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11/1/2017
1
Mitchell A. Ahrens, M.D. FCCP
Pulmonary, Critical Care, Sleep
CoxHealth, Ferrell-Duncan Clinic
Conflicts of Interest� None
Topics� Respiratory management
� Cardiovascular management
� Fever & Infectious issues
� Glycemic management
� Prophylaxis
� Nutrition
11/1/2017
2
Goals� Identify common respiratory issues with acute stroke
� Identify common cardiac and renal issues that may arise with acute stroke.
Positioning� Optimal positioning is unclear from studies.
� Lower SpO2 in supine position with comorbidities
� Cardiovascular or Pulmonary disease
� Obesity
� High risk patients recommended to keep HOB 15 – 30°
� Aspiration
� Intracranial hypertension
� Cardiac or pulmonary disease
Ref: 1.
Positioning
https://ars.els-cdn.com/content/image/1-s2.0-S0735109713022481-gr1_lrg.jpg
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Figure 1. MAP, ICP, and VmMCA on both sides in a 58-year old, medically treated patient with a left-sided complete MCA territory infarction.
Stefan Schwarz et al. Stroke. 2002;33:497-501
Copyright © American Heart Association, Inc. All rights reserved.
� Exclusions: “hypothermia, pyrexia, anemia, acute respiratory infection, if they were cardiovascularly unstable, if they had a condition that could result in a preexisting restrictive respiratory deficit, if they were medically unwell, if they were receiving medication that would depress respiratory function”
Journal of Gerontology: 2000, Vol. 55A, No. 4, M239–M244
Hypoxemia� Present in majority of patients in
the first 48 hrs after stroke
� Supplemental oxygen should be provided to maintain oxygen saturation >94%.
� Supplemental oxygen is not recommended non-hypoxemic patients with acute ischemic stroke.
Ref: 1. & www.researchgate.net
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4
Simple oxygen options
Hypoxemia caveats� Treat & Identify cause
� ABC’s
� Physical Exam� Adventitial sounds
� Airway assessment
� Comorbid conditions� CHF, chronic lung disease, OSA
� Chest X-ray
� ABG� Hypoventilation – hypercapnia
Ref: Radiopaedia.org
Hypercapnia� Signs/symptoms
� Hypoxemia
� Decreased level of consciousness – Normal pts 75-80 mmHg PaCO2
� Hypoventilation – shallow or slow respirations
� Measurement
� ABG
� EtCO2 monitoring
� Transcutaneous CO2 – not typically available
Ref: UpToDate
11/1/2017
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Hypercapnia� Treat underlying cause
� Airway obstruction
� Positioning
� Underlying lung disease – COPD, asthma, edema
� Sedatives
� Ventilatory assistance
� Noninvasive ventilation – BiLevel > CPAP
� Intubation & Mechanical Ventilation
Respiratory Support� Airway patency
� HOB elevation
� Oral or nasal airways
� Noninvasive ventilator
� Intubation
� Atelectasis
� Incentive spirometer
� Respiratory treatments
� EZPAP
Airway Management� Patient positioning
� HOB 15-30 degrees
� Head positioning
� Neutral to extension
� Impingement of pharyngeal tissue with flexion
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Anatomical measurements.
Mingshu Cai et al. J Appl Physiol 2016;120:758-765
©2016 by American Physiological Society
Upper Airway
aneskey.com/emergency-airway-management/
� Oropharyngeal airways
� Poor tolerance – gagging/vomiting
� Nasal airway (Trumpet)
� Tip should reach the angle of the mandible
� Excessive length may reach esophagus
� Epistaxis
Advanced Oxygenation/Ventilation� High Flow Nasal Cannula
� Noninvasive Ventilation – CPAP/BiPAP-BiLevel
� Intubation/Mechanical Ventilation
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High Flow Nasal Cannula� Eliminate anatomic dead space
� Reservoir of high FiO2 in nose
� Improve gas exchange, CPAP effect
� Reduce the work of breathing
� Up to 60 L/min or higher
Ref: ResMed.com
Noninvasive Ventilation� Positive airway pressure
� Nasal mask or Full Face mask
� Helmet
� Benefits
� Improves airway patency, alveolar ventilation, reduce work of breathing
� Risks
� Aspiration
� Inability to protect airway, difficult to clear secretions
� Headgear requirements
Noninvasive Ventilation
https://careforyou.com.hk & CaStar CPAP Hood
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Mechanical Ventilation� Indications
� Inability to maintain airway
� Oxygenation or ventilation failure not amenable to other therapies
� Benefits
� Secure airway, ability to clear secretions, improvement of oxygenation & ventilation, & reduced work of breathing
� Drawbacks
� Sedation requirements, risk of infections, reduced mobility
� Liberation
Altered Respiration
Ref: UpToDate
� Seen in 60% of stroke
� More in more severe stroke
� Poorer outcome noted with sustained hypocarbia
� Ondine’s Curse
� Posterior/Brainstem strokes
Cardiac Complications� Hypertension very common on presentation
� 15% >184 mmHg
� 77% >139 mmHg
� Regression during first few hours post stroke
� Troponin elevations – 15%
� Arrhythmias
� Tachycardia - Atrial fibrillation 11%
� Bradycardia - Atrial fibrillation 5%
Ref: 1.
