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Subarachnoid Hemorrhage and Ventriculitis

Clinical signs of ventriculitis are difficult to recognize in SAH patients who are sedated, who have recently undergone neurosurgery, or have a sterile inflammatory response in the CSF due to the SAH.  Clinical symptoms of SAH (headache, nuchal rigidity, AMS) closely resemble bacterial ventriculitis.

Suspect with:
  • new fever
    • Fever occurs in 40 % after SAH +/- infection
  • new nuchal rigidity

 

What to do?

Exclude other causes of infection

  1. physical examination
  2. blood / sputum / urinary cultures
  3. CXR

Exclude other causes of AMS (HCP and ischemia)

  • Neuroimaging with plain CT scan
Work-up:
  • Serum:  CRP WBC glucose
  • CSF analysis (cell count, GS / CS, glu / protein)
    • Interpretation of CSF WBC problematic; CSF RBC causes aseptic ventriculitis
    • CSF cell count  helpful but low sensitivity and specificity
      CSF RBC higher in CSF culture-negative bacterial ventriculitis
    • cell index for EVD-related ventriculitis with IVH (formula proposed, but not yet validated)
  • Blood cultures
  • CSF lactate, cytokine levels, and serum procalcitonin
    • Also disturbed after SAH
    • procalcitonin discriminates between SIRS and systemic infection but value for aseptic vs bacterial ventriculitis is limited
  • CSF PCR for bacterial pathogens – low sensitivity in EVD related bacterial ventriculitis and aseptic ventriculitis after surgery
Case definitions:
  1. Clincally suspected bacterial ventriculitis – empirical antibiotic treatment for bacterial ventriculitis, but negative CSF cultures
  2. Confirmed Bacterial ventriculitis – (+) CSF culture for bacteria; if staph epidermidis – needs 2 consecutive positive cultures to rule out contamination
Treatment:
  • No good discriminative tests, treatment initiated on first suspicion
  • Antibiotic regimen for bacterial ventriculitis
    •  ceftriaxone 2 g BID + vancomycin 2 g BID
    •  ceftazidime 2 g TID + vancomycin 2 g BID if external CSF catheter in place
  • Duration
    • culture negative – discontinue ABx (after 72h)
    • culture positive – 2 weeks

 

ORDERS:
  1. Physical Examination
  2. Assessment:
    • clinically suspected bacterial ventriculitis
    • confirmed bacterial ventriculitis
  3. Blood work:
    • CBC (WBC)
    • BMP (glucose)
    • Blood cultures x 2
    • CRP
    • Procalcitonin
  4. sputum cultures
  5. urinalysis with reflex to urine culture if (+)
  6. CXR
  7. Plain CT scan
  8. CSF studies
    • cell count
    • Gram stain and culture
    • CSF glucose
    • CSF protein
    • calculate cell index
    • CSF lactate
    • *CSF cytokine levels
    • *CSF PCR for bacterial pathogens
  9. Treatment x 2 weeks
    • ceftriaxone 2 g BID + vancomycin 2 g BID
    • ceftazidime 2 g TID + vancomycin 2 g BID if (+) EVD
    • discontinue within 72 hours if cultures are negative

 

Reference:

Hoogmoed, J. et al. “Clinical And Laboratory Characteristics For The Diagnosis Of Bacterial Ventriculitis After Aneurysmal Subarachnoid Hemorrhage”. Neurocritical Care (2016): 1-9.

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Adult Organ Donor Order Set

Labs: (stat and q6h)

  • CBC with differential
  • BMP, Mg, Phos, Ca
  • Amylase, Lipase
  • Pregnancy test x1 on all females
  • hepatic panel, LDH, GGTP, direct bilirubin
  • PT/PTT, Fibrinogen
  • Cardiac panel with troponin
  • USG and serum osmolality
  • Blood CS x 1 now and q24h
  • urine CS x1 now and q24h
  • Sputum CS x1 now and q24h
  • sputum GS
  • Others:  A1C, type and screen x1
  • ABG now, then q6h and PRN

 

Respiratory:

  • AC, TV @8cc/Kg, +5 PEEP
  • APRV or PRVC if indicated
    • P high 5 cmH20 below patients plateau pressure not to exceed 30 cm H20
    • P low 0 cm H20
    • T high 4.4-5.4 secs
    • T low 0.6-0.8 secs
  • Recruit Manuevers
    • Switch to CPAP of 0 dial PEEP up to 30 cm H20, give 1 breath and hold x 30 seconds x2 q4h then ABG in 30 minutes
    • Pressure control ventilation with PIP 25 cm h20 and PEEP of 15 cm H20 x 2 hours then switch back to volume control ventilation followed by O2 challenge
    • O2 challenge on all potentail lung donors:  Increase FiO2 to 100% + PEEP 5 x 30 minutes, draw ABG, decraese FiO2 to 40% plus PEEP 5 x 30 minutes, draw ABG and return to original ventilator settings, Desired PaO2/FiO2 30 minutes post lung recruitment is 300 mm Hg or greater

