[Management of SAH]. / Prise en charge de la HSA.

Every year, the neurosurgical intensive care unit at Grenoble's university hospital (CHU) receives a large number of cerebrovascular patients. Data collected in the department during 2023 show that subarachnoid hemorrhage (SAH) is one of the most frequent causes of the pathologies treated. In this article, we focus on the appropriate course of action.

Application of inter-professional care model in patients with aneurysmal subarachnoid haemorrhage.

OBJECTIVE: To explore the feasibility and effect of the inter-professional care model in patients with aneurysmal subarachnoid haemorrhage. METHODS: A convenient sampling method was used to recruit inpatients of a hospital as subjects from July 2016 to July 2018. According to the even/odd attribute of admission number, subjects were divided into a control group and an observation group. The number of recruited subjects was 311: the control group comprised 135 participants and the observation group 176. The average length of hospital stay, hospital fees, quality of life, and satisfaction with the quality of nursing were compared between the two groups. SPIRIT checklist was completed (see File S1). RESULTS: After intervention, patients in the observation group had shorter average hospital stay (15.98 ± 2.7), lower hospital fees (81,018 ± 1.3), higher satisfaction with the quality of nursing (98.3%), lower incidence of complications (19.89%), improved ability to perform activities of daily living, and lower rate of disease outcome and re-admission, with statistically significant differences from the control group (p < .05). CONCLUSION: The application of inter-professional care model in single disease patients with aneurysmal subarachnoid haemorrhage can shorten the average hospital stay, reduce hospital fees, improve the quality of life of patients, and increase patients' satisfaction with the quality of nursing, which is worthy of clinical promotion and application. IMPLICATIONS FOR NURSING MANAGEMENT SECTION: Nursing managers can use this model to improve the ability to ensure coordination between medical professionals and integrate the ability of nursing problems, the ability to make rational distribution of nursing human resources, and the ability of critical thinking. It can be used as reference to improve the nursing management of all kinds of single diseases.

Management of Subarachnoid Hemorrhage.

Subarachnoid hemorrhage is an often devastating intracranial hemorrhage resulting from acute bleeding into the subarachnoid space. Although its overall incidence is less than that of acute ischemic stroke, sub-arachnoid hemorrhage carries increased risks of both mortality and disability. Although many patients with subarachnoid hemorrhage are transferred to specialty centers, they might initially present to small community-based hospitals. Treatment for these patients is complex, requiring specialized care and knowledge, and various complications can occur quickly and without warning. Therefore, all members of the health care team who care for these patients must understand proper management. Nurses in the intensive care unit play an important role in influencing outcomes, as they are best positioned to recognize neurological decline and provide rapid intervention. This article discusses the anatomy relevant to, and the epidemiology and pathophysiology of, subarachnoid hemorrhage and provides an overview of current evidence and clinical guidelines for managing this brain injury.

Acute Headache in the Emergency Department: Is Lumbar Puncture Still Necessary to Rule Out Subarachnoid Hemorrhage?

The purpose of the Research to Practice column is to review current primary journal articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of Carpenter et al. (2016) from their article, "Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds." The authors concluded that although no history or physical examination finding can be used to rule in or rule out spontaneous subarachnoid hemorrhage (SAH), the complaint of neck stiffness can increase the likelihood of SAH. In addition, the authors concluded that noncontrast head computed tomography (CT) is accurate in ruling out/in SAH when performed within 6 hr of symptom onset in adults with symptoms consistent with SAH and that the traditional gold standard of confirmatory lumbar puncture after a negative head CT scan is only helpful in patients with a very high pretest probability of SAH. By applying the evidence-based criteria presented in this study, the emergency department APN can confidently rule out SAH and reduce patient risks from unnecessary invasive and costly testing.

Cerebral Microdialysis.

A variety of neuromonitoring techniques are available to aid in the care of neurocritically ill patients. However, traditional monitors lack the ability to measure brain biochemistry and may provide inadequate warning of potentially reversible deleterious conditions. Cerebral microdialysis (CMD) is a safe, novel method of monitoring regional brain biochemistry. Analysis of CMD analytes as part of a multimodal approach may help inform clinical decision making, guide medical treatments, and aid in prognostication of patient outcome. Its use is most frequently documented in traumatic brain injury and subarachnoid hemorrhage. Incorporating CMD into clinical practice is a multidisciplinary effort.

