Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

MANAGEMENT OF THE PATIENT WITH CEREBRAL ANEURYSM / ANEURYSMAL SUBARACHNOID HAEMORRHAGE (SAH)
Expected Outcome
Staff utilising the following protocol will have the necessary information to appropriately monitor, assess and intervene in the care of patients who have been diagnosed with a cerebral aneurysm and/or have had a subarachnoid haemorrhage requiring medical management, surgical clipping or endovascular coiling of the aneurysm. Patients admitted to Liverpool Health Service with a diagnosis of cerebral aneurysm/aneurysmal subarachnoid haemorrhage will be managed in a holistic manner incorporating all members of the health care team whose goals are to: prevent cerebral bleeding, infection and the consequences of vasospasm and hydrocephalus. reduce intracranial pressure and neurological deficits related to the primary mechanism of injury. avoid hypoxia and secondary brain damage. commence rehabilitation and foster neurological and total body functioning to preadmission state or better.

Policy Statement

Haemodynamic or neurological deterioration (as per the patients level of consciousness, Glasgow Coma Score assessment or evidence of focal deficit) will be assessed, documented and reported - intervention strategies will be implemented and assessed for their effectiveness.

Protocol Contents:
3.1.1. 3.1.2 3.1.3. 3.1.4. 3.1.5. 3.1.6. 3.1.7. Pre-operative management of the patient with suspected subarachnoid haemorrhage [SAH] in the Emergency Department or ICU. Pre-operative management of the patient with confirmed subarachnoid haemorrhage and vasospasm in the Intensive Care Unit. Pre-operative management of the patient with suspected subarachnoid haemorrhage [SAH] in the Neurosurgical Ward. Post-operative management of the patient with elective clipping/coiling of a cerebral aneurysm. Post-operative management of the patient with aneurysmal subarachnoid haemorrhage in the Recovery Room and ICU. Post-operative management of the patient with aneurysmal subarachnoid haemorrhage in the Neurosurgical Ward.

Background Information for these Policies: Vasospasm Cranial Nerve Deficit Testing Focal Deficits Hunt and Hess Classification of SAH Grades References

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

PRE-OPERATIVE MANAGEMENT OF THE PATIENT WITH SUSPECTED SAH IN THE EMERGENCY DEPARTMENT OR ICU
Expected Outcome
Patients presenting to the Emergency Department and transferred to the Intensive Care Unit with a diagnosis of subarachnoid haemorrhage will have haemodynamic monitoring and neurological assessment performed frequently to assess current condition and allow interventions to occur.

Policy Statement
The Neurosurgical Registrar must be informed when a patient with a suspected or confirmed subarachnoid haemorrhage arrives in the Emergency Department - prior to a proposed transfer to the Ward or ICU. The patient will have continuous haemodynamic monitoring with attention to electrocardiograph (ECG) irregularities and prompt intervention. Blood pressure (BP) will be normalised to the patients pre-morbid level and peaks and troughs in the BP will be avoided or managed. Frequent neurological assessment using the Glasgow Coma Scale (GCS) will be attended as the patient is at risk of re-bleeding (estimated incidence of 35-40%). History should be assessed for incidence of a previous cerebral bleed (sentinel bleed), as vasospasm may already be insitu, thus delaying surgery. The presence of vasospasm, raised intracranial pressure and/or neurological deterioration necessitates transfer to the Intensive Care Unit. There is to be no avoidable delay in the commencement of the prescribed drug therapy nimodipine. A Medical Emergency Team (MET) call is to be initiated when the GCS falls by 2 points, and as per MET calling criteria. Documentation of neurological assessment is to occur even where protocols exist for documentation by exception.

Emergency and ICU Observations

Hourly or more frequent neurological and haemodynamic observations. Maintain systolic BP <140 - 160mmHg; if grossly labile consider infusion of sodium nitroprusside, avoid peaks and troughs in blood pressure. Maintain SpO2 95% with nil respiratory distress. If GCS < 9, protect the airway and prepare for intubation. Obtain 12 lead ECG, commence continuous ECG monitoring; observe and treat cardiac dysrhythmias. If monitoring Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP) is maintained at 70mmHg, ICP is tolerated at 20mmHg if higher, drain cerebrospinal fluid (CSF), then utilise drug therapies as prescribed by Intensive Care Registrar or Senior Neurosurgical Registrar. Maintain normothermia if temperature increases above 370C, use paracetamol and cooling measures (as per Temperature Regulation guidelines, No._); avoid shivering. Maintain normal electrolyte and blood sugar levels. Ensure accurate fluid balance documentation, urinary output at minimum of 0.5mL/kg/hr. Ensure family/carers informed, contact Social Worker as required; document all teaching/information given. If vasospasm is present upon admission, surgery may be delayed. Optimise CPP without causing a high systolic blood pressure with risk of further bleeding. Report any deterioration in the Glasgow Coma Score (GCS) or evidence of focal deficit immediately.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

Environment: non-stimulating, quiet, comfortable.

Maintain patient on bed-rest with toilet privileges or as required. Visitors are limited. Assist with activities of daily living. Antiembolic stockings are worn to reduce the incidence of deep venous thrombosis or calf-compression device is insitu. Hair wash (gentle) on day of surgery where possible, nil head shave unless specifically requested.

ICU Procedures
Insert a triple lumen central venous access using a subclavian or internal jugular approach. Attach a transducer and monitor central venous pressure. Intubate and ventilate as indicated. Utilise a volume-controlled ventilatory mode e.g. Synchronised intermittent mandatory ventilation with pressure support (SIMV + PS), it is inappropriate to wean ventilation prior to surgery.

