大半球梗死的管理

1、Evidence-Based Guidelines for the Management of Large Hemispheric InfarctionEvidence-Based Guidelines for the Management of Large Hemispheric Infarction Although the recently published American Heart Association guidelines on management of cerebral and cerebellar infraction with swelling addressed s

2、ome of the critical care management issues, this statement is addressing specific questions that intensivists deal with on a day-to-day basis on rounds.Evidence-Based Guidelines for the Management of Large Hemispheric Infarction The definition of LHI with regard to this consensus statement is an isc

3、hemic stroke affecting the total or subtotal territory of the MCA, involving the basal ganglia at least partially, with or without involvement of the adjacent (i.e., ACA or PCA) territories.Airway Management GCS 2/3 of MCA territory, Midline shift on imaging co-existence of pulmonary edema or pneumo

4、niaMilhaud D, Popp J, Thouvenot E, Heroum C, Bonafe A. Mechanical ventilation in ischemic stroke. J Stroke Cerebrovasc Dis. 2004;13(4):1838.Airway Management The prediction of successful extubation is equally crucial. Impaired LOC and a high prevalence of dysphagia In a small retrospective study of

5、MCA stroke patients, a composite GCS score8 with an eye subscore of 4 was associated with successful extubationWendell LC, Raser J, Kasner S, Park S. Predictors of extubation success in patients with middle cerebral artery acute ischemic stroke. Stroke Res Treat. 2011;2011:248789.Airway Management M

6、ore recent randomized trial on early tracheostomy(within day 1-3 from intubation) in mixed cerebrovascular ICU patients demonstrated safety, feasibility, and reduction of sedation needs.(SETPOINT)Bosel J, Schiller P, Hook Y, Andes M, Neumann JO, Poli S, et al. Stroke-related early tracheostomy versu

7、s prolonged orotracheal intubation in neurocritical care trial (SETPOINT): A Randomized Pilot Trial. Stroke. 2012.Airway Management LHI patients with signs of respiratory insufficiency or neurological deterioration should be intubated immediately (strong recommendation, very low quality of evidence)

8、. Extubation should be attempted in LHI patients who meet the following criteria, even if communication and cooperation cannot be established (strong recommendation, very low quality of evidence): Successful spontaneous breathing trials Absence of oropharyngeal saliva collections Absence of demand f

9、or frequent suctioning Presence of cough reflex and tube intolerance, Free of analgesia and sedation Tracheostomy should be considered in LHI patients failing extubation or in whom extubation is not feasible by 714 days from intubation (weak recommendation, low quality of evidence).Hyperventilation過

10、度通氣PCO235mmHg腦血管收縮(反盜血)ICP起效快（數(shù)分鐘）最大起效（30min）1-3h后開始失效6-12h緩慢停止過度通氣腦血管收縮腦梗死ICP反跳Hyperventilation We recommend against prophylactic hyperventilation in LHI patients (strong recommendation, very low quality of evidence). We suggest using hyperventilation for short period of time as a rescue maneuver i

11、n LHI patients showing clinical signs of brain herniation (weak recommendation,very low quality of evidence).Analgesia and Sedation However, patients with exhausted ICP compliance may pose a high risk for critical ICP increase during wake-up trials.Skoglund K, Enblad P, Marklund N. Effects of the ne

12、urological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care. 2009;11(2):13542.Analgesia and Sedation We recommend analgesia and sedation if signs of pain, anxiety, or agitation arise in LHI patients (strong recommendation, very low quali

13、ty of evidence). We recommend the lowest possible sedation intensity and earliest possible sedation cessation, while avoiding physiologic instability and discomfort in LHI patients (strong recommendation, very low quality of evidence). We recommend against the routine use of daily wakeup trials in L

14、HI patients. Caution is particularly warranted in patients prone to ICP crises. Neuromonitoring of at least ICP and CPP is recommended toguide sedation, and daily wake-up trials should be abandoned or postponed at signs of physiological compromise or discomfort (strong recommendation, very low quali

15、ty of evidence).Gastrointestinal Tract We suggest dysphagia screening in the early phase of LHI. Dysphagia can be assessed once the patient is weaned from sedation and ventilation (weak recommendation, very low quality of evidence). LHI patients with dysphagia should receive a nasogastric tube as so

16、on as possible (weak recommendation, very low quality of evidence).Glucose Control We recommend that hypoglycemia and hyperglycemia should be avoided in LHI. Intermediate glycemic control (serum glucose level 140180 mg/dl) should be the target of insulin therapy in LHI patients (strong recommendatio

17、n, very low quality of evidence). We recommend that intravenous sugar solutions should be avoided in LHI (strong recommendation, very low quality of evidence)Hemoglobin Control We recommend maintaining a hemoglobin of 7 g/dl or higher in LHI patients (strong recommendation, very low quality of evide

18、nce). Clinicians should also consider specific situations such as planned surgery, hemodynamic status, cardiac ischemia, active significant bleeding, and arteriovenous oxygen extraction compromise when determining the ideal hemoglobin for a patient (weak recommendation,very low quality of evidence).

