REFERENCE:
LHH Guideline
Surrogate hierarchy: Legal guardian*, spouse or domestic partner, adult child, parent, adult sibling, patien representative or close friend.
*Contact Social Work for verification of the legal guardian’s authority to make MOLST decisions.
Capacity Determination:
• Adults are presumed to have the capacity to make medical decisions, unless demonstrated otherwise. The determination that a patient lacks capacity to make the medical decisions at hand must be documented by a physician/Nurse Practitioner (NP)/Physician Assistant (PA). Concurring determination by two Health Care Practitioners (of which one must be a physician/NP/PA) for patients who lack capacity for medical reasons if decisions involve withholding or withdrawing life sustaining treatment. A concurring Health Care Practitioner [defined as a licensed physician (other than the attending), registered nurse, LCSW, licensed psychologist, Nurse Practitioner, or Physician Assistant selected by the attending) signs in this section to attest to the capacity determination. If incapacity is due to a psychiatric or developmental disorder, then a psychiatrist or specially trained psychologist is required.
Decision-Maker:
• A patient with capacity decides for him/herself, unless he or she wishes to defer to a loved one. If a patient made a specific health care decision prior to losing capacity, that decision must be honored if still applicable.
• Health Care Agent (HCA) is the legal term for Health Care Proxy. The HCA is a person formally appointed by the patient.
There must either be a form documenting the appointment of a CA, or a verbal appointment must have been witnessed by 2 members of the health care staff.
• A Surrogate may make health care decisions for a patient who lacks capacity and does not have a HCA. There is a descending hierarchy of individuals who may act as a health care Surrogate (noted on form). Assist loved ones to designate one person in the hierarchy to serve in this role.
• No Surrogate must be indicated for a patient who lacks capacity and has no HCA and no one willing or available to act as Surrogate. These are “unrepresented” patients. Physicians are permitted to decide to withhold or withdraw Life Sustaining Treatment (LST) on behalf of unrepresented patients under specified criteria listed on form. Ethics consultation should be triggered when making high stakes decisions for the unrepresented patient.
• Anyone / everyone deciding on behalf of an incapacitated patient must act in accord with the patient’s wishes (if known), the patient’s goals, values and beliefs (if known), and in the patient’s best interest.
Medical Criteria for Patients without Capacity:
• A patient with decisional capacity may refuse any and all treatment without specific medical criteria.
• A health care agent (HCA) may act as the patient, but must know the patient’s wishes re: artificial feeding and hydration.
• When a surrogate decides to withhold or withdraw LST for an incapacitated patient, there are medical criteria which must be met in order to authorize withholding or withdrawing of LST. The physician/NP/PA must indicate which criteria are met in the
“surrogate without health care agent” section.
• If there is no CA or surrogate, then physicians may decide to withhold/withdraw LST in the patient’s best interest. Two Health Care Practitioners (of which one must be a physician) must attest that the criteria indicated on the form are met. The concurring Health Care Practitioner signs as indicated.
Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology. 2023 Dec 12;101(24):1112-1132. doi: 10.1212/WNL.0000000000207740. Epub 2023 Oct 11. Erratum in: Neurology. 2024 Feb 13;102(3):e208108. PMID: 37821233; PMCID: PMC10791061.
REFERENCE:
Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology. 2023 Dec 12;101(24):1112-1132. doi: 10.1212/WNL.0000000000207740. Epub 2023 Oct 11. Erratum in: Neurology. 2024 Feb 13;102(3):e208108. PMID: 37821233; PMCID: PMC10791061.
Cangrelor Dosing Guideline for Emergency Stent Placement in Interventional Neuroradiology
Background:
In interventional cardiology, the loading dose for cangrelor has been 15-30 mcg/Kg, and maintenance dose has been 4 mcg/kg/min. This dose has been reduced in interventional neuroradiology (INR) procedures because of the higher risks of intracranial bleed. This guideline presents recommendations for dosing and monitoring of cangrelor in INR procedures.
Neurologic Indications:
- Acute ischemic stroke with tandem occlusion requiring emergent carotid artery stenting
- Acute ischemic stroke with intracranial stenosis requiring emergent stenting
- Ruptured or unruptured intracranial aneurysm requiring bailout stenting
PROTOCOL
Give cangrelor IV bolus and start cangrelor drip.
