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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Tjerkstra MA, Verbaan D, Coert BA, Post R, van den Berg R, Coutinho JM, Horn J, Vandertop WP. Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage. World Neurosurg 2022; 160:e412-e420. [PMID: 35033694 DOI: 10.1016/j.wneu.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) contributes to poor outcomes after subarachnoid hemorrhage (SAH). The pathophysiology of DCI is not fully understood, which has hindered the adoption of a uniform definition. Furthermore, a reliable diagnostic test and an effective evidence-based treatment are lacking. This could lead to variations in care. METHODS A web-based survey on the variations in the definition, diagnosis, and treatment of DCI was designed and sent to 314 intensivists, neurologists, and neurosurgeons of all 9 hospitals in the Netherlands who care for patients with SAH. The responders were categorized into physicians responsible for the coordination of SAH care and those who were not. For questions on the definition and diagnosis, only the responses from the coordinating physicians were evaluated. For the treatment questions, all the responses were evaluated. RESULTS The response rate was 34% (106 of 314). All 9 hospitals were represented. Of the responses, 27 did not provide answers for the definition, diagnosis, or treatment questions; 79 responses were used for analysis. Signs of vasospasm were required by 21 of the 47 coordinating physicians (44%) when considering DCI. Of the 47 coordinating physicians, 24 (51%) did not use a diagnostic test results for a positive diagnosis of DCI. When patients were discharged within 21 days, 33 of the 73 responders (45%) did not provide a prescription for nimodipine continuation. Finally, all but one hospital had treated DCI with hypertension induction. CONCLUSIONS We found large variations in the definition, diagnosis, and treatment of DCI in the Netherlands. In the absence of evidence-based treatment, standardization of management seems warranted in an effort to optimize DCI care.
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Affiliation(s)
- Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Nimodipine after aneurysmal subarachnoid hemorrhage: Fourteen-day course for patients that meet criteria for early hospital discharge. Clin Neurol Neurosurg 2020; 200:106299. [PMID: 33092929 DOI: 10.1016/j.clineuro.2020.106299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Randomized-controlled trials and meta-analyses showed nimodipine use after aneurysmal subarachnoid hemorrhage (aSAH) leads to reduction in incidence of cerebral infarction, persistent neurological deficits, and poor outcomes. Trials administered it for 21 days; however, we assessed whether a shorter duration might be reasonable for a subset of patients. METHODS We performed a retrospective single-center study to compare outcomes between patients who received ≤14 days, 15-20 days or ≥21 days of nimodipine. Primary outcome was defined as rate of good functional outcome at final follow-up, assessed using dichotomized modified Rankin Score (mRS). Secondary outcomes included median mRS at follow-up, discharge disposition, and readmission for stroke or vasospasm. RESULTS 195 patients were included: 101 patients received nimodipine for ≤14 days, 72 patients for 15-20 days, and 22 patients for ≥21 days. There were differences in baseline characteristics of the groups. The shorter duration groups had higher admission GCS score (GCS 15 for ≤14 days, GCS 13 for 15-20 days, GCS 8 for ≥21 days, p = 0.003) and lower Hunt-Hess grade (2 for ≤14 days, 3 for 15-20 days, 4 for ≥21 days, p = 0.001). Of the group of patients that received ≤14 days of nimodipine, 3 patients (3%) were readmitted for concerns for possible stroke or vasospasm, but they did not experience worsening of their functional status related to this. CONCLUSION Our data suggests a more limited 14-day course of nimodipine therapy after aSAH may be reasonable and efficacious in patients with higher GCS and lower Hunt-Hess grade on presentation.