19、 Consider reducing blood sampling wherever possible inorder to decrease the risk of anemia in LHI (Weak recommendation, very low quality of evidence).Deep Venous Thrombosis Prophylaxis We recommend early mobilization to prevent DVT in hemodynamically stable LHI patients with no evidence of increased

20、 ICP (strong recommendation, very low quality of evidence). We recommend DVT prophylaxis for all LHI patients upon admission to the ICU and for the duration of immobilization (strong recommendation, very low quality of evidence). We recommend using IPC for DVT prophylaxis (strong recommendation, mod

21、erate quality of evidence) We recommend using LMWH for DVT prophylaxis (strong recommendation, low quality of evidence). We recommend against the use of compression stockings for DVT prophylaxis (strong recommendation, moderate quality of evidence). 【64 5% vs 16 1%; odds ratio 4.18, 95% CI 2.40-7.27

22、】Dennis M, Sandercock PA, Reid J, Graham C, Murray G, Venables G, et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 2009;373(9679):195865.Anticoagulation We

23、 suggest that oral anticoagulation be reinitiated 24 weeks after LHI in patients at high thromboembolic risk (weak recommendation, very low quality of evidence). We suggest that earlier re-initiation of oral anticoagulationshould be based on clinical risk assessment and additional diagnostic tests (

24、e.g., prosthetic valve, acute DVT, acute PE, or TEE showing intracardiac thrombus) (weak recommendation, very low quality of evidence). We suggest using aspirin during the period of no anticoagulation in LHI with AF or increased thromboembolic risk, provided surgery is not imminent (weak recommendat

25、ion, very low quality of evidence).Blood Pressure Management We recommend that clinicians follow current blood pressure management guidelines for ischemic stroke in general when caring for LHI patients. Maintain a MAP 85 mmHg in ischemic stroke without hemorrhagic transformation. Lower SBP to 220 mm

26、Hg (strong recommendation, low quality of evidence). We suggest avoiding blood pressure variability, especially in the early phase of LHI treatment (weak recommendation, low quality of evidence).Steroid Therapy&Barbiturate Therapy We recommend against using steroids for brain edema in patients w

27、ith LHI (strong recommendation, low quality of evidence). Barbiturate therapy is not recommended in patients with LHI because the risks outweigh the benefits (strong recommendation, low quality of evidence).Temperature Control We suggest considering hypothermia as a treatment option in patients who

28、are not eligible for surgical intervention(weak recommendation, low quality of evidence). If hypothermia is considered, we suggest a target temperature of 3336 C for duration of 2472 h (weakrecommendation, low quality of evidence). We suggest maintaining normal core body temperature(weak recommendat

29、ion, very low quality of evidence).Head Position We suggest a horizontal body position in most patients with LHI. However in patients with increased ICP, we suggest a 30 backrest elevation (weak recommendation, very low quality of evidence).Osmotic Therapy We recommend using mannitol and hypertonic

30、saline for reducing brain edema and tissue shifts in LHI only when there is clinical evidence of cerebral edema (strong recommendation, moderate quality of evidence). We suggest using osmolar gap instead of serum osmolality to guide mannitol dosing and treatment duration (weak recommendation, low qu

31、ality of evidence). Hypertonic saline dosing should be guided by serum osmolality and serum sodium (strong recommendation, moderate quality of evidence). We recommend using mannitol cautiously in patients with acute renal impairment (strong recommendation, moderate quality of evidence). We recommend

32、 using hypertonic saline cautiously in patients with volume overload states (i.e., heart failure, cirrhosis, etc.,) since this agent will expand intravascular volume (strong recommendation, high quality of evidence).Osmotic Therapy OG = measured serum osmolality - calculated osmolality Calculated os

33、molality = 2 x Na mmol/L + glucose mmol/L + urea mmol/L + 1.25 x Ethanol mmol/L A normal osmol gap is 10 mOsm/kg Neuroimaging by CT and MRI&Ultrasound We recommend using early changes on CT and MRI to predict malignant edema after LHI strong recommendation, low quality of evidence). We suggest u

34、sing TCCS as a complimentary test to predict malignant course and possibly as a primary test if the patient is too unstable to be transferred outside the ICU for neuroimaging (weak recommendation, low quality of evidence).Evoked Potentials We suggest considering BAEP as a complimentary method to pre

35、dict malignant course within the first 24 h after MCA infarction, particularly in patients too unstable to be transported to neuroimaging (weak recommendation, very low quality of evidence).EEG We suggest considering EEG in the first 24 h after stroke to assist with predicting clinical course in LHI

36、 (weak recommendation, very low quality of evidence). We suggest that continuous and quantitative EEG represent a promising non-invasive monitoring technique and a tool for estimation of prognosis after LHI that might be useful in the future pending further study (weak recommendation, very low quali

37、ty of evidence).Surgical Management We recommend DHC as a potential therapy to improve survival after LHI regardless of patient age (strong recommendation, high quality of evidence). In patients older than 60 years, we recommend taking in consideration patients and family wishes, since in this age group, DHC can reduce mortality rate but with a higher likelihood of being severely disabled (strong recommendation, moderate quality of evidence). There is currently insufficient data to recommend against