- BOLUS: Give 7 mcg/Kg IV bolus, 2-5 minutes prior to stent placement.
- MAINTENANCE DRIP: Start 1-2 mcg/Kg/min 30 seconds after bolus dose has been given.
- NOTE: No heparin is to be given during the neurointerventional procedure.
Check PRU 7-10 minutes after cangrelor drip has been started.
- PRU goal should be specified by interventionalist.
- If PRU is not at goal, adjust by 0.25 mcg/Kg/min, recheck PRU.
Maintain cangrelor drip x 2-6 hours.
Obtain non contrast head CT if needed to rule out hemorrhage.
Once maintenance drip is completed, switch to an oral agent.
Ticagrelor (preferred)
- LOAD: Administer 180mg of ticagrelor (loading dose) at any time during cangrelor infusion or immediately after discontinuing cangrelor infusion
- MAINTENANCE: After loading dose, start maintenance dose of 60-90mg PO BID
Alternative agents:
- Clopidogrel:
- LOAD: Administer 600mg of clopidogrel immediately after discontinuing cangrelor infusion.
- Do not administer clopidogrel prior to cangrelor discontinuation.
- MAINTENANCE: After loading dose, start maintenance dose of 75mg once daily.
- Prasugrel:
- LOAD: Administer 60mg of prasugrel immediately after discontinuing cangrelor infusion.
- Do not administer prasugrel prior to cangrelor discontinuation.
- MAINTENANCE: After loading dose, start maintenance dose of 10mg once daily.
- NOTE: Patients with history of TIA or stroke are associated with increased risk of fatal bleeding with the use of prasugrel. Prasugrel is also not recommended in patients 75 years or older and patients <60 Kg. Reduced dosing is available for patients <60Kg, but other agents as above are preferred.
Start aspirin 325 mg PO on day 1 followed by subsequent doses of 81mg PO daily, together with maintenance dose of oral P2Y12 inhibitor.
- NOTE: Maintenance doses of aspirin >100 mg daily reduce the effectiveness of ticagrelor and should be avoided. This warning does not apply to clopidogrel or prasugrel.
Obtain CT/CTA in a.m.
References:
- Cagnazzo F, Radu RA, Derraz I, Lefevre PH, Dargazanli C, Machi P, Morganti R, Gascou G, Fendeleur J, Rapido F, Costalat V. Efficacy and safety of low dose intravenous cangrelor in a consecutive cohort of patients undergoing neuroendovascular procedures. J Neurointerv Surg. 2023 Mar 15:jnis-2023-020094. doi: 10.1136/jnis-2023-020094. Epub ahead of print. PMID: 36922032.
- Linfante I, Ravipati K, Starosciak AK, Reyes D, Dabus G. Intravenous cangrelor and oral ticagrelor as an alternative to clopidogrel in acute intervention. J Neurointerv Surg. 2021 Jan;13(1):30-32. doi: 10.1136/neurintsurg-2020-015841. Epub 2020 May 15. PMID: 32414891.
- Aguilar-Salinas P, Agnoletto GJ, Brasiliense LBC, Santos R, Granja MF, Gonsales D, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study. J Neurointerv Surg. 2019 Apr;11(4):347-351. doi: 10.1136/neurintsurg-2018-014396. Epub 2018 Dec 14. PMID: 30552167.
- Cheddad El Aouni M, Magro E, Abdelrady M, Nonent M, Gentric JC, Ognard J. Safety and Efficacy of Cangrelor Among Three Antiplatelet Regimens During Stent-Assisted Endovascular Treatment of Unruptured Intracranial Aneurysm: A Single-Center Retrospective Study. Front Neurol. 2022 Mar 4;13:727026. doi: 10.3389/fneur.2022.727026. PMID: 35309565; PMCID: PMC8931395.
- Holden DN, Entezami P, Bush MC, Field NC, Paul AR, Boulos AS, Yamamoto J, Dalfino JC. Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients. Pharmacotherapy. 2021 Oct;41(10):811-819. doi: 10.1002/phar.2619. Epub 2021 Sep 18. PMID: 34496076.
