU practices in aSAH patients in Germany. Methods: We conducted a nationwide survey on ICU practices in aSAH in Germany. Secondarily, we assessed the existence of and compliance with current guidelines regarding ICU practices. The questionnaire was designed in interdisciplinary fashion and distributed online through the kwiksurvey ® platform (Bristol, UK). Results: A total of 50 responses were received, accounting for a response rate of 49%. Twenty-one were university hospitals (UH), 23 high-volume centers (HVC), 6 low-volume centers (LVC). Half of the participating centers do not take into consideration WFNS at presentation to indicate ventilation. While 42% of centers rely on the P/F ratio to indicate ventilation, 62% of them have a cutoff value of < 200, and 38% of < 100. While most UH and HVC used propofol for the first phase of sedation (95%), LVC employed benzodiazepines (100%). Sedation deepening was done with ketamine in UH (75%) and HVC (60%), whereas LVC used predominantly clonidine (100%). Conclusions: Our study clearly demonstrates that attitudes and practices pertaining to ICU management in aSAH are enormously heterogeneous, reflecting the lack of good quality evidence and differing interpretations thereof.

COVID-19 and cerebrovascular diseases: a comprehensive overview

“…However, data to date have suggested that patients with ICH and COVID-19 present with lower systolic blood pressure, relative to spontaneous ICH. 14 Furthermore, ACE2 dysregulation may also contribute to the post-ischemic inflammation cascade through the accumulation of angiotensin 2, resulting in decreased perfusion in the ischemic zone and the development of larger infarct volumes. 15,16 The impaired endothelial function in cerebral arteries caused by ACE2 inactivation has also been implicated in the pathogenesis of cerebrovascular events, including both ischemic and hemorrhagic stroke.…”

“…Cerebral hemorrhage. Several case reports and cohort studies have recently been published presenting COVID-19 patients with parenchymal hemorrhage, 58,59,[79][80][81][82][83][84][85] subarachnoid hemorrhage, 14,58,59,86 and subdural hematoma. 59 A retrospective case series of five patients showed that COVID-19 patients with ICH were younger than expected and mostly suffered from lobar ICH.…”

COVID-19-Associated Stroke

“…The authors found that the relative risk of stroke in the group of patients with COVID-19 was 8.1 (95% CI 2.5-26.6), as compared with 4.6 (95% CI 1.4-15.7) in the reference group [5]. This study is of great interest, as the authors took into account the infl uence of infection COVID-19 show lower values for systolic BP than patients without COVID-19 [17], which requires further investigation. Impairment to the operation of ACER2 receptors promotes triggering of the postischemic infl ammatory cascade due to accumulation of angiotensin 2, which has nothing to bind to, which in turn exacerbates hypoperfusion in the cerebral ischemia zone and promotes expansion of the volume of cerebral infarct [18].…”

Neurocritical care complications and interventions influence the outcome in aneurysmal subarachnoid hemorrhage

“…There are lacking standards regarding ventilation-, monitoring- and sedation-management after aneurysmal SAH, which are also assumed to have effects on the outcome [ 45 ]. With the help of a questionnaire ICU practices in aneurysmal SAH in Germany were evaluated and compared to guidelines, if existing.…”

“…In this study, ICU management after aneurysmal SAH was found to be very heterogeneous. This leads to the conclusion, that evidence in this area of SAH-management is insufficient [ 45 ]. There is a necessity to define optimal requirements and guidelines of ICU management after SAH, particularly management of ventilation, timing of tracheostomy, sedation and intracranial pressure (ICP) / cerebral metabolism monitoring.…”