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The impacts of medication shortages on patient outcomes: A scoping review. PLoS One 2019; 14:e0215837. [PMID: 31050671 PMCID: PMC6499468 DOI: 10.1371/journal.pone.0215837] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 04/09/2019] [Indexed: 12/29/2022] Open
Abstract
Background In recent years, medication shortages have become a growing worldwide issue. This scoping review aimed to systematically synthesise the literature to report on the economic, clinical, and humanistic impacts of medication shortages on patient outcomes. Methods Medline, Embase, Global Health, PsycINFO and International Pharmaceutical Abstracts were searched using the two key concepts of medicine shortage and patient outcomes. Articles were limited to the English language, human studies and there were no limits to the year of publication. Manuscripts included contained information regarding the shortage of a scheduled medication and had gathered data regarding the economic, clinical, and/or humanistic outcomes of drug shortages on human patients. Findings We found that drug shortages were predominantly reported to have adverse economic, clinical and humanistic outcomes to patients. Patients were more commonly reported to have increased out of pocket costs, rates of drug errors, adverse events, mortality, and complaints during times of shortage. There were also reports of equivalent and improved patient outcomes in some cases. Conclusions The results of this review provide valuable insights into the impact drug shortages have on patient outcomes. The majority of studies reported medication shortages resulted in negative patient clinical, economic and humanistic outcomes.
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Zhang C, Zhao S, Zang Y, Zhao W, Song Q, Feng S, Hu L, Gu F. Magnesium sulfate in combination with nimodipine for the treatment of subarachnoid hemorrhage: a randomized controlled clinical study. Neurol Res 2018. [PMID: 29540123 DOI: 10.1080/01616412.2018.1426207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective Cerebral vasospasm(CVS) after Subarachnoid hemorrhage (SAH) can cause delayed cerebral ischemia,secondary cerebral infarction, and rehemorrhage, which are the leading causes of mutilation and death. Nimodipine has been shown to prevent CVS. Magnesium ion (Mg2+) can competitively inhibit the influx of calcium (Ca2+) and prevent vasospasm. There is evidence that magnesium sulfate can prevent CVS and reduce infarct volume after SAH. In this study, we evaluated the efficacy and safety of intravenous magnesium sulfate combined with oral nimodipine on CVS, delayed cerebral ischemia, secondary cerebral infarction, and rehemorrhage after SAH. Methods This is a prospective randomized, double-blind trial of 120 patients with SAH who were recruited between January 2003 and January 2009. These patients were assigned to two groups and received the same basic treatment and symptomatic treatment. In group A, patients received 14 days of intravenous administration of 1400 mL 0.9% normal saline + 40 mL 25% magnesium sulfate, 1 mL/min, once per day, followed 7 days of intravenous administration of 500 mL 0.9% normal saline + 15 mL 25% magnesium sulfate, 1 mL/min, once per day and oral nimodipine, 20 mg once, four times a day, for 21 days. Patients in group B received identical treatment to that in group A, except that 25% magnesium sulfate was replaced by placebo. On day 22 of treatment, incidences of intracranial CVS, delayed cerebral ischemia, secondary cerebral infarction, rehemorrhage, neurologic deficits, and death were assessed and adverse events were monitored. Results CVS occurred in 4, 12 patients, lasting for 11.09 ± 5.38, 13.73 ± 6.24 hours, mean velocity (Vm) of 143.2 ± 12.7, 149.6 ± 18.9 cm/s in group A, B; Delayed cerebral ischemia occurred in 3, 10 patients, lasting for 13.16 ± 4.82, 15.57 ± 5.35 hours in group A, B; Secondary cerebral infarction occurred in 2 and 8 patients in groups A and B; Neurologic deficits occurred in3 and 11 patients in groups A and B, All P < 0.05; Rehemorrhage occurred in 4 and 5 patients; Death occurred in 5 and 8 patients in groups A and B, respectively, P >0.05. No obvious adverse events were found in both groups. Conclusion Intravenous magnesium sulfate in combination with oral nimodipine for the treatment of SAH can help reduce the incidences of CVS, delayed cerebral ischemia, secondary cerebral infarction, and neurologic deficits with good safety, but it does not reduce the incidences of rehemorrhage and death.