ICU Tests
ECG. Chest X-Ray. Bloods: as per Medical Officer.

Neurological status
Report any deterioration in the level of consciousness and neurological functioning. Maintain hourly assessment of GCS, observe for focal neurological deficits (see Background Information Policies at the end of this document). If a change is noted, record and report to the Intensive Care Registrar and Neurosurgical Registrar. Maintain patient position at 15-300 head up.

Hydration/Nutrition
Nil by Mouth (NBM) if for surgery maintain euvolaemia using IV sterile 0.9% normal saline at 1.5mL/kg/hr. Enteral nutrition/oral diet as tolerated if not for same-day surgery. May require indwelling urinary catheter if using excess energy to move or urinate. Avoid straining or valsalva manoeuvres, consider laxative and stool softener. Nil digital examination or medication rectally.

Drug Therapy
Nimodipine 30mg x 2 orally every 4 hours or nimodipine 10mg/50mL vial IV, via central access, dedicated lumen at a rate as specified in the drug protocol. Interruption to the IV infusion or delay in administering oral/nasogastric dose must be avoided. Oral dosage must be administered at 4/24 intervals neither late nor early. When NBM prior to surgery, ensure patient receives oral medications or have the prescription altered to an appropriate route. Histamine antagonist if NBM for > 48 hours or on steroidal therapy. Surgeons preference for both steroid and anti-convulsant therapy. Analgesia is vital: oral paracetamol/codeine or subcutaneous/IV morphine. IV morphine in association with midazolam when patient is ventilated. Regardless of choice of analgesia, obtain regular prescription for stool softener and laxative to prevent straining.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

PRE-OPERATIVE MANAGEMENT OF THE PATIENT WITH SUSPECTED SAH AND VASOSPASM (VSP) IN THE INTENSIVE CARE UNIT. Expected Outcome
Patients diagnosed with vasospasm preoperatively will be managed supportively to reduce the effects of VSP (decreased blood flow with ischaemia and infarction) until surgery is possible.

Policy Statement
Patients presenting to the hospital with a diagnosis of ruptured cerebral aneurysm will be assessed for a history of previous headache suggestive of aneurysmal haemorrhage. Patients with suspected previous aneurysmal headache will be assessed for evidence of clinical VSP or VSP evidenced on angiography or with the use of transcranial Doppler (tcD) ultrasonography. Patients admitted to the hospital for clipping of a cerebral aneurysm with a diagnosis of subarachnoid haemorrhage and vasospasm, will be transferred to the Intensive Care Unit for on-going management. The Neurosurgical Registrar must be informed when a patient with a suspected or confirmed subarachnoid haemorrhage arrives in the Emergency Department - prior to a proposed transfer to the Ward or ICU. The Intensive Care Registrar and the Neurosurgeon/Neurosurgical Registrar will be informed when a patient has neurological deterioration/increased intracranial pressures. The patient will have continuous haemodynamic monitoring with attention to ECG irregularities and prompt intervention. Blood pressure (BP) management will occur to ensure adequate cerebral perfusion in the presence of vasospasm without incidence of peaks and troughs in the systolic BP. Frequent neurological assessment using the Glasgow Coma Scale (GCS) will be attended as the patient is at risk for re-bleeding (estimated incidence of 35-40%) or infarction due to VSP. There is to be no avoidable delay in the commencement or progression of the prescribed drug therapy nimodipine. A MET call is to be initiated when the GCS falls by 2 points, and as per calling criteria. Documentation of the neurological assessment, ICP and Cerebral Perfusion Pressure (CPP) is to occur even where protocols exist for documentation by exception.

Emergency and ICU Observations:

Hourly or more frequent neurological and haemodynamic observations. Maintain systolic BP at 140-160mmHg to create a systolic push, aid cerebral perfusion and avoid re-rupture of the aneurysm. Maintain mean arterial pressure (MAP) at 90 110 mmHg; inotrope of choice may be adrenaline (as opposed to first-line choice of noradrenaline) to maintain an increased MAP without undue increase in the systolic pressure, thus avoiding peaks and troughs in blood pressure. Maintain SpO2 95% with nil respiratory distress. If GCS < 9, protect the airway and prepare for intubation. Obtain 12 lead ECG, commence continuous ECG monitoring; observe and treat cardiac dysrhythmias. If monitoring Intracranial Pressure (ICP), Cerebral Perfusion Pressures [CPP] is maintained at 70mmHg. ICP is tolerated at 20mmHg if higher, drain cerebrospinal fluid (CSF), then utilise drug therapies as prescribed by Intensive Care or Senior Neurosurgical Registrar. Maintain normothermia if temperature increases above 370C, use paracetamol and cooling (as per the Temperature Regulation protocol); avoid shivering. Maintain normal electrolyte and blood sugar levels.
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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

Ensure accurate fluid balance documentation, urinary output at minimum of 0.5mls/kg/hr. Ensure family/carers informed, contact Social Worker as required; document all teaching/information given. Report any deterioration in the Glasgow Coma Score or evidence of focal deficit immediately.

Environment: non-stimulating, quiet, comfortable

Maintain patient on bed-rest with toilet privileges or as required. Visitors are limited. Assist with activities of daily living. Antiembolic stockings are worn to reduce the incidence of deep venous thrombosis or calf-compression device is insitu. Hair wash (gentle) on day of surgery where possible, nil head shave unless specifically requested.

ICU Procedures
Insert a triple lumen central venous access using a subclavian or internal jugular approach. Attach a transducer and monitor central venous pressure. Intubate and ventilate as indicated. Utilise a volume-controlled ventilatory mode e.g. SIMV + PS, it is inappropriate to wean ventilation prior to surgery.

