Transcript Massive hemoptysis

Yasser B. Abulhasan, MBChB, FRCPC
Assistant Professor of Anesthesiology
Faculty of Medicine, Kuwait University
Specialist in Neuroanethesiolgy and Neurocritical Care
Department of Anesthesia and Intensive Care Unit, Ibn Sinai Hospital, Kuwait
Disclosure

No conflict of interest relevant to this lecture
Outline

Overview and Epidemiology

Early Patient Care

Recommendations
Background

aSAH is a devastating neurological emergency, can
have long term consequences

The major cause of morbidity and mortality
 Initial hemorrhage (ictus)
 Rebleeding (1-3 days)
 Cerebral ischemia due to vasospasm (4 – 14 days)
Definitions

Delayed neurological deterioration (DND):
clinically detectable neurological deterioration
in a SAH patient following initial stabilization

Vasospasm: arterial narrowing after SAH
demonstrated by radiographic images or
sonography

Delayed Cerebral Ischemia (DCI): neurological
deterioration (e.g. hemiparesis, aphasia,
altered consciousness) presumed related to
ischemia / hypoperfusion for more than an
hour – cerebral infarction
Epidemiology

6 - 21 per 100,000 patient years

5% of acute cerebrovascular events

27.3% of all stroke-related years of
potential mortality <65
Johnston, S.C., et al. Neurology, 1998. 50(5): p. 1413-8.
van Gijn, J., R.S. Kerr, and G.J. Rinkel. Lancet, 2007. 369(9558): p. 306-18.
Lloyd-Jones, D., et al. Circulation, 2009. 119(3): p. e21-181.
Natural History

10% die immediately

25% die within 24 hours

40% die in the first 30 days

Mortality and severe morbidity 60%
Early Patient Care
 Prevention of rebleeding
 Seizure prophylaxis
 Treatment of acute hydrocephalus
 ICP control
 Analgesia
 Cardiopulmonary Complications
 Intravascular Volume Status
 Glucose management
Early Patient Care
 Prevention of rebleeding
 Seizure prophylaxis
 Treatment of acute hydrocephalus
 ICP control
 Analgesia
 Cardiopulmonary Complications
 Intravascular Volume Status
 Glucose management
GRADE system

Keeps quality of data and
recommendations explicitly separate

Allows for strong recommendations in
the setting of lower quality evidence

Useful in the ICU
Atkins, D., et al., BMJ, 2004. 328(7454): p. 1490.
Rebleeding
Common
 5 – 10% within the first 72 hours
 Mortality as high as 80% in patients who
rebleed

 Risk factors
○ Larger aneurysms
○ Poor grade SAH
○ Presenting with LOC or sentinel bleeds
○ Catheter angiography within 3 hours of ictus
Molyneux, A.J., et al., (ISAT). Lancet, 2005. 366(9488): p. 809-17.
Preventing Rebleeding

Early securing the ruptured aneurysm
(< 4 days)
 Coil embolization
 Microsurgical exclusion
○ Delays in aneurysmal repair
Preventing Rebleeding

Does stringent BP reduction reduce the incidence
or rebleeding in patients awaiting definitive
management?

Do any medical interventions reduce the incidence
of rebleeding in patients awaiting definitive
management of their ruptured aneurysm?
Preventing Rebleeding
Does stringent BP reduction reduce the incidence or
rebleeding in patients awaiting definitive
management?
 No systematic data addressing BP levels
 Consensus - modest BP elevation (SBP
<160 or MAP <110) is acceptable
Preventing Rebleeding

Do any medical interventions reduce the incidence of
rebleeding in patients awaiting definitive
management of their ruptured aneurysm?

Antifibrinolytics (TXA, EACA)
 Prior to 2002, 9 studies showed no benefit on poor
outcome or death despite significant reduction in
rebleeding
○ Higher incidence of cerebral ischemia
 Weeks of therapy
 Late start
Harrigan, M.R., et al., Neurosurgery, 2010. 67(4): p. 935-9; discussion 939-40.
Hillman, J., et al., Journal of neurosurgery, 2002. 97(4): p. 771-8.
Starke, R.M., et al., Stroke; a journal of cerebral circulation, 2008. 39(9): p. 2617-21.
Antifibrinolytics
 2002 – 2010, 1 randomized trial, 2 case
studies
○ Early, short course of antifibrinolytics reduced
rebleeding
 Risk reduction 2.5 – 11%
Starke, R.M. and E.S. Connolly, Jr., Neurocritical care, 2011. 15(2): p. 241-6.
Recommendations

“Delayed (>48 h after the ictus) or prolonged
antifibrinolytic therapy exposes patients to side effects
of therapy when the risk of rebleeding is sharply
reduced and should be avoided”
 (High quality evidence: Strong recommendation)

Antifibrinolytic therapy is relatively contraindicated in
patients with risk factors for thromboembolic
complications
 (Moderate quality evidence: Strong recommendation)

An early, short course of antifibrinolytic therapy should
be considered
 (Low quality evidence: Weak recommendation)
Seizures and Prophylactic
Anticonvulsants

Does anticonvulsant prophylaxis influence the
incidence or convulsive and non-convulsive seizures
after aSAH?

Seizure-like activities are common
 True seizure versus posturing at ictus

Incidence 1 – 7 % and often manifestation of rerupture

Risk factors
 Surgical aneurysm repair in patients >65
 Thick subarachnoid clot
 Intraparenchymal hematoma or infarction
Seizures and Prophylactic
Anticonvulsants

Prophylactic treatment with anticonvulsants
is common place

Outcome studies have showed worsened
long term outcome (phenytoin)
 Other anticonvulants’ impact is less clear

In patients with no history of seizure, “a
short course (72hrs) of anticonvulsant
medications seems as effective as a more
prolonged course in preventing seizures”
Chumnanvej, S.. Neurosurgery, 2007. 60(1): p. 99-102; discussion 102-3.
Seizures and Prophylactic
Anticonvulsants

In poor grade SAH patients
 Non-convulsize seizures, worsened outcome
 cEEG may detect 10 – 20%
 Impact of successful treatment has not been studied
 In higher risk groups, short course (3-7 days) seems
considerable
 Evidential seizure (epileptic focus) should be treated for 3
– 6 months.
Recommendation

Routine use of anticonvulsant prophylaxis with
phenytoin is not recommended after SAH

“Continuous EEG monitoring should be
considered in patients with poor-grade SAH
who fail to improve or have neurological
deterioration of undetermined etiology”
 (low quality evidence – strong recommendation)
Conclusion
 aSAH
is a devastating neurological
emergency, can have long term
consequences

Recommendation from the consensus
conference are a first step towards
improving patient care of aSAH patients
Thank you for your
attentive attendance