Neurocritical care
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Review Practice Guideline
Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference.
Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. ⋯ Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.
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Hyponatremia is the most common electrolyte imbalance seen in patients with aneurysmal subarachnoid hemorrhage, occurring in one-third to one-half of patients. Hyponatremia may be caused by cerebral salt wasting and by the syndrome of inappropriate secretion of antidiuretic hormone or a combination of both. Limited data are available describing hyponatremia treatment in subarachnoid hemorrhage patients. ⋯ Seven appropriate articles were identified as followed: three testing fludrocortisone, two hydrocortisone, and one each for hypertonic saline and 5% albumin. Data quality for treatment efficacy and safety were moderate for corticosteroid studies and low or very low for hypertonic saline and 5% albumin. Available data, although limited, support early treatment with corticosteroids to limit hyponatremia, with fludrocortisone causing fewer side effects.
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An electronic literature search through August 2010 was performed to obtain articles describing fever incidence, impact, and treatment in patients with subarachnoid hemorrhage. A total of 24 original research studies evaluating fever in SAH were identified, with studies evaluating fever and outcome, temperature control strategies, and shivering. Fever during acute hospitalization for subarachnoid hemorrhage was consistently linked with worsened outcome and increased mortality. Antipyretic medications, surface cooling, and intravascular cooling may all reduce temperatures in patients with subarachnoid hemorrhage; however, benefits from cooling may be offset by negative consequences from shivering.
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Disruption of the hypothalamic-pituitary-adrenal axes may occur after aneurysmal subarachnoid hemorrhage, resulting in hypopituitarism. An electronic literature search was conducted to identify articles with English-language abstracts published between 1980 and March 2011, which addressed hypothalamic-pituitary-adrenal axis insufficiency and hormone replacement. A total of 18 observational and prospective, randomized studies were selected for this review. ⋯ Overall, after acute subarachnoid hemorrhage, cortisol levels may initially be supranormal, decreasing toward normal levels over time. During the months to years after subarachnoid hemorrhage, pituitary deficiency may occur in one out of three patients. Limited data suggest modest outcome benefits with fludrocortisone and no benefit or harm from corticosteroids.
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Several non-invasive and invasive modalities have been used to monitor patients for cerebral ischemia after subarachnoid hemorrhage. A literature search was performed to identify original research studies testing monitors that may be used in addition to the standard measures of brain function and cerebral blood flow. Fifty observational studies were identified that evaluated the role of electroencephalography, brain tissue oxygenation monitoring, cerebral microdialysis, thermal diffusion flowmetry, or near-infrared spectroscopy in patients after subarachnoid hemorrhage.