- Rodriguez‐Calienes, A., et al. Safety of Intravenous Cangrelor Versus Dual Oral Antiplatelet Loading Therapy in Endovascular Treatment of Tandem Lesions: An Observational Cohort Study. Stroke: Vascular and Interventional Neurology. 2023;0:e001020. Oct 2023 doi.org/10.1161/SVIN.123.001020.
NORTHWELL SYSTEM POLICY*
Patients should be monitored daily for tolerance of EN. Tolerance of EN may be determined by physical examination, passage of flatus and stool, radiologic evaluations, and absence of patient complaints such as pain or abdominal distention. GI intolerance has been variably defined (eg, absence or abnormal bowel sounds, vomiting, bowel dilatation, diarrhea, GI bleeding, high gastric residual volumes [GRVs]). GRV should not be used as part of routine care to monitor patients receiving EN, especially in Intensive Care Units. Gastric residuals may be checked if patients display any of the signs/symptoms of intolerance. If residual gastric content is greater than or equal to 500 mL; tube feeding intolerance should be considered.
If GRV is greater than or equal to 500 mL, with additional signs of intolerance:
- Recommend use of prokinetic agents
- Hold feeding and notify provider
- Document notification using a Provider Contact Note
- Not to be used for Jejunostomy, Keofeed or Dobhoff feeding tubes.
UPTODATE:
Routine measurement of gastric residual volume (GRV) to assess feeding tolerance and prevent aspiration is not recommended. GRV is only measured in patients showing signs of intolerance, and if the volume exceeds 500 mL, feeding is halted. The cause of elevated GRV should be investigated before resuming feeding. Studies have shown a poor correlation between GRV and pneumonia risk. Holding feeds for high GRV (>250 mL) can decrease calorie delivery without significant impact on pneumonia rates or other ICU outcomes. Instead, adjustments in feeding rates are made based on clinical signs such as vomiting or regurgitation. Resumption of feeds should occur promptly to minimize the risk of malnutrition from delayed feeding.
Extravasation of vasopressors, although rare, can result in significant tissue damage and complications. Here is a guideline for the management of extravasation events involving vasopressors, specifically focusing on norepinephrine.
A. General Considerations
- Assessment: Promptly assess the extravasation site and the patient’s condition. Determine the severity of symptoms, including pain and tissue ischemia.
- Non-Pharmacologic Management: In most cases, accidental vasopressor extravasations can be managed without pharmacologic treatment. Conservative measures such as elevation of the affected limb and application of warm compresses may be sufficient. Pharmacologic treatment should be considered only in patients with refractory pain or significant tissue ischemia.
- Pharmacologic Management:
- Peripheral extravasation of norepinephrine (labeled use) and other sympathomimetic vasopressors (off-label use), management:
- Subcutaneous (SUBQ) Route
- Administer 5 to 10 mg of norepinephrine (diluted in 10 mL Normal Saline – NS) divided into multiple SUBQ injections along the area of extravasation.
- If the intravenous (IV) catheter remains in place, administer the initial dose intravenously through the catheter.
- Administer the medication as soon as possible and within 12 hours of extravasation.
- Consider re-administering the medication in 60 minutes if the patient remains symptomatic.
- Management of Digital Epinephrine Injection (Accidental)
- Subcutaneous (SUBQ) Route
- Administer 0.5 to 4.5 mg of epinephrine (diluted in 5 mL Normal Saline – NS) divided into multiple SUBQ injections along the area of accidental injury.
- Administer the medication as soon as possible and within 12 hours of extravasation.
- Consider re-administering the medication in 60 minutes if the patient remains symptomatic.
