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Table 1 List of consensus recommendations

From: Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

No.

Recommendation

Level

1

We recommend that all salvageable spontaneous SAH patients (i.e., patients who may recover, at least to some extent, with appropriate treatment) admitted in a Spoke center be rapidly transferred to a Hub center after hemodynamic and respiratory stabilization.

Strong recommendation

2

We recommend using a telemedicine service for image transfer from the Spoke to the Hub center.

Strong recommendation

3

We recommend that the transfer of SAH patients should be performed by a physician with:

experience in advanced airway management and life support strategies and

basic knowledge in neurocritical care (i.e., medical management of cerebral swelling, herniation).

Strong recommendation

4

We recommend sedation, intubation and mechanical ventilation for SAH patients in coma (Glasgow Coma Scale (GCS) score ≤ 8) and/or with inadequate airway protection or respiratory failure.

Strong recommendation

5

We recommend sedation, intubation, and mechanical ventilation also for SAH cases with severe agitation, if this persists despite mild sedation and pain control.

Weak recommendation

6

We recommend, in poor-grade SAH patients needing transfer to the Hub center, an invasive monitoring of arterial blood pressure (ABP) in addition to the standard cardiorespiratory monitoring (electrocardiogram (ECG), heart rate (HR), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2)).

Strong recommendation

7

We recommend, to avoid aneurysmal rebleeding and to ensure an adequate CPP, the maintenance of systolic arterial pressure (SAP) between 120 and 160 mmHg. It is also reasonable to individualize the target considering patient’s clinical history (i.e., arterial hypertension) and/or radiological signs of intracranial hypertension.

Strong recommendation

8

We recommend the maintenance of SAP values close to the lower limit (120 mmHg) in SAH patients without a history of arterial hypertension and/or radiological signs of elevated ICP.

Strong recommendation

9

We recommend the maintenance of SAP values close to the upper limit (160 mmHg), avoiding fluctuations, in SAH patients with a history of arterial hypertension and/or radiological signs of elevated ICP.

Strong recommendation

10

We recommend the maintenance of a platelet (PLT) count > 100,000/mm3 in all salvageable SAH patients, possibly candidates for neurosurgical intervention.

Strong recommendation

11

We recommend maintaining a prothrombin time (PT)/ activated partial thromboplastin time (aPTT) value < 1.5 the normal control in all salvageable SAH patients.

Strong recommendation

12

We recommend the early reversal of anticoagulants drugs in all salvageable SAH patients.

Strong recommendation

13

We recommend against the utilization of routine tranexamic acid for a short-term therapy before aneurysm treatment to prevent rebleeding of cerebral aneurysm/s.

Weak recommendation

14

We are unable to provide any recommendation regarding the use of routine seizure prophylaxis in all SAH patients.

No recommendation

  1. Abbreviations: SAH subarachnoid hemorrhage, ICP intracranial pressure, GCS Glasgow Coma Scale, ABP arterial blood pressure, ECG electrocardiogram, HR heart rate, SpO2 peripheral oxygen saturation, ETCO2 end-tidal carbon dioxide, CPP cerebral perfusion pressure, SAP systolic arterial pressure, PLTs platelets, PT prothrombin time, aPTT activated partial thromboplastin time.