[Pain management in severe subarachnoid haemorrhage]

The Longitudinal Course of Pain and Analgesic Therapy Following Aneurysmal Subarachnoid Hemorrhage: A Cohort Study

OBJECTIVE

The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage.

BACKGROUND

Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage.

METHODS

A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption.

RESULTS

Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P < .001), mean [CI 95] maximal daily pain changed at a rate of -0.03 [-0.06, 0.01] units/day, which is not significantly different than zero (P = .15). Pain was located primarily in the head in 76% of subjects but pain in the back, neck, limbs, and eyes was also reported. All patients received oral acetaminophen with increasing daily doses. All but three patients, received opioids, most commonly intravenous fentanyl and oral oxycodone. The mean [95 CI] intravenous morphine equivalent dose of opioids consumed was 15.7 [10.3, 21.1] mg/day and changed at a rate of -0.11 [-0.37, 0.15] mg/day which is not significantly different than zero (P = .40).

CONCLUSION

Despite steady consumption of analgesics, the pain reported by conscious patients while recovering from subarachnoid hemorrhage in the hospital is often severe and persists throughout hospitalization.

[Pain management in subarachnoid hemorrhages]

Pain and anxiety are among the recurring complaints in patients with a subarachnoid haemorrhage. A team assessed the efficacy and quality of pain management in a clinical neuroradiology unit. A global pain management procedure, including antalgic drug protocols and recommendations, was then put in place.

The impact of nonsteroidal anti-inflammatory drugs on inflammatory response after aneurysmal subarachnoid hemorrhage

BACKGROUND

The degree of inflammatory response with cytokine release is associated with poor outcomes after aneurysmal subarachnoid hemorrhage (SAH). Previously, we reported on an association between systemic IL-6 levels and clinical outcome in patients with aneurysmal SAH. The intention was to assess the impact of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen on the inflammatory response after SAH.

METHODS

Our method involved exploratory analysis of data and samples collected within a previous study. In 138 patients with SAH, systemic interleukin (IL-6) and c-reactive protein (CRP) were measured daily up to day 14 after SAH. The correlations among the cumulatively applied amount of NSAIDs, inflammatory parameters, and clinical outcome were calculated.

RESULTS

An inverse correlation between cumulatively applied NSAIDs and both IL-6 and CRP levels was found (r = -0.437, p < 0.001 and r = -0.369, p < 0.001 respectively). Multivariable linear regression analysis showed a cumulative amount of NSAIDs to be independently predictive for systemic IL-6 and CRP levels. The cumulative amount of NSAIDs reduced the odds for unfavorable outcome, defined as Glasgow outcome scale 1-3.

CONCLUSIONS

The results indicate a potential beneficial effect of NSAIDs in patients with SAH in terms of ameliorating inflammatory response, which might have an impact on outcome.

Traitement de l'hémorragie méningée anévrismale

The incidence of subarachnoid hemorrhages is about 10.5/100,000 persons/year. Early obliteration of the aneurysmal sac is necessary to avoid rebleeding. The neurovascular staff meeting must decide the appropriate obliteration procedure for each patient. Intraoperative morbidity is 8% after endovascular coiling and 10% after microsurgical clipping. Endovascular coiling leads to complete obliteration of the aneurysm in 60% of patients and microsurgical clipping in 95%. Delayed ischemic deficits may be prevented by volemic expansion and calcium channel blockers. Hospitalization and general prophylaxis against deep venous thrombosis, pain and seizures are essential. Curative treatment is required against common complications such as intraparenchymatous hematoma, hydrocephalus, and delayed ischemic deficit.

[Pain management in subarachnoid haemorrhage: a survey of French analgesic practices]

OBJECTIVE

Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres.

STUDY DESIGN

Nationwide survey.

METHODS

A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management.

RESULTS

Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS.

CONCLUSION

The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.