Detrimental effects of intrahospital transport on cerebral metabolism in patients suffering severe aneurysmal subarachnoid hemorrhage

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  • 1 Department of Neurosurgery, Medical University of Vienna, Austria;
  • | 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn;
  • | 3 Department of Neurosurgery, University Hospital Essen, Germany;
  • | 4 Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Austria;
  • | 5 Department of Neurosurgery, University Hospital Düsseldorf, Germany;
  • | 6 Departments of Anesthesia, General Intensive Care Medicine and Pain Management and
  • | 7 Clinical Pharmacology, Medical University of Vienna; and
  • | 8 Department of Neurosurgery, Johannes Kepler University, Linz, Austria
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OBJECTIVE

Intrahospital transport for CT scans is routinely performed for neurosurgical patients. Particularly in the sedated and mechanically ventilated patient, intracranial hypertension and blood pressure fluctuations that might impair cerebral perfusion are frequently observed during these interventions. This study quantifies the impact of intrahospital patient transport on multimodality monitoring measurements, with a particular focus on cerebral metabolism.

METHODS

Forty intrahospital transports in 20 consecutive patients suffering severe aneurysmal subarachnoid hemorrhage (SAH) under continuous intracranial pressure (ICP), brain tissue oxygen tension (pbtO2), and cerebral microdialysis monitoring were prospectively included. Changes in multimodality neuromonitoring data during intrahospital transport to the CT scanner and the subsequent 10 hours were evaluated using linear mixed models. Furthermore, the impact of risk factors at transportation, such as cerebral vasospasm, cerebral hypoxia (pbtO2 < 15 mm Hg), metabolic crisis (lactate-pyruvate ratio [LPR] > 40), and transport duration on cerebral metabolism, was analyzed.

RESULTS

During the transport, the mean ICP significantly increased from 7.1 ± 3.9 mm Hg to 13.5 ± 6.0 mm Hg (p < 0.001). The ICP exceeded 20 mm Hg in 92.5% of patients; pbtO2 showed a parallel rise from 23.1 ± 13.3 mm Hg to 28.5 ± 23.6 mm Hg (p = 0.02) due to an increase in the fraction of inspired oxygen during the transport. Both ICP and pbtO2 returned to baseline values thereafter. Cerebral glycerol significantly increased from 71.0 ± 54.9 µmol/L to 75.3 ± 56.0 µmol/L during the transport (p = 0.01) and remained elevated for the following 9 hours. In contrast, cerebral pyruvate and lactate levels were stable during the transport but showed a significant secondary increase 1–8 hours and 2–9 hours, respectively, thereafter (p < 0.05). However, the LPR remained stable over the entire observation period. Patients with extended transport duration (more than 25 minutes) were found to have significantly higher levels of cerebral pyruvate and lactate as well as lower glutamate concentrations in the posttransport period.

CONCLUSIONS

Intrahospital transport and horizontal positioning during CT scans induce immediate intracranial hypertension and an increase in cerebral glycerol, suggesting neuronal injury. Afterward, sustained impairment of neuronal metabolism for several hours could be observed, which might increase the risk of secondary ischemic events. Therefore, intrahospital transport for neuroradiological imaging should be strongly reconsidered and only indicated if the expected benefit of imaging results outweighs the risks of transportation.

ABBREVIATIONS

CTA = angiography; FiO2 = fraction of inspired oxygen; ICP = intracranial pressure; ICU = intensive care unit; LPR = lactate-pyruvate ratio; MAP = mean arterial blood pressure; pbtO2 = brain tissue oxygen tension; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler.

Illustration from Fan et al. (pp 1298–1309). Copyright Jun Fan. Published with permission.

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