Medications:

  • Zosyn 3.375 g now then q6h for prophylaxis
  • bronchodilator q4-6h
  • 10% mucomyst q4h and PRn for thick secretions
  • diflucan 400mg IV now and daily (if +yeast at any site)
  • levaquin 750mg IV stat then q24h if intubated .5d with GNR on GS
  • vancomycin 1g IV now then q12h if MRSA identified
  • artificial tears: 2 drops to B eyes q2h to maintain lubrication
  • replace K:
    • 3.6-4.0 = KCl 20mEq x1 over 1 hour
    • 3.0-3.5 = KCl 20mEq x2 over 2 hours
    • <3.0       = KCl 20mEq x3 over 3 hours
  • Magnesium sulfate 2g max IVPB over 1 hour for Mg <1.5
  • Calcium chloride 1g IVPB over 1 hour for corrected calcium <7.8 or less
  • consider ISS as per hospital protocol if glu >180

Fluids and Medication Drips:

  • Calculate water deficit
    • if hypernatremic, give D5W boluses over 12 hours
    • if no results noted in 12 hours, add 250-300cc free water per NGT
  • transfuse 1 unit pRBC if Hct < 20%
  • maintenance IV:  0.45% NaCl at 100ml/hr
  • inotropic medications to maintain SBP >100mmHg or MAP >60
    • dopamine 1-50 ug/kg/min
    • neosynephrine 40-180ug/min
    • levophed 0.5-12 ug/min
    • dobutamine 0.5-5 ug/kg/min

Hormonal Replacement:

  • levothyroxine 20ug IV bolus over 3 minutes then continuous infusion of 200 ug in 500NS at 25 ml/hr (10ug/hr) to stimulate cellular metabolism donor management; titrate to maintain SBP >100mm Hg or MAP >60 to max of 50ml/hr (20 ug/hr)
  • solumedrol (15mg/kg) in 100ml D5W over 15 minutes and q24h to stimulate cellular metabolism (max 1g/24h)
  • vasopressin:  initial bolus 1 u IV then continuous infusion 25 u in 250ml D5W to start at 5ml/hr (0.5 u/hr) and titrate to as high as 40ml (4u/hr) for DI

 

Other orders:

  • Stat EKG and PRN
  • echo after 6 hours of levothyroxine infusion
  • cardiology consults for Echo, EKG readings and cardiac cath if indicated
  • surgical consult for:
    • central venous access
    • PA catheter placement
    • arterial line placement
    • placement of dialysis catheter
  • pulmonary consult for bronchoscopy, lung evaluation stat, send specimen for GS/CS (no bronchial alveolar lavage)

Radiologic Testing:

  • stat portabls CXR for line placement and status of heart and lungs, for lung donors, repeat CXR daily adn 3h before allocation adn PRN
  • bedside liver biopsy if indicated
  • full body CT scan or thoracic / abd / pelvic
  • abdominal ultrasound
  • cardiac cath
  • echocardiogram on all potential thoracic donors

Nursing:

  • Strict VS CVP I and O and O2 sats q1h
  • NGT / OGT to low intermittent suction
  • PA wedge pressure, CO, CI, SVR q1h when available
  • chest percussion q2h
  • HOB 30deg
  • normothermia within 36-37.5C with heating/cooling devices
  • suction q1h and turn q2h

 

Reference:

*adapted from LiveOnNY Adult Organ Donor Set

 

Meningitis Orders

meningitis

 

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Additional testing on CSF for CNS infection

Test Utility
Cryptococcal antigen High in immunosuppressed patients; recommended in suspected cases
Pneumococcal antigen High; recommended when Gram’s stain/culture not available or when antibiotics have been administered prior to culture. Urinary pneumococcal antigen testing is an alternative when CSF examination cannot be performed
Herpes simplex virus (HSV) PCR High; common, treatable cause of viral meningoencephalitis
West Nile virus (WNV) IgM High in appropriate clinical setting: viral encephalitis, WNV endemic area, appropriate season
HHV-6 PCR High in appropriate clinical setting: viral encephalitis in an immunocompromised host
Cytomegalovirus (CMV) PCR Low; not routinely recommended even in immunocompromised patients
Epstein–Barr virus (EBV) PCR Low; false positives common, not routinely recommended even in immunocompromised patients

References

O’Horo, J. and Sampathkumar, P. (2017). Infections in Neurocritical Care. Neurocritical Care.