ICU Tests
ECG, Chest X-Ray, Bloods: as per Medical Officer. Repeat tcD, angiogram, CT as per Intensive Care Registrar/Neurosurgical Registrar.

Neurological status
Report any deterioration in the level of consciousness and neurological functioning. Maintain hourly assessment of GCS, observe for focal neurological deficits (see Background Information for Protocol at the end of this document). If change is noted, record and report to the Intensive Care/Neurosurgical Registrar. Maintain patient position at 15-300 head up.

Hydration/Nutrition
NBM if for surgery maintain euvolaemia using IV Normal Saline at 1.5ml/kg/hr. Enteral nutrition/oral diet as tolerated if not for same day surgery. May require indwelling urinary catheter if using excess energy to move or urinate. Avoid straining or valsalva manoeuvres, consider laxative and stool softener. Nil digital examination or medication rectally.

Drug Therapy
Nimodipine 30mg x 2 orally every 4 hours or nimodipine 10mg/50mL vial IV, via central access, dedicated lumen at a rate as specified in the drug protocol. Interruption to the IV infusion or delay in administering oral/NG dose must be avoided. Oral dosage must be administered at fourth hourly intervals neither late nor early. When NBM prior to surgery, ensure patient receives oral medications or have the prescription altered to an appropriate route. Histamine antagonist if NBM for > 48 hours or on steroidal therapy. Surgeons preference for both steroid and anti-convulsant therapy. Analgesia is vital: oral paracetamol/codeine or subcutaneous/IV morphine. IV morphine in association with midazolam when patient is ventilated. Regardless of choice of analgesia, obtain regular prescription for stool softener and laxative to prevent straining.
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Reviewed: October 2004 Review Date: October 2006

Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

PRE-OPERATIVE MANAGEMENT OF THE PATIENT WITH SUSPECTED SAH IN THE NEUROLOGICAL WARD. Expected Outcome
Patients presenting to the Emergency Department and then transferred to the Ward with a diagnosis of subarachnoid haemorrhage will have haemodynamic monitoring and neurological assessment performed frequently to assess current condition and allow interventions.

Policy Statement
The Neurosurgical Registrar must be informed when a patient with a suspected or confirmed subarachnoid haemorrhage arrives in the Emergency Department - prior to a proposed transfer to the Ward. Patients who are stable (haemodynamically and neurologically) with no focal deficits and a Glasgow Coma Score (GCS) > 12 may be transferred to a neurosurgical ward that has adequate registered nurse staffing levels. Patients who deteriorate neurologically or who are haemodynamically unstable or who have labile blood pressure must be transferred to the ICU. The patient will have frequent haemodynamic monitoring including heart rate, blood pressure, respiratory rate, temperature and SpO2 monitoring. Blood pressure (BP) will be normalised to the patients pre-morbid level and peaks and troughs in the BP will be avoided or managed. Frequent neurological assessment using the Glasgow Coma Scale (GCS) will be attended as the patient is at risk for re-bleeding (estimated incidence of 35-40%). There is to be no avoidable delay in the commencement of the prescribed drug therapy nimodipine. A MET call is to be initiated when the GCS falls by 2 points.

Nursing Care of the Patient in the Ward Environment: Environment: non-stimulating, quiet, comfortable.
Maintain patient on bed-rest with toilet privileges. Visitors are limited. Assist with activities of daily living. Antiembolic stockings are worn to reduce the incidence of deep venous thrombosis. Hair wash (gentle) on day of surgery where possible, nil head shave unless specifically requested.

Haemodynamic and Neurological Assessment:

If the patient has a Glasgow Coma Score less than 13 or evidence of focal deficits the Neurosurgical Registrar is informed and liases with the ICU Senior Registrar for patient transfer to the ICU. Observations are performed 2 - 4th hourly or more frequently if the patient deteriorates Maintain systolic BP <140mmHg; if grossly labile, organise patient transfer to ICU. Maintain SpO2 95%, heart rate regular and nil signs of respiratory distress; if present report to the medical officer immediately. Maintain normothermia if temperature increases above 370C, use paracetamol and cooling; avoid shivering. Maintain a normal blood sugar level. Ensure accurate fluid balance documentation. Ensure family/carers informed, contact Social Worker as required; document all teaching/information given.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

Ward Procedures
Insert an intravenous line for medications.

Ward Tests
ECG if not attended in Emergency Department or if heart rate becomes irregular. Bloods: as per Medical Officer.

Neurological status
Report any deterioration in the level of consciousness and neurological functioning. Maintain 2nd - 4th hourly assessment of GCS, observe for focal neurological deficits (see Background Information for Protocols at the end of this document). If a change is noted, record and report to the Medical Officer/Neurosurgical Registrar immediately. Maintain patient position at 15-300 head up.

Hydration/Nutrition
Patient kept NBM if for surgery. Maintain hydration using IV Normal Saline at 1.5ml/kg/hr. Encourage fluid intake if surgery not scheduled report incidences of nausea and vomiting as this may indicate neurological deterioration. Enteral nutrition/oral diet as tolerated if not for same day surgery. May require indwelling urinary catheter if using excess energy to move or urinate. Avoid straining or valsalva manoeuvres, consider laxative and stool softener. Nil digital examination or medication rectally.

