Scientific letter
Survey of neurocritical patient care in Spain. Part 2: Cerebrovascular disease
Encuesta de atención al paciente neurocrítico en España. Parte 2: Patología cerebrovascular
J.A. Llompart-Poua,
, J.A. Barea-Mendozab, J. Pérez-Bárcenaa, M. Sánchez-Casadoc, M.Á. Ballesteros-Sanzd, M. Chico-Fernándezb, Representing the GT Neurointensivismo y Trauma SEMICYUC
Corresponding author
a Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain
b UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
c Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain
d Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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"apellidos" => "Palomar Martínez" ] 6 => array:1 [ "colaborador" => "SEMICYUC Toxicology Working Groud and the participants of EMPIUCI 13-14" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210569120301856" "doi" => "10.1016/j.medin.2020.06.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569120301856?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572721000795?idApp=WMIE" "url" => "/21735727/0000004500000007/v1_202109230629/S2173572721000795/v1_202109230629/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572721000746" "issn" => "21735727" "doi" => "10.1016/j.medine.2021.06.004" "estado" => "S300" "fechaPublicacion" => "2021-10-01" "aid" => "1448" "copyright" => "Elsevier España, S.L.U. and SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Intensiva. 2021;45:437-41" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Management of the difficult to sedate patient in the Intensive Care Setting" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "437" "paginaFinal" => "441" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo del paciente con sedación difícil en el ámbito de la Medicina Intensiva" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3959 "Ancho" => 2809 "Tamanyo" => 551105 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Recommended algorithm for the management of patients with difficult sedation. The mentioned drugs are not stated according to order of priority. It is advisable to base the choice of drug taking into account the characteristics of the patient and the possible side effects.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dexmedetomidine is recommended in sequential sedation (when we wish to switch from deep sedation to mild sedation), for the treatment of alcohol or pharmacological privation (including benzodiazepines), in patients subjected to extracorporeal membrane oxygenation (ECMO), and in situations of hyperactive delirium. Ketamine should be considered in patients with poor control of pain, status asthmaticus, in individuals subjected to ECMO or in hemodynamically unstable patients. In selected patients, inhalatory anesthetics may be regarded as a first choice, even over benzodiazepines, for maintaining RASS ≤ −4, and can also be used in patients with status asthmaticus or epilepticus. Although typical antipsychotics (haloperidol) and atypical antipsychotics (quetiapine and olanzapine) have not been shown to shorten the duration of delirium, MV or stay in IC, they can be used to control symptoms such as agitation, anxiety or hallucinations. Valproic acid can be used in the case of symptoms refractory to antipsychotic agents. In this regard, we can administer 1500 mg/day divided into 3–4 doses, that may be preceded by a loading dose of 28 mg/kg.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CAM-ICU: Confusion Assessment Method for the ICU.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Alcántara Carmona, M. García Sánchez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Alcántara Carmona" ] 1 => array:2 [ "nombre" => "M." 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"apellidos" => "Llompart-Pou" "email" => array:1 [ 0 => "juanantonio.llompart@ssib.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.A." "apellidos" => "Barea-Mendoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Pérez-Bárcena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Sánchez-Casado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "M.Á." "apellidos" => "Ballesteros-Sanz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Chico-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:1 [ "colaborador" => "Representing the GT Neurointensivismo y Trauma SEMICYUC" ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "UCI de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Virgen de la Salud, Toledo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Encuesta de atención al paciente neurocrítico en España. Parte 2: Patología cerebrovascular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1243 "Ancho" => 2088 "Tamanyo" => 117309 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Objectives of the monitoring, diagnosis and treatment of cerebral aneurysms.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The characteristics of the Units that treat neurocritical patients with cerebrovascular disease are highly variable and can influence the care which such individuals receive.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The Neurointensive Care and Trauma Working Group of the <span class="elsevierStyleItalic">SEMICYUC</span> has conducted a survey on the management of neurocritical patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The characteristics of the survey, the structural aspects of the centers that participated in it, and the common treatment features of all the diseases have been reported elsewhere.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The present study analyzes the clinical aspects referred to patients with central nervous system (CNS) disorders of cerebrovascular origin (non-traumatic subarachnoid hemorrhage [SAH] and acute cerebrovascular disease [ACVD] of hemorrhagic and ischemic origin). The data obtained are reported as frequencies (percentages) or the median (interquartile range [IQR]).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Forty-one valid responses were received (response rate 22.3%). The centers that answered the survey are specified in online Supplementary material.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Subarachnoid hemorrhage</span><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 28 centers (70.7%) treated patients with SAH. The median (IQR) patients/year was 33 (40). The intensivist supervised initial care in 51.7% of the centers.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The following scales were used: Hunt-Hess 93.1%, World Federation Neurological Surgeons 51.7% and Fisher 96.6%. A total of 27.6% of the centers used corticosteroids for the control of headache. In turn, 31% administered antiseizure prophylaxis (27.6% in low-grade SAH and 3.4% on a routine basis), and 41.4% performed triple H (hypertension, hypervolemia, hemodilution) therapy – in all cases using noradrenaline.