Abstract
BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) are common in intensive care units (ICU). In patients with aSAH, sedation is used as a neuroprotective measure in order to secure adequate cerebral perfusion pressure (CPP). Compared with the use of an endotracheal tube, a tracheotomy has the advantage of securing the airway at a much lower level of distress, and aSAH patients can often be awakened more rapidly. Little is known about the impact of tracheotomy on the consumption of sedative/analgesic and vasoactive drugs and the maintenance of CPP within defined limits in aSAH patients.MethodsWe conducted an observational study of aSAH patients who underwent percutaneous tracheotomy. A prospective registry of patient data was supplemented with retrospective retrievals from medical records. Sedative, analgesic and vasoactive drug doses were registered for 3 days prior to and after percutaneous tracheotomy, respectively. Blood pressure, CPP, and the mode of mechanical ventilation were registered 24 h prior to and after tracheotomy.ResultsBetween January 2001 and June 2009, 902 aSAH patients were admitted to our hospital; 74 (8%) were deeply comatose/dying upon arrival. The ruptured aneurysm was repaired in 828 patients (surgical repair 50%) and percutaneous tracheotomy was performed 182 times in 178 patients (59 men and 119 women). This subpopulation (178 of 828 patients) was significantly older (56 vs. 53 years) and presented with a more severe Hunt & Hess grade (p < 0.001). Percutaneous tracheotomy caused a marked decline in mean daily consumption of the analgesics/sedatives fentanyl, midazolam, and propofol, as well as the vasoactive drugs noradrenaline and dopamine. These declines were statistically and clinically significant. The mean CPP was 76 mmHg (SD 8.6) the day before and 79 mmHg (SD 9.6) 24 h after percutaneous tracheotomy. After percutaneous tracheotomy, mechanical ventilatory support could be reduced to a patient-controlled ventilatory support mode in a significant number of patients (p < 0.001).ConclusionsPercutaneous tracheotomy in aSAH patients is a swift procedure with low risk that is associated with a significant decline in the consumption of sedative/analgesic and vasoactive drugs while clinical surveillance parameters remain stable or improve.
Highlights
Patients with aneurysmal subarachnoid hemorrhage are common in intensive care units (ICU)
Adequate cerebral perfusion pressure (CPP), which is defined by the difference between mean arterial blood pressure (ABP) and mean intracranial pressure (ICP), is a cornerstone of optimal management
Difficulties during insertion of cannula, guide wire, or tracheal tube were registered in 19 patients, and minor bleeding was registered in 11 patients
Summary
Patients with aneurysmal subarachnoid hemorrhage (aSAH) are common in intensive care units (ICU). In patients with aSAH, sedation is used as a neuroprotective measure in order to secure adequate cerebral perfusion pressure (CPP). Patients with aneurysmal subarachnoid hemorrhage (aSAH) are common in neurocritical care departments. In conjunction with sedation and continuous monitoring in the intensive care unit (ICU), early aneurysm repair and adequate management of acute hydrocephalus are crucial parts of initial treatment. Local management guidelines include sedation protocols, regulation of arterial blood pressure (ABP), and maintenance of intracranial pressure (ICP) below the defined critical threshold. Adequate cerebral perfusion pressure (CPP), which is defined by the difference between mean ABP and mean ICP, is a cornerstone of optimal management. Our departmental guidelines consider CPP >70 mmHg to be the goal for most aSAH patients. In the presence of severe cerebral vasospasm, the CPP threshold can be raised to >90 mmHg
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