The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review
CCCF ePoster library. Taran S. Oct 4, 2017; 198207; 95
Shaurya Taran
Shaurya Taran
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The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review

Taran, Shaurya1; Trivedi, Vatsal2; Singh, Jeffrey3,4; English, Shane5; McCredie, Victoria3,4

1 Division of Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada

2 Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada

3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada

4 Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, Toronto, ON Canada

5 Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON, Canada


The ICU management of subarachnoid hemorrhage (SAH) is challenging, due in part to the severity of the underlying insult, competing systemic injuries, and unpredictable clinical course. Even with specialist management in dedicated critical care settings, morbidity and mortality from this condition remains high. Complex care decisions in SAH management may be simplified with the use of standardized management protocols (SMPs), which provide clinicians with an algorithm to guide patient care. However, despite their postulated benefit, it is currently unknown if SMPs are associated with improved clinical outcomes in patients with SAH.
We conducted a systematic review to determine whether the use of SMPs is associated with improved outcomes in patients admitted to the ICU with non-traumatic SAH. Primary outcomes included mortality at 6 months or greater and neurologic outcome at hospital discharge and follow-up. Secondary outcomes included length of stay in hospital, duration of mechanical ventilation, rates of aneurysm rebleeding and vasospasm, and healthcare costs. We additionally assessed the quality of the published literature in this domain with a validated grading tool.
We developed comprehensive search strategies for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL to identify studies for inclusion. We also scanned the gray literature and reviewed published abstracts from relevant conference proceedings to locate further potential material. Our search yielded 9,585 articles, of which 9,151 were excluded by title and abstract screening. 404 studies were reviewed in full, and 15 observational studies were selected for final inclusion. Information on study design, baseline characteristics, and patient outcomes was extracted from each article into a pre-piloted data collection form and aggregated for analysis. Study quality was assessed according to a modified version of the Newcastle Ottawa Scale (NOS).
Most studies presented either a descriptive pathway or a flow diagram, with the majority of SMPs addressing the ICU management of delayed cerebral ischemia and corresponding vasospam. Of the 15 studies, 9 did not include a control group. 5 of these studies assessed functional outcomes but did not report them according to a recognized performance scale. 3 studies did not specify when they measured one or more of their primary outcomes. A total of 6 studies assessed SMP-related outcomes against a control group; 5 of these 6 studies showed statistically significant (p<0.05) improvements in one or more primary or secondary outcomes in the protocol-managed group. Only 2 studies reported level of adherence to the SMP. Overall study quality varied significantly based on NOS grading. Meta-analysis of the data was not possible given the dearth of studies meeting our inclusion criteria. Additionally, we noted significant sources of heterogeneity (variation in study design, non-standardized outcome reporting, and SMP design) between studies, rendering further inferences or statistical analysis difficult.
The efficacy of SMPs in SAH management cannot be determined from the available literature. Based on a subset of 6 studies that permitted direct comparisons with a control group, SMPs may hold promise as a low-cost initiative to improve clinical outcomes in SAH management. This data should be regarded as preliminary; further studies are needed to rigorously examine the efficacy of SMPs for non-traumatic SAH.

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