Article
Intensive care management of aneurysmal subarachnoid haemorrhage in Germany – lack of guidelines fosters treatment heterogeneity
Intensivmedizin in aneurysmatischer Subarachnoidalblutung in Deutschland – fehlende Leitlinien fördern Heterogenität
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Published: | June 26, 2020 |
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Objective: Current evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage (SAH) focus primarily on the timing, modality and technique of aneurysm occlusion, and the prevention and treatment of delayed cerebral ischemia. Significant aspects of management in the intensive care unit (ICU) during the later course of SAH are completely unaddressed, such as ventilation and sedation (VST). SAH patients present unique challenges not accounted for in general VST recommendations and guidelines, which is why we attempted to elucidate VST practices in SAH patients in Germany.
Methods: We conducted a nation-wide survey on VST practices in SAH in Germany. Secondarily, we assessed the existence of and compliance with current guidelines regarding VST practices. The questionnaire was designed in interdisciplinary fashion and distributed online via the kwiksurvey® platform (Bristol, UK).
Results: A total of 50 responses were received, accounting for a response rate of 49%. Twenty-one were university hospitals (UH), 23 high-volume centers (HVC), 6 low-volume centers (LVC). Half of the participating centers do not take into consideration WFNS at presentation to indicate ventilation. While 42% of centers rely on the Horowitz index to indicate ventilation, 62% of them have a cutoff-value of <200, and 38% of <100. Most UH and HVC use propofol for induction of sedation (95%); LVC employ benzodiazepines (100%). Sedation enhancement is done with ketamine in UH (75%) and HVC (60%), whereas LVC use clonidine (100%). These results show great heterogeneity in clinical practice, especially between UH/HVC and LVC. When analyzing existing ICU guidelines, including AWMF, AHA and Neurocritical Care Society, there is a paucity of SAH-tailored recommendations, possibly contributing to the variability reflected in our survey.
Conclusion: Our study clearly demonstrates that attitudes and practices pertaining to VST in SAH are enormously heterogeneous, reflecting the lack of good quality evidence and differing interpretations thereof. While the overall outcome of SAH depends on a multitude of factors, the establishment of evidence-based protocols for the management of these patients in the ICU can potentially solve one part of the puzzle and lead to improved outcomes.