Abstract 2561: Blood Pressure Variation Associated with Emergent Intubation and During Endovascular Treatment in Acute Stroke Patients
Maintenance of airway stability is an essential part of critical care management of patients undergoing endovascular treatment for acute stroke. While some patients may undergo endovascular treatment utilizing conscious sedation alone, many patients require deeper sedation and emergent mechanical ventilation due to need to control patient movement, stabilize the airway, and facilitate patient comfort during prolonged procedures (average duration 1.9 hrs). Nine patients undergoing emergent intubation prior to endovascular treatment for acute stroke underwent observational study. Following completion of IRB-approved consent for study participation, patients received arterial line placement and vital signs were collected before, during, and after intubation and throughout endovascular treatment. Intubation was performed by experienced ED physicians using a variety of medications. An immediate and dramatic rise in mean arterial pressure (MAP) was associated with intubation (increased by 172% over baseline) followed by a decrease in the MAP (12% below baseline) in the ED prior to patient transfer to angiography. No consist trend was noted in PaCO2 levels drawn immediately after intubation but prior to initiation of mechanical ventilation. Average MAP in the angiogram suite during endovascular therapy was almost identical to pre-intubation baseline MAP (101% of baseline) despite utilization by interventionalists of a number of sedative medications. Transient decreases in the MAP to a nadir of 75 - 80 were seen during endovascular therapy in 3 patients; more significant drops did not occur. Mean duration of intubation, ICU stay, and total hospitalization was 3 days, 8 days, and 12 days respectively. In conclusion, real-world emergent intubation by ED physicians of acute stroke patients just prior to endovascular treatment is associated with significant fluctuations in MAP. Such fluctuations in either direction may further jeopardize tissue at risk. Recent reports from the national MERCI Registry Database indicate worse outcomes in intubated patients for unclear reasons; this could be due to fluctuations in MAP but might also be due to the effect of anesthesia itself. Assuming that these hemodynamic changes are causal in reducing clinical outcomes, ED intubation and angiographic sedation protocols should be designed to minimize fluctuations in MAP. Further investigations documenting improved MAP control utilizing standardized protocols are needed.
- © 2012 by American Heart Association, Inc.