Download PDF
CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2021; 08(02): 99-105
DOI: 10.1055/s-0040-1718504
Original Article

Protocol Adherence in the Intensive Care Unit for the Management of Adult Patients Admitted with Acute Aneurysmal Subarachnoid Hemorrhage

Lily Taylor
1   Department of Internal Medicine, Orange Health Service, Orange NSW, Australia
,
Andrew S. Lane
2   Sydney Medical School, University of Sydney, Australia
3   Discipline of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Background There are recognized protocols that exist for management with minimal data regarding protocol adherence. We conducted a retrospective analysis of aneurysmal subarachnoid hemorrhage (aSAH) to determine whether the level of protocol adherence varied based on patient demographics or specific aspects of management.

Materials and Methods All cases of aSAH admitted to a tertiary-level intensive care unit (ICU) from 2014 to 2016 were identified from the Australia and New Zealand Intensive Care Society Core Database as well as the clinical records system. ICU demographic and descriptive data for protocol adherence, were collected from admission to discharge up to 22 days, or until death whichever was earlier.

Results A total of 58 cases of aSAH were registered; mean age was 56.7 years, 70.7% of patients were female, and mean length of stay was 12.6 days. World Federation of Neurosurgical Societies (WFNS) scale was documented more than Fisher grading. Of the 58 cases, 63.7% (37) underwent surgical clipping, with 83.7% (30) patients having this surgery within 48 hours. SBP/MAP were the most consistently recorded observations within protocol ranges, with adherence of 82.4% and 82.1%, respectively. Thirty-two percent of temperature measurements were outside of the normothermic range of 36.5 to 37.5°C with a mean adherence of 47.5% (standard deviation = ±0.24, median = 40). There was no correlation between adherence and patient, disease, or admission factors.

Conclusion This study demonstrated that there was no association between variation in protocol adherence based on age, admission dates, or disease factors including WFNS grade and Fisher scale. Best protocol adherence protocol for the management of aSAH within the ICU was blood pressure control. Areas for improvement were documentation of the WFNS and Fisher grading, and temperature measurement and management.

Keywords

acute aneurysmal subarachnoid hemorrhage - blood pressure control - protocol adherence