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Presentation BPHigh & low pressure associated with increased early & late mortality.
Optimal presenting SBP
130 mmHg, > in HTN pts
High BP associated with HTN
Low BP associated with CHF & CAD
Ref: 4.
Managing BP in Acute Ischemic Stroke� Optimal Blood Pressure is To Be Determined…..
� Studies don’t indicate aggressive treatment is beneficial
� Treatment for SBP >220 mmHg or DBP >120 mmHg
� Must account for patient factors
� Etiology
� Comorbid conditions
� CHF
� CKD
� CAD
Ref: 1. 3.
BP with Subarachnoid Hemorrhage� INTERACT2
� goal of achieving a systolic blood-pressure level of less than 140 mm Hg within 1 hour after randomization and of maintaining this level for the next 7 days
� No overt change in death or major disability either + or -
� Improved functional outcomes on modified Rankin scale
N Engl J Med 2013; 368:2355-2365
11/1/2017
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Thrombolytic BP� Prior to therapy
� SBP <185, DBP <110
� Post rtPA
� SBP <180, DPB < 105
� Elevated risk of ICH
Ref: 1.
Hypertensive Medications� Adrenergic Blockers – Heart rate reduction, reduced contractility, vasodilation
� Labetalol, Esmolol, Metoprolol� Risks – bradycardia, decompensation of CHF, COPD/asthma?
� Dihydropyridine Calcium Channel Blockers – Arterial vasodilation� Nicardipine & Clevidipine
� Risks - CAD
� ACE Inhibitor - Vasodilation� Enalaprilat
� Risks – renal insufficency
� Vasodilator – Arteriolar vasodilation� Hydralazine
� Risks - hypotension
� Nitrates – Venous & arteriolar vasodilation� Nitroprusside
� Risks – Cyanide toxicity
Hypertension – Long term therapy� Pre-stroke diagnosis or new onset HTN
� JNC 7 guidelines
� Resumption after 24 hours of home regimen
Ref: 1. & Hypertension. 2003;42:1206
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Hypotension� Typically secondary
� 2.5% SBP <100
� Poor outcome
� Causes
� Hypovolemia
� Cardiac – AMI, CHF
� Infection – Sepsis
� Medication induced
� Hypothyroid, adrenal crisis, …
� EKG
� Volume assessment
� Noninvasive measurement
� CVP has ~50% accuracy
� Echocardiogram
� Chest X - ray
Ref: 1.
Volume expansion� Crystalloid IVF
� LR or NS
� Colloid
� Plasma
� Albumin
� Starches
� Elevated risk of renal injury
� Studies generally suggest equivocal outcomes with Crystalloid solutions vs Colloid
Maintenance of hydration� Daily fluid maintenance for adults about 30 mL/Kg/day
� 70kg patient – 2100 mL/day
� Isotonic fluid – 0.9% NaCl or Lactated Ringers
� Hypervolemia & Hypotonic fluid may increase edema
Ref: 1.
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Vasopressors� Norepinephrine
� Alpha 1 & Beta 1 � Vasoconstriction & mild increase in cardiac output
� Phenylephrine� Alpha 1� Vasoconstriction
� Dopamine� Beta 1 & Alpha 1 – dose dependent >5 mcg/min� Increase heart rate then vasoconstriction
� Epinephrine� Potent Beta 1, modest Beta 2 & Alpha 1� Increase cardiac output, heart rate then vasoconstriction
� Vasopressin� Antidiuretic hormone, used in conjunction with other vasopressors - vasoconstrictor
Ref: UpToDate
Diabetes Insipidus� 2 types – Nephrogenic & Central
� Central
� Deficient secretion of antidiuretic hormone (ADH)
� ADH causes resorption of water in kidney
� Signs
� Polyuria
� >3L/day - >125 mL/hr
� High-normal plasma sodium concentration
� Urine osmolality (<290 mOsm/kg) < plasma osmolality
� Urine specific gravity <1.005
Ref: Uptodate
https://basicmedicalkey.com/the-endocrine-system-7/
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Diabetes Insipidus� Water replacement
� Hypotonic IV fluids or free water
� NaCl 0.225% or 0.45%
� D5W
� >1L/hr must monitor glucose levels
� Glucosuria may exacerbate DI
� Desmopressin
� ADH analogue
� Vasopressin
� 5 units SQ q6hr
Ref: Uptodate
Fevers & Infections� 1/3 of stroke patients will become hyperthermic >37.6C
� Associated with worse outcome
� ASA/APAP beneficial if temp <38C
� Routine use of prophylactic antibiotics has not been shown to be beneficial.