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The monitoring of intracranial pressure (ICP) in patients with Glasgow Coma Scale (GCS) <9 and the aspects related to the diagnosis and management of the aneurysm are summarized in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Treatment of the aneurysm was preferentially endovascular. In almost all 28 of the centers that treated this disease, surgery was performed in less than 25% of the cases. A total of 89.7% had a specific management protocol, and 27.6% had participated in multicenter studies during the previous 5 years.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Acute hemorrhagic cerebrovascular disease</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 37 centers (90.2%) treated patients with ACVD of hemorrhagic origin. The median (IQR) patients/year was 30 (25). The intensivist supervised initial care in 54.1% of the centers.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 10.8% of the centers used corticosteroids to treat perilesional edema, and 32.4% administered antiseizure treatment on a routine basis. In turn, 33.3% of the centers monitored intracranial pressure in 76–100% of the patients with GCS < 9. The blood pressure targets in the acute phase, and the most frequently administered drugs used for this purpose are described in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. A total of 40.5% had a specific management protocol, and 5.4% had participated in multicenter studies during the previous 5 years.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Acute ischemic cerebrovascular disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 36 centers (87.8%) treated patients with ACVD of ischemic origin. The median (IQR) patients/year was 34 (70). The intensivist supervised initial care in only 16.7% of the centers, while the neurologist was in charge in 72.2%.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to the organizational characteristics and the availability of procedures, 94.4% of the centers had a stroke/tele-stroke code, 72.2% were able to provide 24-h intraarterial thrombolysis/mechanical thrombectomy, and 83.3% were able to perform decompressive craniotomy in acute malignant middle cerebral artery disease of ischemic origin. Great variability was observed regarding the time limit for decompressive surgery: <24 h (12.9%); <48 h (29%); <72 h (19.4%); and no time limit (38.7%). A total of 63.9% of the centers had a specific management protocol, and 2.8% had participated in multicenter studies during the previous 5 years.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our results are consistent with those found in the literature regarding the diagnosis of exclusion of aneurysm and the sealing of these lesions. Most of the centers (96.6%) performed the diagnosis of exclusion of aneurysm within the first 48 h. In the recently updated quality indicators of the SEMICYUC, indicator 35 addresses this issue, considering it necessary to reach 90% within the first 24 h.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although no direct comparison can be made because of the variations in time window, the survey responses obtained suggest good compliance in our Units. With regard to aneurysm management, the percentages obtained are in line with the data of the cerebrovascular disease group of the Spanish society of Neurosurgery,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which evidence a predominance of endovascular treatment and an incidence of up to 17% of untreated aneurysms.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The management of blood pressure in ACVD of hemorrhagic origin is more controversial. Three treatment groups are contemplated. In 63.9% of the centers treatment was adjusted to a systolic blood pressure (SBP) target of 140–180 mmHg, while 33.3% sought a target of <140 mmHg. The INTERACT study compared a SBP target of 140 mmHg versus 180 mmHg, and found a pressure target of 140 mmHg to be associated to a decrease in hematoma growth without major side effects,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> defining it as a standard of care. Posteriorly, the ATACH-II study compared standard treatment (blood pressure 140–179 mmHg) versus intensive care (blood pressure 110–139 mmHg). No differences were observed between the two groups in terms of the neurological outcome, though the patients subjected to intensive care had a greater incidence of renal failure (9% versus 4%; p = 0.002).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Thus, in our opinion an initial target of 140–180 mmHg seems reasonable, with more aggressive intervention in young individuals without comorbidities (in such cases a target of slightly under 140 mmHg may even be considered) and more permissive management (in the range of 160–180 mmHg) in older individuals, long-evolving hypertensive patients and subjects with important comorbidities.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In relation to ACVD of ischemic origin, the intensivist did not supervise initial management, which fundamentally corresponded to the neurologist. In addition, there was practically no participation of intensivists in multicenter studies. This evidences that with the exception of certain Departments of Intensive Care Medicine,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> the role of the intensivist in the initial management of ACVD of ischemic origin is very limited. We observed great variability in terms of the time limit for decompressive surgery. A recent study has shown that the earlier the intervention, the better the final outcome. Although a 48-h time window was suggested, the patient course was more closely related to the performance of hemi-craniectomy before herniation than to any concrete time window.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Subarachnoid hemorrhage" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Acute hemorrhagic cerebrovascular disease" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Acute ischemic cerebrovascular disease" ] ] ] 1 => array:2 [ "identificador" => "xack556902" "titulo" => "Acknowledgements" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Llompart-Pou JA, Barea-Mendoza JA, Pérez-Bárcena J, Sánchez-Casado M, Ballesteros-Sanz MÁ, Chico-Fernández M. Encuesta de atención al paciente neurocrítico en España. Parte 2: Patología cerebrovascular. Med Intensiva. 2021;45:e1–e3.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0025" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1243 "Ancho" => 2088 "Tamanyo" => 117309 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Objectives of the monitoring, diagnosis and treatment of cerebral aneurysms.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1898 "Ancho" => 1591 "Tamanyo" => 110462 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Blood pressure target in the acute phase of hemorrhagic cerebrovascular disease and the most commonly used drugs.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 65524 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "PRINCE Study Investigators. 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