Abstract SNACC-8

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Perioperative management of aneurysmal subarachnoid hemorrhage: European and American survey results

1Fabregas N, 2Velly L, 3Soehle M, 4Bilotta F, 2Bruder N, 5Nathanson M
1Hospital Clinic Barcelona, Barcelona, Barcelona, España; 2University Hospital Timone, Marseille, , Francia; 3University Hospital Bonn, Bonn, , Germany; 4Sapienza University Rome, Rome, , Italy; 5University Hospital Queens Medical Centre, Nottingham, , United kingdom

Background and Goal of Study: Many aspects of aneurysmal subarachnoid hemorrhage (SAH) therapy remain controversial. The European Neuroanaesthesia and Critical Care Interest Group (ENIG group) conducted a survey to determine the clinical practices of physicians treating SAH, and to evaluate the discrepancy between practice and published evidence.
Materials and Methods: The research team generated a 31-item online questionnaire, which was distributed by the ENIG Group. The survey remained online from early October to the end of November 2012 in Europe; and from January 6 until February 7 2014 through the SNACC web for its members. Fisher´s exact test was used for the analysis of responder subgroups.
Results and Discussion: There were 268 completed surveys from Europe (ENIG) and 76 from SNACC (mainly United States). In our sample, 44.8% of ENIG respondents worked either in Neuroanaesthesia or Neurointensive Care or both, vs 25% of SNACC (P<0.05); 29.9% were mainly involved in Neuroanaesthesia in ENIG vs 72.4% in SNACC (P<0.05). Regarding criteria for intensive care unit (ICU) admission, 72% in ENIG and 89.6% in SNACC (P< 0.25) of respondents admitted all patients after SAH in ICU; and 28% only high-grade patients (WFNS 3-5) in ENIG vs 10.4% in SNACC (P<0.05). In both samples there were no differences in delay to treat the aneurysm; however, regarding aneurisms repair methods, less ENIG respondents (10.4%) used clipping in >60% cases than respondents in SNACC (36.8%)(P<0.05). There were great differences involving the anesthetic technique during the aneurysm repair, more than 70% of respondents used total intravenous anesthesia in ENIG vs 47.2% in SNACC (P<0.05); being the opposite for inhalational anesthesia (22.8% ENIG vs 55.6% SNACC; P<0.05). The most commonly used narcotic was remifentanil (70% ENIG vs 63.5% SNACC). Regarding neuroprotective strategy during temporary clipping, SNACC respondents used more “burst suppression” (57.9%) than ENIG (36.6 %) (P<0.05). The most commonly used vasoconstrictor during the procedure was noradrenaline in ENIG respondents (56.3% ENIG vs 11.8% SNACC; P<0.05), whereas it was phenylephrine in SNACC respondents (11.6% ENIG vs 77.6% SNACC; P<0.05). More ENIG respondents delayed recovery and tracheal extubation after uncomplicated clipping surgery in ICU (12.7% ENIG vs 3.9% SNACC; P=0.05).
Conclusion: This study found striking variability in practice patterns of European and United States physicians involved in SAH. These heterogeneous practices are frequently at variance with available guidelines on SAH management.

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