[General management in intensive care of patient with spontaneous subarachnoid hemorrhage]

Safety of Early Mobilization in Adult Neurocritical Patients: An Exploratory Review

Introduction: Early mobilization has shown significant benefits in the rehabilitation of critically ill patients, including improved muscle strength, prevention of physical deconditioning, and reduced hospital length of stay. However, its safety in neurocritical patients, such as those with strokes, traumatic brain injuries, and postsurgical brain surgeries, remains uncertain. This study aims to map and examine the available evidence on the safety of early mobilization in adult neurocritical patients. Methods: A scoping review was conducted following PRISMA-SCR guidelines and the Joanna Briggs Institute (JBI) methodology. The research question focused on the safety of early mobilization in neurocritical patients, considering adverse events, neurological changes, hemodynamic changes, and respiratory changes. A comprehensive search was performed in databases such as PubMed, BVS-LILACS, Ovid MEDLINE, and ScienceDirect, using specific search strategies. The selected studies were assessed for methodological quality using JBI tools. Results: Of 1310 identified articles, 25 were included in the review. These studies comprised randomized controlled trials, prospective observational studies, retrospective studies, and pre- and postimplementation intervention studies. The review found that early mobilization in neurocritical patients is generally safe, with a low incidence of severe adverse events, and does not increase the risk of vasospasm, and most complications were manageable with protocol adjustments and continuous monitoring. Conclusion: Early mobilization in neurocritical patients has been shown to be potentially safe under specific conditions, without a significant increase in severe complications when properly monitored. However, the available evidence is limited by the heterogeneity of protocols and study designs, emphasizing the need for further research. The importance of tailoring mobilization protocols to each patient and ensuring continuous monitoring is highlighted. Additional studies with larger sample sizes are needed to fully understand the associated risks and optimize mobilization strategies.

Construction and Verification of a Risk Prediction Model for the Occurrence of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage Requiring Mechanical Ventilation

Objectives

Delayed cerebral ischemia (DCI) contributes to poor aneurysm prognosis. Subarachnoid hemorrhage and DCI have irreversible and severe consequences once they occur; therefore, early prediction and prevention are important. We investigated the risk factors for postoperative complications of DCI in patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation in intensive care and validated a prediction model.

Methods

We retrospectively analyzed patients with aSAH who were treated in a French university hospital neuro-ICU between January 2010 and December 2015. The patients were randomized into a training group (144) and verification groups (60). Nomograms were validated in the training and verification groups, where receiver operating characteristic curve analysis was used to verify model discrimination; calibration curve and Hosmer-Lemeshow test were used to determine model calibration; and decision curve analysis (DCA) was used to verify clinical validity of the model.

Results

External ventricular drain (EVD), duration of mechanical ventilation, and treatment were significantly associated in the univariate analysis; EVD and rebleeding were significantly associated with the occurrence of DCI after aSAH. Binary logistic regression was used to select five clinicopathological characteristics to predict the occurrence of DCI in patients with aSAH requiring mechanical ventilation nomograms of the risk of DCI. Area under the curve values for the training and verification groups were 0.768 and 0.246, with Brier scores of 0.166 and 0.163, respectively. Hosmer-Lemeshow calibration test values for the training and verification groups were x ² = 3.824 (P = 0.923) and x ² = 10.868 (P = 0.285), respectively. Calibration curves showed good agreement. DCA indicated that the training and verification groups showed large positive returns in the broad risk range of 0-77% and 0-63%, respectively.

Conclusions

The predictive model of concurrent DCI in aSAH has theoretical and practical values and can provide individualized treatment options for patients with aSAH who require mechanical ventilation.

Role of L-type Ca(2+) channels, sarcoplasmic reticulum and Rho kinase in rat basilar artery contractile properties in a new model of subarachnoid hemorrhage

We have previously described that L-type Ca(2+) channels' (LTCCs) activation and metabotropic Ca(2+) release from the sarcoplasmic reticulum (SR) regulate RhoA/Rho kinase (ROCK) activity and sustained arterial contraction. We have investigated whether this signaling pathway can be altered in a new experimental model of subarachnoid hemorrhage (SAH). For this purpose, arterial reactivity was evaluated on days 1 to 5 after surgery. A significant increase of basal tone, measured 4 and 60min after normalization, was observed on day 5 after SAH and at 60min on days 2 and 3 after SAH. This phenomenon was suppressed with LTCCs and ROCK inhibitors. We have also studied arterial rings vasoreactivity in response to high K(+) solutions. Interestingly, there were no significant differences in the phasic component of the high K(+)-induced contraction between sham and SAH groups, whereas a significant increase in the sustained contraction was observed on day 5 after SAH. This latter component was sensitive to fasudil, and selectively reduced by low nifedipine concentration, and phospholipase C and SR-ATPase inhibitors. Therefore, our data suggest that the metabotropic function of LTCCs is potentiated in SAH. Our results could provide a new strategy to optimize the pharmacological treatment of this pathological process.