- Peripheral extravasation of norepinephrine (labeled use) and other sympathomimetic vasopressors (off-label use), management:
REFERENCE:
- UpToDate, phentolamine, accessed 12/27/2023
| Probe Type | Frequency Range (MHz) | Common Applications |
| Doppler (Continuous Wave) | Variable | Vascular studies, Cardiac studies (blood flow assessment) |
| Curvilinear | 2 – 7 | Abdominal, Obstetric, Gynecologic imaging |
| Phased Array | 1 – 5 | Cardiac, Vascular, Abdominal imaging |
| Micro-Convex (Transesophageal) | 4 – 8 | Cardiac imaging, Transesophageal echocardiography (TEE) |
| Intracavitary (Intracardiac) | 5 – 10 | Cardiac imaging, Intracardiac echocardiography (ICE) |
| Endocavitary (Transvaginal) | 5 – 10 | Obstetric, Gynecologic imaging |
| Linear Array | 5 – 15 | Vascular, Small parts (e.g., musculoskeletal, thyroid) |
| Linear High-Frequency | 7 – 18 | Ophthalmic, Small parts (e.g., superficial vascular, MSK) |
| 3D/4D Volume | Variable | Obstetric, Gynecologic imaging |
| Frequency Range (MHz) | Depth of Penetration | Typical Applications |
|---|---|---|
| 1 – 2 | Greater than 20 cm | Abdominal, Obstetric, Deep musculoskeletal imaging |
| 2 – 5 | 10 – 20 cm | General Abdominal, Pelvic, Cardiac imaging |
| 5 – 10 | 4 – 10 cm | Vascular, Small parts (e.g., thyroid, testicular), Transvaginal |
| 10 – 15 | 2 – 4 cm | Superficial structures, Musculoskeletal |
| 15 – 20 | Less than 2 cm | Ophthalmic, Superficial vascular, Fine musculoskeletal details |
- Background and Purpose:
- Studies suggest CT perfusion (CTP) could overestimate ischemic core in early time frames.
- Aim to evaluate the influence of time and collateral status on ischemic core overestimation.
- Methods:
- Retrospective study on large-vessel stroke patients with reperfusion after endovascular treatment.
- Ischemic core and collateral status estimated on baseline CTP.
- Hypoperfusion intensity ratio used for collateral status assessment.
- Ischemic core overestimation defined when CTP-derived core > final infarct volume.
- Results:
- Analysis of 407 patients with median CTP-derived core of 7 mL and final infarct volume of 20 mL.
- Twenty percent exhibited ischemic core overestimation.
- Poor collateral status and earlier onset to imaging time independently associated with overestimation.
- Poor collateral status impact varied with onset to imaging time, stronger in early imaging patients.
- Conclusions:
- Poor collateral status may lead to higher ischemic core overestimation on CTP, especially in earlier time frames.
- CTP reflects hemodynamic state; consider collateral status and onset to imaging time when estimating core.
Take home:
This study underscores that poor collateral status significantly contributes to overestimating the ischemic core on CT perfusion (CTP), particularly in the early imaging window. CTP should be viewed as reflecting hemodynamic conditions rather than definitive tissue fate. Clinicians should be cautious in interpreting CTP results, considering collateral status and the time from symptom onset to imaging, as these factors play crucial roles in accurate ischemic core estimation.
García-Tornel Á, Campos D, Rubiera M, et al. Ischemic Core Overestimation on Computed Tomography Perfusion. Stroke. 2021;52(5):1751-1760. Accessed November 30, 2023.
- Background:
- Rapid intervention in acute stroke is crucial for maximizing treatment benefits.
- First contact with medical staff often occurs in the emergency room (ER).
- Development and validation of the Recognition of Stroke in the Emergency Room (ROSIER) scale for ER physicians.
- Methods:
- Prospective data collection on suspected acute stroke patients in the ER for 1 year (development phase).
- Excluded suspected transient ischemic attack (TIA) patients without symptoms in the ER.
- Logistic regression analysis and clinical reasoning used to create the ROSIER scale.
- Prospective validation in a new ER patient cohort over 9 months.
- Findings:
- Stroke mimics included seizures (23%), syncope (23%), and sepsis (10%).
- Seven-item ROSIER scale based on clinical history and neurological signs.
- Internally validated sensitivity of 92%, specificity of 86%, PPV of 88%, and NPV of 91%.
- Prospective validation showed sensitivity of 93%, specificity of 83%, PPV of 90%, and NPV of 88%.
- ROSIER scale demonstrated higher sensitivity than existing stroke recognition instruments.
- Interpretation:
- ROSIER scale effectively differentiated acute stroke from mimics in the ER.
- Introduction of the instrument improved the appropriateness of referrals to the stroke team.
Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol. 2005;4(11):727-34. Accessed November 30, 2023.
Peripheral Brain 