Ref: 1. & 3.
Fever evaluation� Physical exam
� Lungs, skin, joints, heart, abdomen
� ETT, NGT, Foley, IV’s, EVD
� Surgical sites
� Diagnostic evaluation� CBC & Chemistries
� Blood cultures� Bacteremia – high risk, paucity of clinical findings
� Chest X-Ray
� Urinalysis
� Sputum
Ref: 3.
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Noninfectious fevers� Drug fever
� Acalculous cholecystitis
� Deep vein thrombosis/Pulmonary embolism
� Pancreatitis
� Transfusion reaction
� Ischemia
� Stroke
Glycemic management� Measure at onset or presentation
� Elevated in >40% of patients with acute ischemic stroke
� Hypoglycemia & hyperglycemia both may be detrimental
� Autonomic symptoms – typically <60mg/dL
� Diaphoresis, Tremor, Anxiety
� Altered mentation – typically <50mg/dL
� Confusion, altered speech
� Symptoms may result at higher levels in poorly controlled diabetes mellitus
Ref: 1., UpToDate
Glycemic management� Lack of good evidence for certain targets of glucose to show improved
outcomes
� American Diabetes Association recommendations
� Range of 140 to 180 mg/dL in all hospitalized patients
� Intensive glucose control - generally 80 to 130 mg/dL
� No difference in outcomes
� Higher rates of hypoglycemia
Ref: 1. & Cochrane Database Syst Rev. 2014
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Therapies� If NPO
� typically stop oral antiglycemics
� Limit Dextrose containing IVF� Maintenance fluids & intermittent infusions
� Typically insulin� Subcutaneous
� 1-4 units/50mg/dL elevation of blood glucose
� IV infusion
� Long acting insulin – NPH, detemir, glargine� 0.2-0.3 units/kg/day
Ref: UpToDate
Thromboembolic complications� High risk especially in first 3 months
� DVT - 10%
� PE - 3%
� Duplex of extremity venous system for DVT
� Inability to evaluate pelvic veins
� CT venography
� PE
� CT angiogram or V/Q scan
Ref: UpToDate
Thromboembolism Prophylaxis� Mechanical
� Pneumatic compression devices – SCD
� TED hose
� Chemical
� Heparin, Low Molecular Heparins
� Xa inhibitors – not studied
� IVC filter
� Only PE prophylaxis
Ref: UpToDate, Cook Medical
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Nutritional support� Catabolic state
� Prevent muscle loss
� Caloric deficit may be associated with increased mortality
� Swallow evaluation
� altered gag reflex, poor cough, dysphonia, incomplete mouth closure, elevated NIHSS score, or cranial nerve palsies
� Nursing evaluation & then Speech Therapist evaluation if needed
� Higher risk of aspiration & pneumonia with dysphagia
Ref: 1. & UpToDate
Nutritional support� Enteral route preferred
� Considered at 48-72 hours
� Variable outcomes in studies
� Early invitation may help with infectious complications & mortality
� Carbohydrate source with impaired fat metabolism
� Complications
� Misplacement
� Sinusitis
Ref: UpToDate
Nutritional support� Parenteral
� Early initiate is not associated with alterations in outcomes
� May have slight increased risk of infectious complications
� Secondary route – unable to give enteral nutrition
� Considered typically after 7 days for reasonably nourished patient
Ref: UpToDate
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17
Hypothermia� Associated with mild improvement in post cardiac arrest patients
� Moderate hypothermia 32°C–33°C
� Mild - 34°C–35°C may have fewer side effects
� Trials have been small & more pilot studies
� “There remains insufficient clinical evidence to establish a class of recommendation for induced hypothermia in acute stroke”
Ref: 1.
References1. Adams HP, et al. Guidelines for the management of patients with acute ischemic stroke: a
statement for healthcare professionals from a special writing group of the Stroke Council, AHA. Circulation. 1994; 90: 1588–1601
2. Torbey, M et al. Evidence-Based Guidelines for the Management of Large Hemispheric Infarction Neurocrit Care (2015) 22:146–164
3. UpToDate
4. Vemmos, K. N., et al. (2004), U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. Journal of Internal Medicine, 255: 257–265.
Hypoxemia
� Etiologies
� Airway obstruction
� Hypoventilation
� Pulmonary parenchymal issues� Atelectasis, Aspiration, Infection
� Preexisting disease
� COPD, CHF & edema
� Thromboembolic disease
Ref: 1.