Health-Related Quality-of-Life Outcomes: Comparing Patients With Aneurysmal and Nonaneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) is divided into two major types (aneurysmal [ASAH] and nonaneurysmal [NASAH]) because, in approximately 15% of the patients who experience SAH, no source of hemorrhage can be identified. Anecdotal evidence and contradictory research suggest that patients with NASAH experience some of the same health-related quality of life (HRQOL) issues as patients with ASAH. This quantitative survey design study compared 1-3 years after hemorrhage the HRQOL in patients who had experienced an NASAH with those who had experienced an ASAH. This is the first U.S. study to specifically investigate HRQOL in NASAH and the second to compare HRQOL outcomes between patients with ASAH and NASAH. These study results corroborate those of the first-that the two groups are much more similar than different. It confirms that the impact on employment for both hemorrhage groups is significant, and it also finds an even greater inability to return to work for the patients with NASAH. Physical symptom complaints were more common in the group with NASAH, whereas the group with ASAH experienced more emotional symptoms. Both groups had low levels of posttraumatic stress disorder (PTSD), with those levels not differing significantly between groups. However, PTSD and social support were shown to impact HRQOL for both groups. The authors recommend that clinicians assess all patients with SAH for PTSD and institute treatment early. This may include offering psychological services or social work early in the hospital course. Further research and policy changes are needed to assist in interventions that improve vocational reintegration after SAH. Patients with NASAH should no longer be described as having experienced a "benign hemorrhage." They have had a life-changing hemorrhage that may forever change their lives and impact their HRQOL.

Temporal Profiles of Cerebral Perfusion Pressure After Subarachnoid Hemorrhage.

INTRODUCTION: Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). METHOD: CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. RESULTS: Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (ß = 0.06, SE = 0.006, p < .001). The covariance (-0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). CONCLUSIONS: The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.

Intervenciones de enfermería en la persona con vasoespasmo cerebral secundario a hemorragia subaracnoidea aneurismática / Nursing interventions in the person with a secondary cerebral vasospasm aneurysmal subarachnoid haemorrhage

Introducción. El vasoespasmo cerebral como complicación de la Hemorragia subaracnoidea aneurismática, es considerado como una vasoconstricción patológica de las arterias principales de la base del encéfalo; es una condición reversible, que se caracteriza con la reducción del calibre de la luz de las arterias y por lo consiguiente una disminución del flujo sanguíneo al área perfundida por el vaso comprometido. Objetivo. Desarrollar un proceso enfermero basado en la taxonomía Nanda, Noc, Nic a una persona con vasoespasmo cerebral. Metodología. Se realizó la elección de un caso clínico, con la metodología del proceso de atención de enfermería estableciendo un plan de cuidados en el área de recuperación y terapia intermedia del Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez durante el periodo postquirúrgico inmediato. Se detectaron las necesidades básicas alteradas al realizar la valoración neurológica de enfermería. Se procedió a formular los diagnósticos de enfermería reales y de riesgo y con base en estos se planearon las intervenciones de enfermería. Conclusión. El realizar las intervenciones de enfermería de forma sistematizada a partir del proceso enfermero, se establece un método científico, en donde cada intervención se fundamenta y da pauta a la aplicación de un cuidado especializado, dirigido hacia la mejora de la persona desde el punto de vista individual y con ello detectar oportunamente signos y síntomas de alarma así como posibles complicaciones.

Introduction. The cerebral vasospasm as complication of the Haemorrhage subarachnoid aneurismática, is considered to be a pathological vasoconstriction of the main arteries of the base of the brain; it is a reversible condition, which is characterized by the reduction of the caliber of the light of the arteries and for consequent a decrease of the blood flow to the area perfundida for the awkward glass. Target. To develop a process nurse based on the taxonomy Nanda, NOC, NIC to a person with vasospasm cerebral. Methodology. There was realized the election of a clinical case, with the methodology of the process of attention of infirmary establishing a care plan in the field of recovery and intermediate therapy of the National Institute of Neurology and Neurosurgery Manuel Velasco Suárez during the immediate postsurgical period. The basic needs were detected altered on having realized the neurological infirmary evaluation. One proceeded to formulate the real diagnoses of infirmary and of risk and with base in these the infirmary interventions were planned. Conclusion. Realizing the interventions of infirmary of form systematized from the process nurse, establishes a scientific method, where every intervention is based and gives rule to the application of a specializing care, directed to the progress of the person from the individual point of view and with it to detect opportunely signs and symptoms of alarm as well as possible complication.

[Standardized impartial assessment of pain in unconscious patients with the Zurich Observation Pain Assessment on a neurosurgical intensive care unit - a case report]. / Die standardisierte Fremdeinschätzung von Schmerzen bei bewusstseinsbeeinträchtigten Patienten mit dem Zurich Observation Pain Assessment (ZOPA©) auf einer neurochirurgischen Intensivstation - Eine Fallstudie.