Publication History

Article published online:
25 May 2021

© 2020. Indian Society of Neuroanaesthesiology and Critical Care. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Udy AA, Vladic C, Saxby ER. et al. Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation. Subarachnoid hemorrhage patients admitted to intensive care in Australia and New Zealand: a multicenter cohort analysis of in-hospital mortality over 15 years. Crit Care Med 2017; 45 (02) e138-e145
    CrossrefPubMedGoogle Scholar
  • 2 Rivero Rodríguez D, Scherle Matamoros C, Cúe LF, Miranda Hernández JL, Pernas Sánchez Y, Pérez Nellar J. Predictor’s of mortality in patients with aneurysmal subarachnoid haemorrhage and rebleding. Neurol Res Int 2015; 2015: 545407
    PubMedGoogle Scholar
  • 3 Zacharia BE, Hickman ZL, Grobelny BT. et al. Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21 (02) 221-233
    CrossrefPubMedGoogle Scholar
  • 4 van J Gijn, Rinkel GJE. Subarachnoid haemorrhage: diagnosis, causes and management. Brain 2001; 124 (Pt 2) 249-278
    CrossrefPubMedGoogle Scholar
  • 5 Cesarini KG, Hårdemark HG, Persson L. Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period. J Neurosurg 1999; 90 (04) 664-672
    CrossrefPubMedGoogle Scholar
  • 6 Lantigua H, Ortega-Gutierrez S, Schmidt JM. et al. Subarachnoid hemorrhage: who dies, and why?. Crit Care 2015; 19 (01) 309-309
    CrossrefPubMedGoogle Scholar
  • 7 Naidech AM, Janjua N, Kreiter KT. et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol 2005; 62 (03) 410-416
    CrossrefPubMedGoogle Scholar
  • 8 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. et al. American Heart Association Stroke Council,, Council on Cardiovascular Radiology and Intervention,, Council on Cardiovascular Nursing,, Council on Cardiovascular Surgery and Anesthesia,, Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43 (06) 1711-1737
    CrossrefPubMedGoogle Scholar
  • 9 Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European Stroke Organization. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013; 35 (02) 93-112
    CrossrefPubMedGoogle Scholar
  • 10 Dewan MC, Mocco J. Current practice regarding seizure prophylaxis in aneurysmal subarachnoid hemorrhage across academic centers. J Neurointerv Surg 2015; 7 (02) 146-149
    CrossrefPubMedGoogle Scholar
  • 11 Rhoney DH, Tipps LB, Murry KR, Basham MC, Michael DB, Coplin WM. Anticonvulsant prophylaxis and timing of seizures after aneurysmal subarachnoid hemorrhage. Neurology 2000; 55 (02) 258-265
    CrossrefPubMedGoogle Scholar
  • 12 Roos Y. STAR Study Group. Antifibrinolytic treatment in subarachnoid hemorrhage: a randomized placebo-controlled trial. Neurology 2000; 54 (01) 77-82
    CrossrefPubMedGoogle Scholar
  • 13 McDougall CG, Spetzler RF, Zabramski JM. et al. The Barrow Ruptured Aneurysm Trial. J Neurosurg 2012; 116 (01) 135-144
    CrossrefPubMedGoogle Scholar
  • 14 Molyneux AJ, Kerr RS, Yu LM. et al. 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) 809-817
    CrossrefPubMedGoogle Scholar
  • 15 Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RS. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet 2015; 385 (9969) :691-697
    CrossrefPubMedGoogle Scholar
  • 16 Worthington JM, Goumas C, Jalaludin B, Gattellari M. Decreasing risk of fatal subarachnoid hemorrhage and other epidemiological trends in the era of coiling implementation in Australia. Front Neurol 2017; 8 (424) 424
    CrossrefPubMedGoogle Scholar
  • 17 Morris AH. Rational use of computerized protocols in the intensive care unit. Crit Care 2001; 5 (05) 249-254
    CrossrefPubMedGoogle Scholar
  • 18 Wall RJ, Dittus RS, Ely EW. Protocol-driven care in the intensive care unit: a tool for quality. Crit Care 2001; 5 (06) 283-285
    CrossrefPubMedGoogle Scholar
  • 19 Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318 (7182) 527-530
    CrossrefPubMedGoogle Scholar
  • 20 Shekelle P, Eccles MP, Grimshaw JM, Woolf SH. When should clinical guidelines be updated?. BMJ 2001; 323 (7305) 155-157
    CrossrefPubMedGoogle Scholar
  • 21 Vernooij RWM, Sanabria AJ, Solà I, Alonso-Coello P, Martínez García L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci 2014; 9: 3-4
    CrossrefPubMedGoogle Scholar
  • 22 Lai L, Morgan MK. Incidence of subarachnoid haemorrhage: an Australian national hospital morbidity database analysis. J Clin Neurosci 2012; 19 (05) 733-739
    CrossrefPubMedGoogle Scholar
  • 23 Epidemiology of aneurysmal subarachnoid hemorrhage in Australia and New Zealand: incidence and case fatality from the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS). Stroke 2000; 31 (08) 1843-1850
    CrossrefPubMedGoogle Scholar
  • 24 Cedzich C, Roth A. Neurological and psychosocial outcome after subarachnoid haemorrhage, and the hunt and hess scale as a predictor of clinical outcome. Zentralbl Neurochir 2005; 66 (03) 112-118
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28 (01) 14-20
    CrossrefPubMedGoogle Scholar
  • 26 Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988; 68 (06) 985-986
    PubMedGoogle Scholar
  • 27 Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980; 6 (01) 1-9
    CrossrefPubMedGoogle Scholar
  • 28 Taylor CJ, Robertson F, Brealey D. et al. Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care. Neurocrit Care 2011; 14 (03) 341-347
    CrossrefPubMedGoogle Scholar
  • 29 Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care 2005; 2 (02) 110-118
    CrossrefPubMedGoogle Scholar
  • 30 Kirkpatrick PJ, Turner CL, Smith C, Hutchinson PJ, Murray GD. STASH Collaborators. Simvastatin in Aneurysmal Subarachnoid Haemorrhage (STASH): a multicentre randomised phase 3 trial. Lancet Neurol 2014; 13 (07) 666-675
    CrossrefPubMedGoogle Scholar
  • 31 Su SH, Xu W, Hai J, Wu YF, Yu F. Effects of statins-use for patients with aneurysmal subarachnoid hemorrhage: a meta-analysis of randomized controlled trials. Sci Rep 2014; 4: 4573
    CrossrefPubMedGoogle Scholar
  • 32 Hocker SE, Tian L, Li G, Steckelberg JM, Mandrekar JN, Rabinstein AA. Indicators of central fever in the neurologic intensive care unit. JAMA Neurol 2013; 70 (12) 1499-1504
    PubMedGoogle Scholar
  • 33 Honig A, Michael S, Eliahou R, Leker RR. Central fever in patients with spontaneous intracerebral hemorrhage: predicting factors and impact on outcome. BMC Neurol 2015; 15: 6
    CrossrefPubMedGoogle Scholar
  • 34 Rabinstein AA, Sandhu K. Non-infectious fever in the neurological intensive care unit: incidence, causes and predictors. J Neurol Neurosurg Psychiatry 2007; 78 (11) 1278-1280
    CrossrefPubMedGoogle Scholar
  • 35 Thompson HJ, Pinto-Martin J, Bullock MR. Neurogenic fever after traumatic brain injury: an epidemiological study. J Neurol Neurosurg Psychiatry 2003; 74 (05) 614-619
    CrossrefPubMedGoogle Scholar
  • 36 Galea JP, Dulhanty L, Patel HC. UK and Ireland Subarachnoid Hemorrhage Database Collaborators. Predictors of outcome in aneurysmal subarachnoid hemorrhage patients: observations from a multicenter data set. Stroke 2017; 48 (11) 2958-2963
    CrossrefPubMedGoogle Scholar
  • 37 Longstreth Jr WT, Nelson LM, Koepsell TD, van Belle G. Clinical course of spontaneous subarachnoid hemorrhage: a population-based study in King County, Washington. Neurology 1993; 43 (04) 712-718
    CrossrefPubMedGoogle Scholar
  • 38 Sudlow CL, Warlow CP. International Stroke Incidence Collaboration. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. Stroke 1997; 28 (03) 491-499
    CrossrefPubMedGoogle Scholar