Subarachnoid Haemorrhage: ICU Management

OVERVIEW

Oli Flower discusses the ICU management of the aneurysmal SAH patient:

GLUCOSE CONTROL

  • target 6-10 mmol/L
  • in the future continuous glucose monitoring may allow lower glucose targets

ANAEMIA

  • higher Hb values associated with improved outcomes
  • injured brains may lose local vasodilation response to anemia, predisposing to neuronal hypoxia
  • higher Hb may lead to vasospasm and the usual risks of transfusion

FEVER

  • T>38.3 occurs in 70% of SAH (usually non-infectious)
  • requires aggressive control
  • associated with poorer cognitive outcomes
  • seek and treat infection, especially LRTIs, UTI, lines and EVD-associated ventriculitis
  • prevent infection
  • neurogenic fever more likely in IVH, continuous high temperature is the norm
  • drugs are less useful in neurogenic fever, paracetamol and ibuprofen are still used
  • effective: surface coiling devices (e.g. Arctic Sun), intravascular cooling
  • less effective: fanning, evaporative cooling
  • treat shivering: surface counter warming, buspirone, magnesium, pethidine, sedation and paralysis

THROMBOPROPHYLAXIS

  • up to 18% risk of VTE, higher with higher grade SAH
  • avoid heparin until 24h after aneurysm is secured
  • use GCS and IPC

FLUIDS

  • close monitoring of fluid balance and fluid status
  • CVP monitoring and routine use of PAC is not recommended
  • avoid hypotonic solutions such as dextrose and Hartmann’s
  • consider normal saline and albumin

References and Links

LITFL


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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