BACKGROUND: International studies show that the majority of patients undergoing treatment in ICUs report moderate to strong levels of pain. It has been established that undetected or insufficiently treated pain can cause severe physical and emotional distress. Therefore, early and effective pain assessment is a primary treatment goal of intensive care, which is a challenge with patients having cognitive impairment. AIM: This article shows how using the Zurich Observation Pain Assessment (ZOPA(©)) as part of a standardized assessment can close this gap. METHOD: An interpretive single case study evaluates the use of ZOPA(©) in nursing practice and its influence on pain management. RESULTS: The study case involved an intensive care patient with a severe subarachnoid haemorrhage for whom a total of 126 single ZOPA(©) assessments were analyzed. A total of 19 assessments showed behavioral characteristics indicative of pain. Immediate interventions to alleviate pain were taken in three quarters of these assessments. The study ICU has used ZOPA(©) for the past five years. This unit has a standard medication procedure, so nurses can administer analgesics on an "as needed" basis and take their responsibility in implementing pain management. CONCLUSION: This study supports the finding that ZOPA(©) can contribute to early and effective detection of pain in cognitively impaired patients, resulting in improved pain treatment.

Fever management practices of neuroscience nurses: what has changed?

Current evidence shows that fever and hyperthermia are especially detrimental to patients with neurologic injury, leading to higher rates of mortality, greater disability, and longer lengths of stay. Although clinical practice guidelines exist for ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury, they lack specificity in their recommendations for fever management, making it difficult to formulate appropriate protocols for care. Using survey methods, the aims of this study were to (a) describe how nursing practices for fever management in this population have changed over the last several years, (b) assess if institutional protocols and nursing judgment follow published national guidelines for fever management in neuroscience patients, and (c) explore whether nurse or institutional characteristics influence decision making. Compared with the previous survey administered in 2007, there was a small increase (8%) in respondents reporting having an institutional fever protocol specific to neurologic patients. Temperatures to initiate treatment either based on protocols or nurse determination did not change from the previous survey. However, nurses with specialty certification and/or working in settings with institutional awards (e.g., Magnet status or Stroke Center Designation) initiated therapy at a lower temperature. Oral acetaminophen continues to be the primary choice for fever management, followed by ice packs and fans. This study encourages the development of a stepwise approach to neuro-specific protocols for fever management. Furthermore, it shows the continuing need to promote further education and specialty training among nurses and encourage collaboration with physicians to establish best practices.

Risk factors for catheter-associated urinary tract infections in critically ill patients with subarachnoid hemorrhage.

BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) are preventable adverse outcomes that cause increased morbidity, mortality, and financial burdens to hospitals. These are particularly prevalent in intensive care units (ICUs). Patients with subarachnoid hemorrhage (SAH) in neurological ICUs have extended lengths of stay and may be at higher risk for CAUTIs. PURPOSE: The purpose of this study was to assess the prevalence of and risk factors for CAUTIs among patients with SAH in the neurological ICU of a large urban teaching hospital in the eastern United States. METHODS: This is a retrospective analysis using the Columbia University SAH Outcomes Project data set collected between 2005 and 2012. Logistic regression is used to identify predictors of CAUTI. RESULTS: Catheterized adult patients (n = 242) with SAH over the 8-year period were included. The rate of CAUTIs was 20.7 per 1,000 catheter days, six times higher than the reported national average. Variables significantly associated with CAUTI were older age (odds ratio [OR] = 1.06, 95% confidence interval [CI] [1.01, 1.11]), blood sugar > 200 mg/dl (OR = 13.0, 95% CI [1.28, 107.4]), and anemia requiring transfusion (OR = 3.78, 95% CI [0.977, 14.67]). CONCLUSIONS: Higher CAUTI rates in this study were likely associated with prolonged catheterization. On the basis of these findings, careful assessment of the need for catheterization and increased vigilance regarding urinary catheter care in patients with SAH is indicated, particularly among those who are older, with anemia requiring transfusion and elevated blood glucose levels.

Factors influencing return to work after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that affects women and men with a mean age of 50 years. Return to work (RTW) has been cited as a strategic goal of patients after injury; however, success rates are low in multiple studies. Therefore, the purpose of this study was to investigate factors influencing RTW after aSAH. The study design was a cross-sectional design at 1-2 years after injury to assess work status in 134 patients who were treated for aSAH. Participants were recruited at one hospital setting via mailed invitations. They were interviewed over the telephone after consent was obtained for chart review and to participate in the study. Eligible participants were asked to complete the Brief Illness Perception Questionnaire and the Functional Status Questionnaire. Data analysis was performed using univariate analysis and logistic regression with Statistical Package for the Social Sciences software. RESULTS: There was a moderate negative correlation between illness perception and RTW. Illness perception was found to significantly predict failure to RTW, whereas marital status improved the prediction model to significantly predict successful RTW. CONCLUSIONS: This study addressed a gap in the literature regarding work status after aSAH and has provided direction for further investigation. Addressing issues surrounding patients' perception of illness may serve as an important conduit to remove barriers to RTW. Recognition of these barriers to RTW in assessing a person's illness perception may be the key to the development of interventions in the recovery process.

Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: a correlational study.

OBJECTIVES: To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH). RESEARCH METHODOLOGY: Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6). RESULTS: DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%. CONCLUSIONS: These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study.

Cerebral aneurysm and aneurysmal subarachnoid haemorrhage.

A cerebral aneurysm is a weak or thin spot on a blood vessel in the brain that swells and fills with blood. Rupture of a cerebral aneurysm, known as aneurysmal subarachnoid haemorrhage, is a medical emergency and is associated with increased mortality. This article explores the anatomy and physiology of the brain and blood vessels. Current research and guidelines are used to highlight risk factors for cerebral aneurysms and their rupture and to discuss best practice for treating both. The article provides information on the management and complications of the condition, alongside nursing considerations, long-term care, discharge and rehabilitation.

Monitoring and sedation differences in the management of severe head injury and subarachnoid hemorrhage among neurocritical care centers.

BACKGROUND: The emergence of specialized neurocritical care (NCC) centers has been associated with an improved survival of patients with severe traumatic brain injury or subarachnoid hemorrhage. However, there are no established guidelines on sedation strategy or the frequency of evaluating the level of consciousness using the neurological wake-up test (NWT) in sedated NCC patients. OBJECTIVES: The aim was to compare the (1) monitoring techniques, (2) sedation principles, and (3) the use of the NWT in patients with severe traumatic brain injury or subarachnoid hemorrhage in 16 NCC centers. METHOD: A systematic survey of all 16 centers providing NCC in Scandinavia was performed using a questionnaire regarding the routine primary choice of sedative and analgesic compounds, monitoring techniques, and the frequency of the NWT, sent to the director of each center during 1999, 2004, and 2009. RESULTS: The response rate was 100%. Except for one center in 1999, all included centers routinely used monitoring of intracranial and cerebral perfusion pressure. In contrast, newer monitoring techniques such as microdialysis, jugular bulb oximetry, and brain tissue oxygenation were infrequently used throughout the survey period. Approximately half of the NCC centers used propofol infusion as the primary sedative, whereas the remaining centers used midazolam infusion, and there was a marked variation in the choice of analgesia in each evaluated year. The NWT was never used in 50% of centers and ≥six times daily in one center from 1999 to 2009. Most differences among the NCC centers remained unchanged over the evaluated 10-year period. DISCUSSION: Although Scandinavian countries have similar healthcare systems, there were marked differences among the participating NCC centers in the choice of monitoring tools and sedatives and the routine use of the NWT. These differences likely reflect different clinical management traditions and a lack of evidence-based guidelines in routine NCC.

Nursing interventions and assessments for aneurysmal subarachnoid hemorrhage patients: a mixed methods study involving practicing nurses.

Aneurysmal subarachnoid hemorrhage (aSAH) caused by a ruptured aneurysm is a devastating event that can lead to severe disability or death. Although published guidelines on the management of aSAH exist, research is limited regarding the role of nursing in the care of aSAH patients. The purpose of this study was to describe the interventions and assessments that nurses provide while caring for aSAH patients in the critical care setting. A mixed methods design was utilized for this study. Individual interview sessions with 10 neurocritical care nurses were completed and transcribed verbatim. The transcripts were analyzed and categorized using a predetermined code list based on a theoretical framework derived from the work of McNett and Giankis. The predetermined code list included four areas: (a) neurophysiological, (b) psychosocial, (c) injury prevention, and (d) maintaining therapeutic milieu. Frequencies were also computed based on an investigator-developed questionnaire to identify the most common interventions and assessments. The qualitative data supported the four main areas in the predetermined code list. The neurophysiological theme focused on blood pressure management and detailed neurological exams. The psychosocial theme addressed education, support, and communication. The injury prevention theme involved repositioning and reorienting/distracting the patients. The theme of maintaining a therapeutic milieu focused on decreasing the patients' stimulation. An additional theme emerged and was labeled, "Giving the Patient a Chance." Quantitative data revealed that neurophysiological and psychosocial interventions were most frequent. Nurses are responsible for the complex care of aSAH patients and their families and must implement a variety of nursing interventions and assessments. Further research is needed to identify the impact of these interventions and assessments on the outcome of aSAH patients while in the critical care setting.