Intensive Care Management of Ischemic and Hemorrhagic Stroke

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Intensive Care Management of Ischemic and
Hemorrhagic Stroke

• Northern Michigan Hospitals
• Stroke Care The Pursuit of Clinical Excellence
  Workshop
• 21 September 2007
• William M. Coplin, MD, FCCM
• Associate Professor of Neurology Neurological
  Surgery
• Chief of Neurology and Medical Director of
• Neurotrauma Critical Care
• Detroit Receiving Hospital, Detroit, Michigan
• wcoplin_at_med.wayne.edu

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Usual Disclosures/Disclaimers

• NIH/NINDS
• ACCP
• SCCM
• Astellas Pharma US
• At one time or another I have prescribed the
  drugs manufactured by most of the companies
  producing drugs to alter blood pressure and
  received support from one of them
• PDL BioPharma

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Topics

• Pulmonary Care Breathe Deep
• Blood Pressure Why All the Confusion?
• Electrolytes Spice of Life
• Antibiotics What bugs are in your home?
• Seizures No Shaking Necessary
• VTE Prophylaxis Avoiding the Clots
• Agitation Wake up Swinging
• Outcomes Nihilism or Hopefulness

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• Breathe Deep

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Ventilation and Oxygenation Goals

• Optimize cerebral oxygenation
• Brain consumes 15 of cardiac output and 20 of
  available O2
• Hypoxia associated with poor outcome
• Data supporting oxygen toxicity in critically ill
  patient not compelling
• Hyperventilation
• May treat ICP elevations at the cost of CBF
• Hypoventilation
• Shifts Hgb-O2 saturation curve, facilitating O2
  delivery and improving PbtO2
• Is there a role for permissive hypercarbia?

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Effective Airway Management

• Maintain or establish patent airway early to
  prevent hypoxemia
• Tracheostomy?
• Does it facilitate secretion removal, airway
  management, disposition?
• Safety PEEP lt 8, FiO2 lt 50, able to lie flat x
  30 min
• Extubation requirements
• Can patient oxygenate, ventilate and protect
  airway?
• Do not have to be awake following commands

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Pneumonia Risk

• LOC and EtOH use increase risk of aspiration
• Risk 26-42
• Risk factors include - Staph aureus nasal
  carriage, aspiration, barbiturate use
• Lower PaO2/FiO2 ratio, more febrile days, more
  frequent hypotension, increased ICP
• Coplin W et al. Am J Respir Crit Care Med
  20001611530-6
• Bronchard R et al. Anesthesiology 2004100234-9
• Goals of care
• Eliminate risk factors - vent bundles, oral
  care, hygiene
• Early diagnosis
• Early and appropriate antibiotic therapy

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• Blood Pressure
• Why All The Confusion?

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Randomized Controlled Trials of BP Management
After Stroke/ICH

• (none)

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Evaluation of Nicardipine and Labetalol for Acute
Blood Pressure Control Following Stroke
Xi Liu, PharmD James Janisse, PhD Dennis Parker
Jr, PharmD Joe Ager, PhD William Coplin,
MD Denise Rhoney, PharmD

• Presented at 2006 SCCM Annual Congress

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Blood Pressure Reduction
-6.9 -14.0
-9.5 -15.5
P NS
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Specific Outcomes
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Time to Goal in ICH Patients

• Nicardipine vs. labetalol
• 5.1 times as many patients reached goal within 1
  hr with nicardipine as did with labetalol
• 56 vs 11
• p 0.02
• For comparison
• Nicardipine 14 min to response with 1.5
  adjustments
• SNP 30.4 min to response with 5.1 adjustments
• Halpern NA, et al. Crit Care Med.
  1992201637-1643
• Nicardipine11.5 min to response
• IV Nicardipine Study Group. Chest. 199199393-398

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BP Variability
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Randomization Scheme
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• Spice of Life

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Electrolytes

• Glucose
• Sodium
• Determination of volume status is critical
• Potassium
• May transiently increase with tissue injury or
  underperfusion
• Increased filtered/excreted K with elevated
  aldosterone may cause overall K depletion
• Magnesium
• Potential neuroprotection
• Ongoing study

