Monthly Archives: April 2019

Integrilin (eptifibatide) Dosing Chart

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Helsinki Protocol for Postoperative Management of Arteriovenous Malformations

Patients with small, unruptured AVMs ofSpetzler-Martin grade 1 without surgical complications:

  • No need for a central venous catheter
  • Extubation in the operating room and follow-up in NICU
  • Normal blood pressure (SBP generally under 150 mmHg)
  • Strict fluid balance postoperatively
  • Antihypertensive medication if needed (vasodilating beta blocker or a calcium channel blocker) for 1 to 2 weeks postoperatively

Patients with medium to large AVMs without and small bAVMs with surgical complications or if ruptured preoperatively

  • Recovery from general anesthesia in NICU. According to the clinical evaluation, propofol dexmedetomidine sedation until the postoperative control imaging (CT-scan, DS- or CT angiogram) has been performed.
  • Head of bed elevation 15-30%
  • Restricted intravenous fluid administration postoperatively
  • Low SBP target (generally under 120-130 mmhlg) and avoidance of sudden increase in SBP
  • Labetalol, hydralazine and clonidine are used to lower blood pressure
  • Dexmedetomidine for sedation (0.2-1.5 ug/kg/h infusion)
  • Patient in NICU until stabilized, usually up to several days
  • Antihypertensive medication (a vasodilating beta blocker or a calcium channel blocker) for 1 to 2 weeks postoperatively

Patients with large AVMs

  • Placement of central venous catheter preoperatively
  • Propofol and/or dexmedetomidine sedation until the postoperative control imaging has been performed or even longer
  • Head of bed elevation 15-30%
  • Restricted intravenous fluid administration postoperatively
  • Avoidance of any sudden increase in SBP
  • Low SBP target: first under 90-110 mmhlg,then gradually increased 110 to 120 to 130 to 140 to 150 mmHg
  • Patient in NICU until stabilized, usually up to several days
  • Antihypertensive medication (a vasodilating beta blocker or a calcium channel blocker) for one to two weeks postoperatively

Figure. Delayed postoperative hemorrhage (DPH) by Spetzler Martin grade.

Reference:

Niini, T., Laakso, A., Tanskanen, P., Niemelä, M. and Luostarinen, T. (2019). Perioperative Treatment of Brain Arteriovenous Malformations Between 2006 and 2014: The Helsinki Protocol. Neurocritical Care.

Transcranial Doppler in patients with Decompressive Hemicraniectomy

A certain percentage of patients have poor windows for TCDs. Hemicraniectomy patients have an outstanding window that allow real-time imaging of the brain structures. TCD is underutilized in hemicraniectomy patients.

Possible uses:

1. Monitoring post-op complications – hygromas, SDH

2. Monitor midline shift

References

Srinivasan, V., Smith, M. and Bonomo, J. (2019). Bedside Cranial Ultrasonography in Patients with Hemicraniectomies: A Novel Window into Pathology. Neurocritical Care.

Cilostazol for DCI Prevention

Cilostazol is a phosphodiesterase III inhibitor which increases cAMP and leads to reversible inhibition of platelet aggregation, vasodilation and inhibition of vascular smooth muscle cell proliferation.  A systematic review was recently published in the Journal of Neurology on the effect of cilostazol on the incidence of delayed cerebral ischemia in subarachnoid hemorrhage (Department of Neurosurgery, West China Hospital).

The meta-analysis included seven studies, all of which were done in Japan:  three were randomized controlled studies, 3 were retrospective studies and one was a prospective study.  Most studies used cilostazol at 200mg per day for 14 days.

studies

Forest plots for the outcomes provided below:

A. Severe angiographic vasospasm

forest plot 1

B. Symptomatic vasospasm

forest plot 2

C. New cerebral infarction

forest plot 3

D. Poor outcome

forest plot 4

E.  Mortality

forest plot 5

Adverse effects related to cilostazol administration in the studies include diarrhea, transaminitis, tachycardia, headaches, hemorrhagic and cardiac events.

The meta-analysis concluded that cilostazol effectively reduced the incidence of severe angiographic vasospasm, symptomatic vasospasm, new cerebral infarction and poor outcome in patients with aneurysmal subarachnoid hemorrhage, but does not reduce mortality significantly.

It is important to note that all of the studies included in the meta-analysis were from one country (Japan), which precludes the generalization of the results to the general population.  Also, none of the patients in the studies received nimodipine, which has not been approved for SAH treatment in Japan.  Whether or not the co-administration of nimodipine would add to or nullify the benefits seen with cilostazol requires further investigation.

Take home message:  should not change current practice, needs further research.

 

References:

Shan, T., Zhang, T., Qian, W., Ma, L., Li, H., You, C. and Xie, X. (2019). Effectiveness and feasibility of cilostazol in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Journal of Neurology.

Uptodate.com. (2019). UpToDate. [online] Available at: https://www.uptodate.com/contents/cilostazol-drug-information?sectionName=Adult&topicId=8872&search=cilostazol&usage_type=panel&anchor=F151445&source=panel_search_result&selectedTitle=1~36&kp_tab=drug_general&display_rank=1#F151413 [Accessed 6 Apr. 2019].