Drug Therapy
Administer nimodipine 30mg x 2 orally every 4 hours as prescribed (longer intervals or a decreased dose is inappropriate). Delay in administering oral/NG dose must be avoided. Oral dosage must be administered at 4/24 intervals neither late nor early. When NBM prior to surgery, ensure patient receives oral medications or have the prescription altered to an appropriate route. Histamine antagonist if NBM for > 48 hours or on steroidal therapy. Surgeons preference for steroid, anti-convulsant therapy. Analgesia is vital: oral paracetamol/codeine or SC morphine for headache is essential. Regardless of the choice of analgesia, obtain regular prescription for stool softener and laxative to prevent straining.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

POST OPERATIVE MANAGEMENT OF THE PATIENT WITH ELECTIVE CLIPPING/COILING OF A CEREBRAL ANEURYSM
Expected Outcome
Patients presenting to the hospital with a diagnosis of unruptured cerebral aneurysm will be managed for elective neurosurgery and will be nursed in the appropriate environment to ensure their recovery.

Policy Statement
Patients who are stable (haemodynamically and neurologically) with no focal deficits and a Glasgow Coma Score [GCS] > 12 may be transferred to a neurosurgical ward after elective clipping of a cerebral aneurysm. Patients who deteriorate neurologically or who are haemodynamically unstable or who have labile blood pressure will be transferred to the ICU. The patient will have frequent haemodynamic monitoring including heart rate, blood pressure, respiratory rate, temperature and SpO2 monitoring. Blood pressure (BP) will be normalised to the patients pre-morbid level or to a systolic BP than 140-160mmHg. Frequent neurological assessment using the Glasgow Coma Scale (GCS) and assessment for focal deficit will be attended. A MET call is to be initiated if the GCS falls by 2 points.

Patient Care
Maintain blood pressure and fluid status within normal parameters. Administer analgesia and antiemetics. Administer bowel medications to prevent constipation. If managed within the Intensive Care Unit, discharge on Day 1 from ICU when neurological assessment, electrolytes and vital signs are stable. Nimodipine is not indicated unless intra-operative bleeding has occurred: see SAH Post-Operative Management. Patients are managed as per protocols for cranial neurosurgery.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

POST-OPERATIVE MANAGEMENT OF THE PATIENT WITH ANEURYSMAL SAH IN THE RECOVERY ROOM AND ICU.
Expected Outcome
Patients progressing through the Recovery Room to ICU or from the Operating Theatre direct to ICU will be managed in a safe environment with medical, nursing and allied health care to assist in their recovery and the prevention of further brain injury.

Policy Statement
Patients who have not had clipping or coiling of their aneurysm but who have had insertion of an Intracranial Pressure (ICP) monitoring device/External Ventricular Drain (EVD) will be cared for as per Protocol 3.1.1 preoperative management of SAH in the ICU. The Intensive Care Registrar and Neurosurgeon/Neurosurgical Registrar will be informed when a patient has neurological deterioration, increased intracranial pressure or decreased cerebral perfusion pressure. The patient will have frequent (usually hourly) continuous haemodynamic monitoring and neurological assessment. With infratentorial (posterior fossa) approach, haemodynamic and neurological assessment will occur half-hourly, for 6-12 hours or until the patient is stable. There is to be no avoidable delay in the commencement or progression of the prescribed drug therapy nimodipine. A MET call is to be initiated when the GCS falls by 2 points, and as per calling criteria. Documentation of the neurological assessment, ICP and Cerebral Perfusion Pressure (CPP) is to occur even where protocols exist for documentation by exception.

SAH - Post-Operative Management in Recovery

On arrival: q15 minutely vital signs for the first 4 hours, then hourly until transfer (temperature, pulse, BP, RR, SpO2). On arrival GCS, limb strength, pupillary and focal deficit assessment, then every 30 minutes until transfer. Monitor input and output 1/24, maintain urinary output at 0.5mL/kg/hr. Keep within vital sign parameters as per ICU care; seek immediate senior medical intervention if unable to maintain. Any sign of neurological deterioration or new focal deficit - seek immediate neurosurgical registrar intervention. Patients that are nursed within the Recovery Room for extended periods of time will be managed as per the following:

SAH - Post-Operative Management in the ICU

Observe neurological status and immediately intervene to address changes in the level of consciousness, movement, sensation, vitals or blood values using a multidisciplinary approach. Ensure adequate hydration and haemodynamic state, obtain and maintain set blood pressure parameters.

Reviewed: October 2004 Review Date: October 2006

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Liverpool Health Service Policy Issued: July 2002

CORPORATE MANUAL PATIENT CARE

Neurological Care

Vital Signs:
SpO2 95%, unless pre-existing history of pulmonary disease. PETCO2 monitored if ventilated, maintain at a PaCO2 of 35mmHg. MAP via arterial line at minimum of 90mmHg. ICP < 20-25mmHg; record sudden spontaneous spikes, report sustained increase and obtain immediate assessment/intervention. CPP (if monitoring ICP) at 70mHg; consult with Intensivists and Neurosurgeon if unable to maintain. Administer maintenance fluid at 1.5mL/kg/hr sterile 0.9% normal saline and colloid to maintain set BP parameters Monitor CVP and maintain adequate hydration. Administer noradrenaline 4mg/50ml in glucose (in consultation with the Intensivist) to maintain MAP if fluid loading does not achieve goal. Note that pre-existing cardiac disease requires cautious use of fluid and inotropic therapy. HR: observe for cardiac dysrhythmias and treat where indicated; aSAH is associated with cardiac damage signified by inverted T-wave, ST depression, AF and other dysrhythmias. Daily ECG required if unstable ECG rhythm and/or use of inotropic therapy. Temperature kept 370C [brain temp is 10 body temp], initially use passive cooling without shivering, tepid sponging and paracetamol; (see Temperature Regulation protocol No_). Initiate active cooling when patient is ventilated and sedated in the presence of increased ICP and Vasospasm (VSP).