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Glucose Control

• Early hyperglycemia associated with poor outcomes
  after stroke
• Conventional vs. intensive glucose control in
  ischemic stroke and ICH patients
• Insufficient evidence
• In TBI, patients with intensive therapy had
  reduced ICP, less frequent seizures, higher KPS _at_
  6 and 12 months
• Van den Berghe et al. Neurology. 20005641348-53

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Water Balance

• Hyponatremia
• Overall incidence of 7 in ICH and 4.5 in AIS
• Kusuda K. et al. 1989
• Iatrogenic
• Syndrome of Inappropriate ADH (SIADH)
• Cerebral Salt Wasting (CSW)
• Misdiagnosis may exacerbate problem
• Hypernatremia
• Iatrogenic
• Diabetes Insipidus (DI)

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Diabetes Insipidus - Central

• No problemif free access to water
• If nothypernatremic volume contraction
• Treatment
• Replete free water
• Maintain euvolemia - isotonic fluids
• Administer vasopressin or desmopressin
• Avoid offending medications

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Etiology of Hyponatremia

• SIADH
• Increased release of ADH through direct injury,
  hypercapnia, hypoxia, pain, medication effects
• SIADH
• Increased release of atrial naturietic factor
• Renal Na loss

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Hyponatremia SIADH vs CSW

• Key difference response to fluid restriction

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Hyponatremia General Principles

• Determine severity of symptoms
• Seizures
• Abrupt change in LOC
• Worsening edema or ICP
• Determine rate of development
• May be treated more rapidly if acute, rather
  than chronic
• Assess volume status

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Hyponatremia Initial Interventions

• Eliminate sources of free water
• Check medication solutions
• If developed rapidly (gt 0.5 mEq/L/hr)
• May correct _at_ 1-2 mEq/L/hr to achieve Na
  128-130
• Complete normalization over 1-2 days after
  initial correction
• Maximum correction 20 mEq/L in 1st 48 hrs

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SIADH Treatment

• Acute
• Fluid restriction?
• Avoid hypotonic fluids
• Supplementation saline
• Furosemide to enhance free water excretion?
• Follow K closely
• Conivaptan to enhance free water excretion?
• Chronic
• Demeclocycline 300 mg q 6 hrs
• Fludrocortisone 0.1-0.2-0.3 mg/day

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CSW Treatment

• Hydration
• Saline
• Fluid restriction will worsen condition

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Na
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Other Important Equations

• knowledge power
• time money
• power work / time
• ? knowledge work / money
• Solving for money, money work / knowledge
• Thus money approaches 8 as knowledge approaches
  0, regardless of the work done
• Or, the less you know, the more you make

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• What bugs are in your home?

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Rational Antibiotic Therapy

• Every ICU has its own biogram -- ask!
• Organ and Tissue Donation Policy
• Brain Death Protocols
• Donation after Cardiac Death Policy
• No evidence to support empiric antibiotics
• If clinical indications of infection, culture
  then start antibiotics based on biogram
• Believe your cultures
• If negative -- stop antibiotics
• If positive -- narrow spectrum of antibiotics
• Duration of therapy?

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ID Issues
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Suggested Empiric Regimens
Increasing incidence of multi-drug resistant
bacteria
Rational antibiotic use Narrow coverage whenever
possible Set duration of therapy
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• No Shaking Necessary

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Incidence of Seizuresafter Ischemic Stroke

• 2-6 incidence of seizure after stroke
• 22-27 as status epilepticus
• Lobar strokes more likely than others?
• No relation to stroke severity (NIHSS)
• Seizures not predictive of outcome
• No influence on mortality

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Incidence of Seizures afterIntracerebral
Hemorrhage

• 11.2 (n 14) had documented seizures before or
  while in the ED
• Demographic and presenting clinical features
  similar between the seizure and non-seizure groups

Durkee NJ et al.
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CT Characteristics
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Clinical Features
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Outcome

• Having a seizure unrelated to presenting and
  discharge GCS and GOS
• Seizures unrelated to mortality
• 12 (11/91) of survivors
• 9 (3/34) of those dying before discharge

