critical care nursing management of endovascular vasospasm ... · pdf filecritical care...
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CRITICAL CARE NURSING MANAGEMENT OF
ENDOVASCULAR VASOSPASM PATIENTS
LORA CHEEK RN CNRN
ACKNOWLEDGEMENTS : DHEERAJ GANDHI (MD), TIM MILLER (MD), GARAUV JINDAL (MD) ANASTASIA WHITE RT (R)(VI)
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CEREBRAL ANEURYSMS
• Relatively small incidence < 6% of the population• SAH approx. 30,000 per year• Risk of rupture increases with age• Average age, 55 years• 10%-15% of persons have multiple aneurysms• Usually develops in the walls of major cerebral arteries at
branching points
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VASOSPASM
• A focal or diffuse narrowing of intracranial arteries• Usually most severe in arteries adjacent to the
ruptured aneurysm• Results from the presence of blood products in
subarachnoid space• Predicted by amount of blood in subarachnoid space
detected by CT
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VASOSPASM
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VASOSPASM
• Usually more severe in older persons and women
• Usually not present within first 2-3 days after ictus, peaks at 7-14 days, then resolves
• Causes brain ischemia secondary to decreased cerebral blood flow
• TDC or CTA
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CLINICAL ASSESSMENT Frequent neurologic exams are critically
important during the high-risk time window (3-14 days)
Any of the following should raise concern:ConfusionDeliriumDecreased consciousnessNew focal neurologic deficits
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DIAGNOSTIC IMAGING
Bedside evaluation:Transcranial doppler ultrasonography (TCD)
Rule out rehemorrhage or hydrocephalus:Non-contrast head CT
Initial angiographic evaluation:Computed tomography angiography (CTA)
Perfusion evaluation:Computed tomography perfusion (CTP)
Definitive angiographic evaluation:Digital subtraction angiography (DSA)
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62 YO WOMAN WITH RUPTURED ACOM ANEURYSM, DEVELOPS CONFUSION AND SLEEPINESS 6 DAYS AFTER CLIPPING
TCD reveals markedly elevated MCA peak systolic velocities (163 cm/s) suggesting vasospasm
CTA confirms right M1 segment vasospasm
Transcranial Doppler Ultrasound (TCD)MCA
CT Angiogram (CTA)
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AP view: right ICA injectionInitial presentation
AP view: right ICA injection
6 dayslater
Courtesy Of D. Gandhi MD
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Established infarct
Contraindication to aggressive therapyRegions of established infarct have minimal chance of functional recovery and have a high risk of reperfusion hemorrhage
Patient with symptomatic vasospasm
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Patient with symptomatic vasospasm
Salvageable parenchyma1st line for most patients
Medical Therapyhypertension, hemodilution
Patient cannot tolerate hemodynamic therapy
Endovascular Therapy• Intra-Arterial (IA) Vasodilator Infusion• Transluminal Balloon Angioplasty (tBA)• Combination
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AP: left ICA Lateral: left VAAP: right ICA
A1M1
ICA
P1
BAM1A1
ICA
Courtesy Of D. Gandhi MD
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ENDOVASCULAR IA PHARMACOLOGICAL THERAPY
Verapamil (A)• Calcium Channel
Blocker• Acts on smooth muscle
cells • Produces vasodilation• Quick onset
Nicardipine (A/V)• Calcium Channel Blocker• More selectivity for
vascular smooth muscle cells
• Systemic Vasodilatation resulting in DECREASE BP
• Onset within minutes
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TRANSLUMINAL BALLOON ANGIOPLASTYCONSIDERATIONS FOR PROCEDURAL PLANNING
Locations that are amenable for angioplasty include: Proximal vessels of Circle of Willis
Vertebral arteries Basilar artery Supraclinoid internal carotid artery M1 segment
Immediate distal branches A1 Proximal A2 M2 P1, P2
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Right MCA Right ACA Right Supraclinoid ICA
Left MCA Left Supraclinoid ICA Basilar Artery
In the setting of this patient’s general encephalopathic clinical picture, tBA was performed for all proximal vasospasm
Courtesy Of D. Gandhi MD
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CASE STUDY VASOSPASM
• 55 yo Female• Past medical hx of 2 cardiac stents• WHOL at work : 911• CT = SAH• GCS 11, EVD placed ICP’s 10-16 • Ruptured ACOM• Post Bleed, day 6 exam worsened, Neuro IR steps
in
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LEFT ACA VASOSPASM
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PHENYLEPHRINE NEO-SYNEPHRINE
• Alpha-1 adrenergic stimulant• Beta-1 effect – sometimes bradycardia• Vasoconstriction – increase BP and Systemic Vascular
Resistance• Dosing by MD: 100 – 200 mcg IV bolus; may repeat every
10-15 min• Dosing: IV gtt 40 – 60 mcg/min and Titrate to goal SBP• BP > at least 140 systolic or per MD parameters to
maintain adequate cerebral flow
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RIGHT ACA VASOSPASM
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LEVOPHED (NOREPINEPHRINE)
• Alpha-/Beta adrenergic agonist; constrict peripheral arterial system
• Increase BP by Increase afterload• Dosing for severe Hypotension start at 8-12 mcg/min titrate to
goal SBP• BP > at least 140 systolic or MD parameters to maintain
adequate cerebral blood flow
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VASOPRESSIN
• Antidiuretic hormone• Increases BP by peripheral vascular resistance
(vasoconstriction)• Dosing o.o4 units/min
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VASOSPASM PATIENT
• IDEAL• Vented • Central line• Foley• IVC• A-line
• Minimal Recommendations
• 2 Large bore PIV• Foley• Maintain Sats > 95 %
flat
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PLAN OF ACTION• IR Nurses• Neuro IR Attending's and Team• Neuro ICU critical care team• Neurosurgery• Anesthesia• CCRU critical care team
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VASOSPASM CODE
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Medfusion Syringe Pump
Equipment for IA treatments:• Syringe pump (Medfusion 3500)• 60 ml or 30 ml syringe (luer lock tip ONLY)• High pressure tubing x 2 ( Arterial line tubing)- dropped STERILE
on field• Drug of choice ( made up to concentration per MD)• 0.9 NSS IV to mix with drug for MD chosen concentration• NO AIR IN TUBING!!
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THANK YOU FOR YOUR TIME AND ATTENTION