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Affiliation(s)
- Chenhao Zhang
- a Department of Neurology , The Second Hospital of Baoding City , Baoding , China
| | - Shuqin Zhao
- b Department of Internal Medicine , Hospital Affiliated to Hebei University , Baoding , China
| | - Yanjing Zang
- c Department of Geriatric , The Second Hospital of Baoding City , Baoding , China
| | - Weidong Zhao
- d Second Department of Neurology , The Second Hospital of Baoding City , Baoding , China
| | - Qin Song
- d Second Department of Neurology , The Second Hospital of Baoding City , Baoding , China
| | - Shanshan Feng
- a Department of Neurology , The Second Hospital of Baoding City , Baoding , China
| | - Lei Hu
- a Department of Neurology , The Second Hospital of Baoding City , Baoding , China
| | - Fang Gu
- e Fifth Department of Internal Medicine , Baoding Children's Hospital , Baoding , China
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Chen CJ, Turnage C, Sokolowski JD, Kumar JS, Kalani MY, Park MS. Dangers of outpatient nimodipine use after spontaneous subarachnoid hemorrhage in accordance with the Comprehensive Stroke Center guidelines. J Clin Neurosci 2018; 52:151-152. [DOI: 10.1016/j.jocn.2018.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/12/2018] [Accepted: 04/02/2018] [Indexed: 11/30/2022]
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Samseethong T, Suansanae T, Veerasarn K, Liengudom A, Suthisisang C. Impact of Early Versus Late Intravenous Followed by Oral Nimodipine Treatment on the Occurrence of Delayed Cerebral Ischemia Among Patients With Aneurysm Subarachnoid Hemorrhage. Ann Pharmacother 2018; 52:1061-1069. [PMID: 29783859 DOI: 10.1177/1060028018778751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Guidelines for aneurysm subarachnoid hemorrhage (aSAH) management recommend treatment with nimodipine to all patients to reduce delayed cerebral ischemia (DCI) and poor clinical outcome. However, it did not give the most beneficial time to start therapy and route of administration. OBJECTIVES To compare the DCI occurrence and clinical outcome among aSAH patients who received nimodipine treatment at different times. METHODS A retrospective cohort study was conducted by collecting data from medical chart reviews between August 30, 2010, and October 31, 2015, at Prasart Neurological Institute, Thailand. Patients were classified into 2 groups by time to receive nimodipine: early group and late group (<96 and >96 hours, respectively). All patients received intravenous (IV) followed by oral nimodipine to complete treatment course. Clinical outcome was graded using the Glasgow Outcome Scale at 21 days. The factors related to DCI were analyzed using multivariate logistic regression. RESULTS A total of 149 patients were recruited: early (n = 97) and late (n = 52). No difference in baseline characteristics between groups was observed. The occurrence of DCI was not statistically significantly different between groups (early group, 18.60%, vs late group, 20.80%; P = 0.74). The World Federation of Neurosurgical Societies IV to V was associated with DCI occurrence. The proportion of patients with good outcome, poor outcome, or death did not show any difference between groups. CONCLUSIONS AND RELEVANCE Receiving IV nimodipine 3 to 7 days following oral therapy after bleeding can be the alternative regimen in patients who did not start nimodipine within 96 hours.
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Affiliation(s)
- Tipada Samseethong
- 1 Mahidol University, Bangkok, Thailand.,2 Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | | | | | - Anusak Liengudom
- 3 Prasat Neurological Institute, Bangkok, Thailand.,4 Vichaiyut Hospital, Bangkok, Thailand
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Tallarico RT, Pizzi MA, Freeman WD. Investigational drugs for vasospasm after subarachnoid hemorrhage. Expert Opin Investig Drugs 2018; 27:313-324. [DOI: 10.1080/13543784.2018.1460353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Harbin M, Turgeon R. Comment: The Effects of 14 Versus 21 Days of Nimodipine Therapy on Neurological Outcomes in Aneurysmal Subarachnoid Hemorrhage Patients. Ann Pharmacother 2017; 51:717. [PMID: 28413883 DOI: 10.1177/1060028017705394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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