Neurological Assessment
Assess neurological status by performing a GCS and assessment of limb strength and pupillary response. Assess for focal deficit. These may indicate clinical VSP (referred to as delayed ischaemic neurological deficit: DIND), rebleeding or oedema. Observe results of transcranial Doppler (tcD) studies as a possible predictor of deterioration/evidence of VSP. VSP is most likely to present Day 4 Day 10, peak incidence at Day 7 after initial bleed, (admission may not relate to the primary bleed). Observe for cranial nerve dysfunction Observe for focal deficits Report any deterioration in the GCS/focal deficit to the medical officer immediately.

ICU Procedures
Ensure triple lumen central venous access is insitu using a subclavian or internal jugular approach. Attach a transducer and monitor central venous pressure. Intubate and ventilate as indicated, using a volume-controlled ventilatory mode e.g. synchronised intermittent mandatory ventilation with pressure support (SIMV + PS).

ICU Tests upon admission

ECG. Chest X-Ray. Bloods: as per Medical Officer.

Drug Therapy
Nimodipine 30mg x 2 orally every 4 hours or nimodipine 10mg/50mL IV, via central access, dedicated lumen at a rate as specified in the drug protocol. Interruption to the IV infusion or delay in administering oral/NG dose must be avoided. Oral dosage must be administered at 4/24 intervals neither late nor early. When NBM prior to procedure, ensure patient receives oral medications or have the prescription altered to an appropriate route. Histamine antagonist if NBM for > 48 hours or on steroidal therapy.
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CORPORATE MANUAL PATIENT CARE

Neurological Care

Surgeons preference for steroid, anti-convulsant therapy. Analgesia is vital: oral paracetamol/codeine or SC/IV morphine. IV morphine in association with midazolam when patient is ventilated Regardless of choice of analgesia, obtain regular prescription for stool softener and laxative to prevent straining. Commence subcutaneous heparin at twenty four hours post surgery; or as per Neurosurgeons preference.

Analgesia
Administered to relieve pain of residual SAH, effects of surgery, ICU based care, bed rest, headache, raised ICP and stress associated with ventilation. In the presence of deep coma it is logical to suspect a degree of pain from injury. Also, if ICP rises with nursing/medical/ environmental input administer further prescribed medication without unduly affecting neurological assessment and/or haemodynamics. Utilise analgesia as an adjunctive therapy for raised ICP, in combination with sedation, propofol and thiopentone therapy.

Ventilation:
Chest physiotherapy as required. If the patient has raised ICP; avoid percussion and use vibes, suction for < 15 seconds, observe ICP response. Allow adequate rest in between episodes of required suctioning. If patient is analgesed, sedated and nil cough reflex, suction as per respiratory assessment and ventilatory pressures. Maintain SIMV portion of ventilatory support if patient has raised ICP and there are no plans to wean to extubate. Do not wean the patient from ventilatory (and breath rate) support when in the presence of raised ICP that is being actively managed.

IV Therapy, Hydration, Electrolytes

Triple lumen access with transduced CVP required for unstable patients or patients with SAH - Hunt and Hess Grade 3. Maintain euvolaemia using sterile 0.9% normal saline at 1.5ml/kg/hr. Ensure intake at 2-3 litres/day when on nimodipine therapy (IV or oral). Maintain magnesium at 1.5 mmols and 2 mmols, potassium 4.0 and 5.0, normalise phosphate and glucose levels, monitor sodium levels and report high or low levels, keep Hb 100.

GIT/Feeding/Elimination
Monitor fluid balance, maintain adequate urinary output at 0.5mL/kg/hr. Place nasogastric tube, establish if special feeds are required as per sodium levels, preexisting conditions, and trauma. Do not place a nasogastric tube if there is suspicion/evidence of a fractured base of skull; place an orogastric tube. Abdominal assessment and intervention if bowels not opened > 2 days: there is a risk of pseudo-obstruction (Ogilvies syndrome) associated with nimodipine. If patient progresses to oral intake, assess adequate cough reflex to prevent aspiration. If suspected (voice changes to raspy, gurgling or hoarse speech post oral intake, continued coughing or drooling) keep patient NBM and seek swallow assessment consult from Speech Pathologist. Consider removal of indwelling catheter once patient is stable and hydration issues are resolved. Nil digital examination or medication rectally secondary to the risk of a valsalva response and subsequent rise in ICP.
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Neurological Care

Patient Positioning and Care

Maintain neutral alignment, avoid hip flexion, nil compression or kinking of venous drainage vessels, maintain patient position at 15-300 head up. Normalise when acute ICP issues stabilised. Visitors limited in number when patient unstable or ensure quiet environment. Reduce noise wherever possible and allow the patient to have rest periods between nursing, allied health and medical interventions. Antiembolic stockings to reduce incidence of deep venous thrombosis and use of calf compression device. Involve appropriate allied health support, notify Social Worker of unstable SAH patient as their involvement is usually necessitated for patient and family care. Patients with impaired physical mobility/signs of contracture will be referred to the allied health care team. Patients are encouraged to sit out of bed and mobilise with assistance when intracranial pressure and haemodynamic state has stabilised and there is minimal headache. Document communications between medical and nursing staff with family. Document all teaching/explanations conducted at the bedside.

Imaging
Angiogram post clipping of aneurysm to visualise accurate placement as per the Neurosurgeon. CT scan and Angiogram if sudden deterioration/focal deficit such as leg weakness develops that was not present prior to clipping of the aneurysm. Papaverine [an arterial smooth muscle relaxant] or other drugs (eg. verapamil) may be injected during cerebral angiography to relax arteries affected by vasospasm.