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Antiseizure Prophylaxis

• Data insufficient to support recommendation
• No AAN practice parameter
• Expectant management

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Concerns re Prophylaxis

• Side effects
• Cognitive impairment
• Myelosuppression
• Liver dysfunction
• Dermatological
• Socioeconomic issues
• Cost (meds monitoring)
• Discomfort

• Drug-Drug Effects
• Steroids
• Chemotherapy
• Anticoagulation
• Oral Contraceptives
• Anti-hypertensives
• Antibiotics

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• Avoiding the Clots

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DVT Prophylaxis after Stroke

• Prospective study, 1762 patients w/ stroke
• Randomized within 48 hours of stroke for 10 d
• Enoxaparin 40 mg SQ qd
• Unfractionated heparin 5000 units SQ q12h
• Similar symptomatic ICH (1)
• Results
• Increase in major extracranial bleeding
• Enoxaparin reduced risk of VTE by 43

Sherman DG et al. Lancet. 20073691347-55
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DVT Prophylaxis after ICH

• No randomized trials of prophylactic
  anticoagulants
• Intermittent pneumatic compression devices better
  than elastic stockings alone
• Lacut K et al. Neurology. 200565865-9
• Anticoagulation for DVT appears safe
• Kelly J et al. Stroke. 2003342999-3005

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• Wake up Swinging

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ICU Agitation

• Subtype of delirium
• Characterized by excessive behaviors
• Aggression
• Disinhibition
• Emotional lability
• Motor disturbances

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Etiology

• Medical factors
• Infection, metabolic, pain
• Neurological factors
• Intracranial pressure, hydrocephalus
• Injury to fronto-temporal pathways
• Altered reactive response to stimuli
• Multiple cortical, subcortical brainstem
  systems
• Alterations in neurotransmitters
• Catecholamines, serotonin, acetylcholine
• Alterations in sleep-wake cycles

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Pharmacological Management

• Acute safety issues
• Long-term management
• Symptom guided treatment
• Aggression -- serotonin
• Memory -- acetylcholine
• Arousal / Attention -- catecholamines
• Motor disturbances -- dopamine
• Disinhibition/Lability -- combined

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Potentially Harmful Agents

• Benzodiazepines
• Dopamine antagonists
• Neuromuscular blockade
• Anticholinergics
• H2 receptor antagonists ranitidine, etc.
• Antihypertensives clonidine, prazosin
• Anticonvulsants phenytoin, phenobarbital

Goldstein LB. Neurology. 199545865-71
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Pharmacological Management

• Antipsychotics
• Dopamine antagonists
• Treat aggression by causing sedation
• Good immediate intervention for safety issues
• May lower seizure threshold
• Paradoxical agitation
• Long term use can impair motor recovery
• Anxiolytics Benzodiazepines
• GABA pathways
• Utility rapid resolution of violent agitation
• May prolong coma impair learning memory
• Work synergistically with antipsychotics

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Pharmacological Management

• Anticonvulsants GABA ?2-adrenergic pathways
• Treat impulse-control disorders, anxiety
• May slow reaction time visuomotor speed
• Adjust dose by clinical response, not drug
  concentrations
• Stimulants Dopamine agonists
• Treats agitation improves motivation
• Agents amantadine, bromocriptine, Sinemet
• Works or doesnt -- effects noted within
  days
• Stimulants Sympathomimetics (Catecholamine?)
• Treats attention / arousal problems, depression
• Agents methylphenidate, d-amphetamine

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• Nihilism or Hopefulness

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Prognosis

• Predictive algorithms
• Clinical exam
• Electrophysiological studies
• Neuroimaging
• Family education

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Prognosis

• Predictive algorithms
• Clinical exam
• Electrophysiological studies
• Neuroimaging
• Family education

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Transition to Rehabilitation

• Early consultation with rehabilitation
  specialties
• PMR involvement shortly after admission
• Multidisciplinary rounds
• PT, OT, Speech
• Mobilize patient
• Surgical interventions
• Tracheostomy, PEG tube, IVC filter
• Facilitation of transfer to rehabilitation
  setting
• Role of Care Management specialists

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