Unaccounted for enteral volume loss linked to delayed cerebral ischemia after subarachnoid hemorrhage

Abstract

OBJECTIVE Delayed ischemic neurological deficit (DIND) is seen as a clinical manifestation of cerebral vasospasm and is a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Currently, the standard of care for DIND prevention in patients who have sustained aSAH is prophylactic nimodipine therapy and ensuring adequate fluid intake, alongside other treatments such as bowel care. Osmotic laxatives trap water within the bowel lumen to accelerate the transport of the gut contents through the bowel. Given the potential for DIND secondary to cerebral vasospasm, it is perhaps counterintuitive that gastrointestinal fluid loss and use of osmotic laxatives are not commonly considered in many aSAH management protocols. METHODS A retrospective case note analysis was performed for all adult patients (aged > 16 years) admitted to the Department of Neurosurgery at Leeds General Infirmary with a diagnosis of aSAH between August 2019 and September 2020. RESULTS A total of 105 patients were included, 62% of whom were female, with a mean and median age of 54 years (range 24–84 years). Diarrhea was noted in 12 patients (11.4%), 58% of whom subsequently developed DIND (OR 15.30, CI 3.92–59.14; p = 0.0001). All patients received osmotic laxatives (97% having received ≥ 2 laxative agents). CONCLUSIONS Patients with aSAH who subsequently developed diarrhea had significantly increased odds of developing DIND. Enteral volume loss due to osmotic laxative use is a potential risk factor for DIND after aSAH.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

“…In patients with aSAH, maintaining euvolemia can be beneficial in preventing DCI and improving functional outcomes. 320,321 2b B-NR 3. In patients with aSAH and symptomatic vasospasm, elevating systolic BP values may be reasonable to reduce the progression and severity of DCI.…”

“…Maintenance of euvolemia can be effective to prevent DCI and improve functional outcomes after SAH. 356 Gelder and colleagues 321 found that 58% of patients with documented volume depletion developed DCI. Hypervolemia is associated with worse outcomes and higher rates of complications (see Section 8).…”

Guidelines in Action: Volume and Blood Pressure Management After Aneurysmal Subarachnoid Hemorrhage

“…In support of this, in 1 study, including 105 patients with aSAH, investigators found that among patients who developed diarrhea, all of whom had received osmotic laxatives, 58% of patients developed delayed ischemic neurological deficits, compared with 8.6% of patients without diarrhea (odds ratio, 15.30 [95% CI, 3.92-59.14]; P=0.0001). 2 (1) Avoid prophylactic hemodynamic augmentation Consistent with previous guidelines, the 2023 AHA/ ASA aSAH guidelines recommend against the induction of hypervolemia and hypertension to prevent vasospasm and DCI. The guidelines state that induction of hypervolemia is potentially harmful because of the association with excess morbidity (class of recommendation (COR) 3: harm [strong], level of evidence B: randomized) and that prophylactic hemodynamic augmentation should not be performed to reduce iatrogenic patient harm (COR 3: harm [strong], level of evidence B: randomized).…”

“…DCI occurs in ≈30% of patients with aSAH and it is one of the leading causes of functional deficits and mortality after aSAH. [1][2][3][4][5][6][7][8][9] Hypovolemia and intravascular depletion are thought to be risk factors for the development of symptomatic vasospasm and DCI. In support of this, in 1 study, including 105 patients with aSAH, investigators found that among patients who developed diarrhea, all of whom had received osmotic laxatives, 58% of patients developed delayed ischemic neurological deficits, compared with 8.6% of patients without diarrhea (odds ratio, 15.30 [95% CI, 3.92-59.14]; P=0.0001).…”

“…In support of this, in 1 study, including 105 patients with aSAH, investigators found that among patients who developed diarrhea, all of whom had received osmotic laxatives, 58% of patients developed delayed ischemic neurological deficits, compared with 8.6% of patients without diarrhea (odds ratio, 15.30 [95% CI, 3.92–59.14]; P =0.0001). 2…”