Wound Care
A turban-style bandage is to remain insitu until Day 1 post surgery. Observe surgical site for bleeding, CSF ooze or infection, cover wound with non-adherent dressing and secure. Wound may remain exposed 48 hours post surgery and showering/hair wash allowed after this time. Clips/sutures removed at 5-7 days unless union has not occurred (report) or is otherwise prescribed and documented.

Allied Health Involvement

Social Worker Physiotherapist Occupational Therapist Dietitian Speech Pathologist Rehabilitation Team (Referral)

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Liverpool Health Service Policy Issued: July 2002

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POST-OPERATIVE MANAGEMENT OF THE PATIENT WITH ANEURYSMAL SUBARACHNOID HAEMORRHAGE [ASAH] IN THE WARD

Expected Outcome
Patients progressing through the Recovery Room to the Ward will be managed in a safe environment with medical, nursing and allied health care to assist in their recovery and the prevention of further brain injury.

Policy Statement
The Neurosurgeon/Neurosurgical Registrar will be informed when a patient deteriorates neurologically. The patient will have frequent haemodynamic monitoring and neurological assessment. With infratentorial (posterior fossa) approach, haemodynamic and neurological assessment will occur half-hourly for 6 hours or until the patient is stable. There is to be no avoidable delay in the commencement or progression of the prescribed drug therapy nimodipine. A MET call is to be initiated when the GCS falls by 2 points, and as per calling criteria.

Ward management of patient post SAH

Observe neurological status and immediately intervene to address changes in level of consciousness, vital signs, blood values using a multidisciplinary approach. Ensure adequate hydration and haemodynamic status, maintain set blood pressure parameters. Ensure rehabilitation commences in the ward, continue/initiate process of discharge planning.

Vital signs and neurological assessment upon arrival to the Ward from Recovery
Frequency is: Hourly for 6 hours, then if stable, second hourly for 6 hours, then fourth hourly. If deterioration occurs, frequency is increased until the patient has received definitive treatment. If the patient has been transferred from ICU; observations are as per frequency last used within the ICU usually second to fourth hourly. SpO2 95%, unless pre-existing history of pulmonary disease. BP maintained at a normal pre-SAH level or as per pre-existing antihypertensive therapy (SBP at 140-160mmHg). Administer maintenance fluid at 1.5mL/kg/hr sterile o.9% normal saline or as per Medical Officers prescription. Maintain adequate hydration at all times if IV tissues, ensure timely replacement. Hypotension must be avoided, inform Neurosurgical Registrar promptly and ensure therapy implemented to address hypotension. Changes to these guidelines are to be documented by the Neurosurgical Registrar/VMO in patient case notes. HR: observe for irregular rhythm; obtain 12-lead ECG to identify dysrhythmia, repeat BD. External Ventricular Drain (EVD): as per protocol. Temperature: maintain less than 370-37.50C, use passive cooling (tepid sponging and paracetamol) without shivering.

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Neurological Care

Neurological Assessment
Any decrease in the level of consciousness (LOC) must be reported and acted upon. This may indicate clinical vasospasm [VSP], rebleeding or oedema. Call MET if GCS falls by 2 points, and as per calling criteria. Observe results of transcranial Doppler [tcD] sonography as a possible predictor of deterioration/evidence of VSP. VSP is most likely to present Day 4 Day 10, peak incidence at Day 7 after initial bleed. The patient admission may not relate to the primary bleed. Observe for cranial nerve dysfunction, (see appendix Background): any deterioration must be reported and acted upon. Observe for focal deficits (Background): any deterioration must be reported and acted upon.

Respiratory Status:
Chest physiotherapy as required, allow adequate rest in between episodes of required suctioning. Tracheostomy care as per hospital protocol.

IV Therapy, Hydration
Ensure intake at 2-3 litres/day when on nimodipine therapy (IV or oral). Strict fluid balance documentation until nimodipine therapy ceases: inclusive of both input and output.

GIT/Feeding
Monitor fluid balance. Commence nutrition as soon as possible. Establish if special feeds are required as per sodium levels, pre-existing conditions, and trauma. Do not place a nasogastric tube if there is suspicion/evidence of a fractured base of skull; place an orogastric tube. Bowel medications are required due to use of opioids, immobilization, altered nutrition, stress, and use of nimodipine. Abdominal assessment and intervention if bowels not opened > 2 days. There is a risk of pseudo-obstruction (Ogilvies syndrome) associated with Nimodipine. Vomiting must be controlled. Use anti-emetics, ensure medications absorbed and adequate hydration is maintained. Vomiting may be a sign of raised ICP. Oral diet may recommence as soon as the patients level of consciousness is adequate, with nil contraindications. If patient progresses to oral intake, assess for adequate cough reflex to prevent aspiration. If suspect, a swallow assessment is required; consult with Speech Pathologist. Patients who have had posterior fossa approach remain NBM (with enteral feeding) until swallow assessment can be formally obtained. If patient has voice changes [raspy, gurgling, hoarse speech] post oral intake or continued coughing or drooling cease oral intake and obtain Speech Pathology consult.

Analgesia/Agitation
Administered to relieve pain of residual SAH, effects of surgery, bed rest, headache. Obtain prescription to relieve patients perceived level of discomfort; paracetamol with codeine combinations used as a baseline. Agitation may be cerebrally related or be a sinister representation of oxygen/glucose depletion/neurological deterioration. Avoid sedatives until other causes of agitation have been ruled out.