[Patients with subarachnoid haemorrhage in poor grade neurological status: Study of prognostic factors]

OBJECTIVE

To evaluate and predict factors influencing prognosis and/or clinical outcome at 6 months in patients with spontaneous subarachnoid haemorrhage, World Federation of Neurosurgical Societies (WFNS) grades iv and v.

MATERIAL AND METHODS

This was a retrospective study of a consecutive series of 394 patients admitted to our hospital with clinical and radiological diagnosis of spontaneous subarachnoid haemorrhage, from 1 January 1999 to 30 June 2009. We selected 121 patients who met the criteria of being in WFNS grades iv or v before treatment; 3 patients were excluded due to loss of tracking. The outcome variable was assessed 6 months after the event using the Glasgow Outcome Scale. A P value<.05 was considered statistically significant.

RESULTS

One hundred and twenty-one patients were included in the statistical analysis. The average age of the patients in the series was 54 years (14-92). Patients who had a mean Glasgow Coma Scale lower than 7 points (P<.0001), those who were grade v (P<.0001) in the pre-treatment WFNS scale and those with pupillary disorder (P=.002) had a worse clinical outcome. Likewise, those with associated intraparenchymal hematoma (P=.020) and those not receiving any treatment (P=.020) were also associated with a poor clinical outcome. These results were statistically significant.

CONCLUSIONS

Patients admitted with a WFNS grade v and/or presenting pupil disorder and/or intraparenchymal hematoma were associated with worse clinical outcomes.

Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJECTIVE

To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment.

MATERIAL AND METHODS

A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed.

RESULTS

The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm.

CONCLUSIONS

SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Propuesta de plan de cuidado a la persona con aneurisma cerebral

Objetivo: Describir el plan de cuidado a la persona con Aneurisma Cerebral. Métodos: Se identificaron los dominios de Enfermería alterados  y las necesidades frecuentes en el proceso de salud-enfermedad (Aneurisma Cerebral); también se estableció el juicio (Diagnóstico de enfermería NANDA) que orientó la implementación de objetivos (NOC) y desarrollo de actividades e intervenciones de enfermería (NIC); todo ello con el fin de brindar cuidados integrales a la persona, familia y comunidad, conservar el funcionamiento neurológico y prevenir el riesgo de complicaciones en la persona al cuidado de enfermería con una enfermedad cerebrovascular. Resultados y Conclusiones: Los aneurismas cerebrales son dilataciones localizadas de la pared del vaso arterial y por lo general se encuentran en puntos de bifurcación o en relación con el origen de una rama arterial; todos los aneurismas cerebrales tienen potencial de ruptura y causan complicaciones serias como el accidente cerebrovascular hemorrágico, situación clínica crítica conocida como hemorragia subaracnoidea (HSA). Debido al impacto que tiene dicha patología tanto para la persona, familia y comunidad, el profesional de Enfermería requiere fortalecer los  conocimientos acerca de la patología, el cuidado propio de Enfermería y desarrollar las habilidades que permitan un cuidado integral de éste tipo de personas El PAE es una herramienta fundamental utilizada en la práctica asistencial de la disciplina de Enfermería. Éste favorece la perspectiva del profesional de Enfermería hacia la planificación y el desarrollo de cuidados sistematizados, lógicos y racionales centrados en respuestas humanas dentro del proceso de salud – enfermedad, estos cuidados buscan obtener logros tanto en la persona, familia y comunidad sana o enferma, permitiendo tener una visión holística en el proceso del cuidado diario tanto en áreas clínicas como comunitarias. [Acevedo J, Baracaldo H, Padilla C. Propuesta de Plan de Cuidado a la Persona con Aneurisma Cerebral. MedUNAB 2012; 15:46-52].