Artikel
The diversity of mechanical ventilation and sedation therapy in neurointensive care treatment of acute aneurysmal subarachnoid haemorrhage in Germany – representative results of a nationwide survey and a plea for a standardized treatment
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Autoren
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Christian von der Brelie
- Georg-August-Universität Göttingen, Anästhesiologie, Göttingen, Deutschland
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Clara Salfelder
- Georg-August-Universität Göttingen, Anästhesiologie, Göttingen, Deutschland
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Jörn Schäper
- Georg-August-Universität Göttingen, Anästhesiologie, Göttingen, Deutschland
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Veit Rohde
- Georg-August-Universität Göttingen, Anästhesiologie, Göttingen, Deutschland
| Veröffentlicht: | 18. Juni 2018 |
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Gliederung
Text
Objective: Mechanical ventilation and sedation treatment (VST) are key parts of the armamentarium in the acute neurointensive care setting of acute aneurysmal subarachnoid haemorrhage (SAH), but indications and therapy regimen vary enormously. The quest of achieving better outcome should not only focus on neurovascular events like delayed cerebral ischemia and must not underestimate crucial interventions like ventilation and sedation therapy. The aim of this study is to characterize the differences in neurointensive care strategies of acute SAH in Germany and to create the awareness of the usefulness of a standardized guideline.
Methods: A 70 question questionnaire was designed in an interdisciplinary setting and emailed to every SAH treatment center in Germany. The diversity of answers was categorized using a cluster-analysis.
Results: Answers from 49 centers were analyzed. Calculating with an incidence of SAH of 7.5/100.000/ year, the answers represent 58.9% of the nationwide annual treatment volume of SAH. (Neuro)-Intensive care units are lead by anesthesiologists in 61.7%. Indication for ventilation and sedation therapy (VST) as well as implementation varies enormously, e.g. 36% of the centers indicate standard VST in SAH with modified Fisher degree 4. The threshold Horovitz-index for indication of ventilation was different (59% < 200 mmHg and 41% if < 100 mmHg). There are major differences in adjustment of mechanical ventilation to target values (33% adjust the paO2 > 100 mmHg and 20% follow peripheral oxygen saturation values; 51% adjust the paCO2 between 35-45 mmHg and strictly prohibit hypercapnemia). More than ten different drug-combinations are used for standard sedation therapy and dosages vary widely (e.g. maximum dosage of Sufentanil varied from 40µg/h to 250µg/h; Barbiturates were still used by 68%). 54% of the centers use substantiated methods to analyze sedation level (bispectral-index or other surface EEG methods). Standard cardiocirculatory monitoring using pulse-contour-analysis is only used in 35% of all centers. 45% of all centers report frequent severe complications (>10%) due to sedation therapy.
Conclusion: This study shows that a crucial therapeutic part of SAH treatment is carried out with a huge variety. The data clearly argues for development of treatment guidelines.