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Neurological Care

Patient Positioning and Care

When in bed/sitting in chair - maintain neutral alignment, avoid hip flexion, nil compression of venous drainage vessels, head of bed raised 15-300. Visitors encouraged to assist with rehabilitation and arousal therapy, ensure episodes of quiet during each shift. Reduce noise wherever possible and allow the patient to have rest periods between nursing, allied health and medical interventions. Antiembolic stockings to reduce incidence of deep venous thrombosis. Commence subcutaneous heparin at twenty four hours post surgery; or as per Neurosurgeons preference. Involve appropriate allied health support, notify Social Worker of unstable SAH patient. Document communication between medical and nursing staff with families. Document teaching and explanations conducted at the bedside.

Mobilisation
Patient is encouraged to sit out of bed and mobilise with assistance as soon as tolerating an upright position without undue headache. Patients with impaired physical mobility/signs of contracture will be referred to the allied health care team upon transfer or admission to the ward.

Wound Care
A turban-style bandage is to remain insitu until Day 1 post surgery. Observe surgical site for bleeding/CSF ooze/infection, cover with non-adherent dressing and secure. Wound may remain exposed 48 hours post surgery and showering/hair wash allowed after this time. Clips/sutures removed at 5-7 days unless there is poor union (document and report) or is otherwise prescribed and documented.

Discharge Advice: dependent upon the individual Neurosurgeon.

Follow-Up appointment: to be booked for 2 weeks post clipping/coiling of aneurysm and discharge. Swimming: allowed post clipping/coiling of aneurysm - when wound has fully healed. Return to work: as per medical advice at two-week post-discharge from hospital appointment, consult with Neuropsychologist. Flying: as per medical advice at six-week post-discharge from hospital appointment. Driving: allowed at 6 months post clipping/coiling of aneurysm when visual fields cleared; requires neurosurgical and ophthalmology review, also dependent upon being seizure-free. Sexual Activity: according to patient comfort, advise patient to go slowly and gently and determine their response based upon perception of well-being.

Reviewed: October 2004 Review Date: October 2006

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Neurological Care

Background Information for Policies 3.1.1 to 3.1.4 Aneurysmal Subarachnoid Haemorrhage Management
1. Vasospasm:
Spasticity and narrowing of cerebral arteries (vasospasm) affects blood flow to brain tissue, resulting in ischaemia, altered neurological functioning and possible infarction. Signs of vasospasm may include deterioration in the Glasgow Coma Scale or may be seen solely as a focal deficit; both instances indicate direct brain ischaemia/infarct and are as much of an emergency as impending myocardial infarction. Treatment includes administration of nimodipine and if aneurysm is clipped: elevated BP above the normal level. Usually at MAP of 90-110mmHg and SBP at 160180mmHg. Administration of IV fluids and inotropes is used to accomplish this increase. Rarely, vasospasm that is present prior to clipping of the aneurysm may delay surgery. There is concomitant risk of infarction secondary to the vasospasm. The neurosurgical team may, in consultation with the Intensivists, decide to increase MAP with fluid and inotropes to provide perfusion, ensuring that the SBP remains less than @140mmHg. Maintaining BP parameters at all times is imperative swings in BP with an unclipped aneurysm can cause ischaemia/infarction or catastrophic re-bleeding. Alternately, hypotension in the clipped aneurysm patient can lead to brain cell death, widespread infarction, gross neurological disability or death.

2. Fisher Grade for Vasospasm Greenberg, M (1994). Handbook of Neurosurgery.

Greenberg Graphics, Lakeland, Florida, page 720.

Group 1 2 3 4

Blood on CT No blood detected Diffuse or vertical layers < 1mm thick Localized clot and/or vertical layer > 1mm thick Intracerebral or intraventricular clot with diffuse or no SAH

Thus, vasospasm is most likely to occur in Grades 2 and 3 and not likely to occur in Grades 1 and 4.

3. Cranial Nerve Assessment (simplistic outline)

CN I- Olfactory: sense of smell, not tested in acute setting. CN II Optic: vision, test for ability to read, discern number of fingers held in front of patients face. CN III Oculomotor: pupillary constriction and eyelid elevation, shine torch in eye pupil should constrict. CN IV Trochlear: eye muscle control, check gaze by asking patient to look down and out. CN V Trigeminal: sensation to forehead, cheek, jaw; clench jaw, ask patient to grit their teeth observe for symmetry. CN VI Abducens: eye muscle control, ask patient to look to the left and right without moving their head. CN VII Facial: facial muscle control, ask patient to frown and smile observe for symmetry. CN VIII Acoustic [Vestibulocochlear]: hearing/balance, ask patient to repeat whispered statement, test ears separately. CN IX Glossopharyngeal: taste, gag and cough reflex, check with CN X. CN X- Vagus: gag, stimulus results in gagging or bradycardia and increased gut peristalsis to stimulus, check patients cough/ gag reflex. CN XI Spinal Accessory: neck and shoulder muscle innervation, patient shrugs shoulders while assessor presses down, assess equality and strength. CN XII Hypoglossal: tongue movement, ask patient to poke tongue out, assess for deviation to left/right or long term deficit seen as muscle wasting.

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Neurological Care

4. Focal Deficits
A focal (neurologic) deficit is a loss of movement, sensation, or function of a nerve in a specific location. The loss is related to dysfunction in the brain or peripheral nervous system. There may be no decrease in the level of consciousness. Focal neurologic deficits may affect the left or right side of the face, arms or legs or be related to a specific region within the brain e.g. speech may be affected but not the ability to write. Sensation changes include paraesthesia (abnormal sensations), decrease in sensation or numbness. Movement changes include paralysis, weakness, loss of muscle control, increased or decreased muscle tone. The terms paresis and plegia are used to describe severe weakness and lack of movement.

5. Other types of focal deficit:

Speech or language changes such as aphasia or dysarthria (impaired speech and language skills), poor enunciation, poor understanding of speech, impaired writing, impaired ability to read or to understand writing, inability to name objects (anomia). Vision changes such as reduced vision, decreased visual fields, sudden vision loss, double vision (diplopia) or homonymous hemianopia (loss of a visual sector in one eye). Neglect or inattention to the surroundings on one side of the body - see Pronator Drift. Loss of coordination, fine motor control, or ability to perform complex movements. Horner's syndrome: one-sided eyelid drooping (ptosis), absent sweating on one side of the face, and retraction of one eye into the socket, poor gag reflex, swallowing difficulty, and frequent choking.

6. Hunt and Hess Classification of SAH (Greenberg, 1994, page 858)

Grade 0 1 1a 2 3 4 5 Classification Unruptured aneurysm Asymptomatic, or mild headache and slight nuchal rigidity No acute meningeal/brain reaction, but with fixed neurological deficit Cranial nerve palsy (e.g. III, IV), moderate to severe headache, nuchal rigidity Mild focal deficit, lethargy or confusion Stupor, moderate to severe hemiparesis, early decerebrate rigidity Deep coma, decerebrate rigidity, moribund appearance

Add one grade for serious systemic disease (e.g. Hypertension, Diabetes) or severe VSP on angiography

7. World Federation of Neurological Surgeons Scale

(Liebeskind, 2002) Grade I II III IV V Glasgow Coma Scale score 15 15 13 - 14 7 - 12 3-6 Clinical findings No headache or focal signs Headache, nuchal rigidity, no focal signs Headache, nuchal rigidity, no focal signs Headache, rigidity, focal signs Headache, rigidity, focal signs

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References

Ladewig N.E. and Schneider K.L. 1995 Subarachnoid Haemorrhage. In Urban N., Greenle K., Krumberger J. and Winkelman C. [Eds]. Guidelines for critical care nursing. Mosby, St Louis. Cook H.A. 1995 Cerebral Vasospasm. In Urban, N., Greenle, K., Krumberger, J. and Winkelman, C. [eds]. Guidelines for critical care nursing. Mosby, St Louis. Fukuda T., Hasue M. and Ito H. 1998 Does traumatic subarachnoid haemorrhage caused by diffuse brain injury cause delayed ischemic brain damage? Comparison with subarachnoid hemorrhage caused by ruptured intracranial aneurysms. Neurosurgery. 43 (5): 1040-1049. Dorsch N. 1992 Cerebral aneurysms and subarachnoid haemorrhage. Australian Critical Care. 5 (3): 17-19. International Nimodipine Review: recent use in subarachnoid haemorrhage and head injury (2 issue). 1997 Bayer. Professional Communications, Sydney. Rusy K.L. 1996 Rebleeding and vasospasm after subarachnoid hemorrhage: a critical care challenge. Critical Care Nurse. 16 (1): 41-47 Mayberg M., Batjer H., Dacey R., Diringer M., Haley E., Heros R., Sternau L., Torner J., Adams H., Feinberg W. and Thies W. 1994 Guidelines for the management of aneurysmal subarachnoid hemorrhage a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. American Heart Association. Dallas. Maeda K., Kurita H., Nakamura T., Usui M., Tsutsumi K., Morimoto T. and Kirino T. 1997 Occurrence of severe vasospasm following intraventricular hemorrhage from an arteriovenous malformation. Journal of Neurosurgery. 87: 436-439. Weaver J.P. and Fisher M. 1994 Subarachnoid hemorrhage: an update of pathogenesis, diagnosis and management. Journal of the Neurological Sciences. 125:119-131. Hunt W.E. and Hess R.M. 1968 Surgical risk as related to time of intervention in the repair of intracranial aneurysms. Journal of Neurosurgery. 28 (1): 14-20. Lasner T., Weil R., Riina H., King J., Zager E., Raps E. and Flamm E. 1997 Cigarette smoking-induced increase in the risk of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery. 87:381-384. Garretson H.D. 1996 Intracranial arteriovenous malformations. In Wilkins, R.H. and Rengachary, S.S. [eds]. nd Neurosurgery (2 Ed., Volume 2). McGraw-Hill, New York. Evans V. and Barr J. (1998). Case Study: nursing care of the patient with vertebral artery aneurysm treated by endovascular stenting and coil implantation. Journal of Neuroscience Nursing. 30 (5): 279-282. Martin N., Khanna R. and Rodts G. 1993 The intensive care management of patients with subarachnoid hemorrhage. In Andrews, B.T. (Ed.). Neurosurgical Intensive Care. McGraw-Hill, New York. Barry K. 1994 Functional recovery after subarachnoid haemorrhage. Australasian Journal of Neuroscience. 7 (x): 4-8. Morgan M., Day M., Little N., Grinnell V. and Sorby W. 1995 The use of intrarterial papaverine in the management of vasospasm complicating arteriovenous malformation resection. Journal of Neurosurgery. 82: 296-299. Wilkins R.H. 1990 Cerebral vasospasm. Critical Reviews in Neurobiology. 6 (1): 51-77. Focal Deficits: http://thriveonline.com/medical/library/article/003191.html Greenberg M. 1994 Handbook of Neurosurgery. Greenberg Graphics Florida: Lakeland. Liebeskind DE. 2002 Cerebral aneurysms. eMedicine Journal, May 23, 3 (5). http://www.emedicine.com/NEURO/topic503.htm
nd

Policy Author:

M. Edgtton - Winn, CNC ICU for working party: K. Wright, CNC Neurosciences and M. Perry, CNE Recovery.

Policy Reviewer/s: CNC ICU, CNC Neurosciences and Consultant for Intensive Care and Neurosurgery.

Reviewed: October 2004 Review Date: October 2006

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