eJOURNAL CRNA TODAY TM

CONTINUING EDUCATION

May 2017

General Anesthesia versus Conscious Sedation for treatment of acute ischemic stroke with Intra-arterial mechanical thrombectomy: A Case Report Mark Giles, DNP, CRNA

The Nation’s largest Anesthesia staffing agency! Specializing in Locum Tenesn and Permanent Placement of CRNAs and Anesthesiologiest across the country.

9 offices Nationwide CO 800.845.0992 GA 800.235.8986 GA 877.736.9439 FL 800.338.1699 MA 800.509.6427 IA 800.406.1775

Continuing Education eJournal Target Audience- Continuing Education (CE) courses are “Provider-Directed Independent Study” as defined by the AANA, “self-paced learning activity developed for individual use”. These CE’s are intended for Nurse Anesthetist’s practicing anesthesia looking to expand their knowledge. Courses are presented as a group of articles in an e-Journal which can be accessed from any web-based browser. Program- Articles are presented as individual CE material with accompanying Post Test. Course Objectives are provided at the beginning of each article with bibliography and references or links to -specific videos, websites, and/ or additional material. To get FULL CE credit for this program you’ll need to first read each article and pass each Post Test. A passing grade of at least 80% is required to get CE. You’ll have up to three testing opportunities to pass. The Post Test can be completed any time prior to expiration of the course. Attendance records are sent to the AANA at the end of each month, provided you have supplied the correct AANA ID. It is your responsibility to complete all courses in a timely fashion and before the expiration date. Educated Hand and the CRNA Today website are not responsible or liable for the untimely completion of the courses/credits. Each article is the work of the individual presenter, therefore they are experts in the topic and responsible for the content. CRNA Today reviews each article along with outside Editors and Copy Editors, doing our best to assure accurate and current knowledge Publisher

Nicholas G. Crofut CRNA

Editor-in-Chief

Thomas Schultz, PhD, CRNA

Author

Mark Giles, DNP, CRNA

Journal Designer

Sheri Harvey, Shar Graphics

Published by Educated Hand Pub, LLC 806 Greenwich Grand Ledge, MI 48837

 eJOURNAL CRNA TODAY TM

CONTINUING EDUCATION

May 2017

May 2017 Vol. 2 Issue 5

General Anesthesia versus Conscious Sedation for treatment of acute ischemic stroke with Intra-arterial mechanical thrombectomy: A Case Report Mark Giles, DNP, CRNA

www.nwanesthesia.com “There is NO Financial Relationship between the products, devices, or services advertised with the author and CE activity. 2

DISCLAIMER The opinions expressed in this educational activity are those of the author and do not necessarily represent the views of The Educated Hand Publishing. This educational activity does not endorse one particular type of technique, nor is it intended to dictate an exclusive course of practice. It presents one of numerous recognized methods of clinical practice for consideration by CRNAs for incorporation into their practices. Variations of practice taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. Disclosure about patient confidentiality, standards of care, or course of management does not imply endorsement or disapproval of products. For full Terms and Conditions of Use click here – www.crnatoday.com CRNA Today

General Anesthesia versus Conscious Sedation for treatment of acute ischemic stroke with Intra-arterial mechanical thrombectomy: A Case Report Mark Giles, DNP, CRNA Quinnipiac University Funding/Conflict of Interest Statement: None

Learning Objectives Participants will be able to.. 1. Compare the risks and benefits of general anesthesia versus conscious sedation for the treatment of acute ischemic stroke. 2. Discuss the relationship between hypotension and hypertension on patient outcomes. 3. Identify which patients are best treated with conscious sedation and which patient would benefit from general anesthesia. 4. Identify specific anesthesia factors that contribute to a positive outcome. 5. Discuss the 8 recommendations The Society for neuroscience in Anesthesiology and Critical Care (SNACC) has approved for individuals involved in the care of patients with acute ischemic stroke. Abstract: Patients with acute ischemic stroke are treated with several standard- operating principles. The primary goal is to lyse the clot via intravenous fibrinolysis or intra-arterial method to re-establish blood flow in the blocked territory. Current protocols states intra-venous tissue plasminogen activator (IV TPA) should be given within 4.5 hours of stroke onset. Early revascularization has been associated with improved prognosis, and several techniques allow for mechanical removal of the thrombus. Several retrospective studies have noted differences in outcomes in patients receiving general anesthesia versus conscious sedation. Anesthesia providers’ awareness of these differences is imperative for better patient outcomes. Key Words: intra-arterial thrombectomy, general anesthesia, conscious sedation, patient outcomes, acute ischemic stroke.

May 2017

INTRODUCTION Patients presenting with acute ischemic stroke (AIS) must be treated sooner rather than later if we want to see good functional outcomes. The ischemic stroke can be medically treated by lysing the clot via intravenous fibrinolysis or removal of the clot through an intra-arterial method to re-establish blood flow to the blocked vessel. The management of AIS has evolved over the last decade using IV tissue plasminogen activator (tPA), however, a significant number of patients have failed this treatment or have a contraindication for its use. Intra-arterial mechanical thrombectomy was developed to endovascularly remove larger clots thus improving revascularization. Initially, these procedures were performed under general anesthesia, but recent publications of conscious sedation anesthesia have shown improved clinical outcomes. Treatment factors such as hypotension (systolic blood pressure (SBP) less than 140 mmHg and hypertension (SBP greater than 180 mmHg), as well as keeping the patient very still during the procedure have influenced the controversy of the anesthesia technique. Neuroradiologists in favor of general anesthesia site the benefits of patient immobility, potential neuroprotection from inhaled anesthetics, control of blood pressure, and better mapping of images. Those in favor of conscious sedation site the benefits of monitoring patients’ neurologic status during the procedure, as well as the early alert of an intracranial bleed. Davis et al (2012) found the association between general anesthesia (GA) and poor outcomes to be high, with 15% of GA patients having a probability of good outcomes compared with 60% in conscious sedation (CS). Several other retrospective and meta-analysis studies have concluded CS to be associated with lower mortality, improved functional outcome, decreased respiratory issues, and better revascularization compared to GA. A task force for the Society for neuroscience in Anesthesiology and Critical Care (SNACC) published a paper on this subject stating, “the choice of anesthetic technique 3

and pharmacological agents should be individualized based on clinical characteristics of each patient”. When patients present who are uncooperative, agitated, or cannot protect their own airway, GA is the preferable choice. The posterior circulation stroke victim usually presents in this fashion. Anterior circulation stroke victims usually present with an intact airway, and are cooperative which makes CS feasible, but the anesthesia provider must always be prepared to convert to GA if necessary. The SNACC task force has recommended several key points for the individuals involved in the care of patients with acute ischemic stroke. Summaries of those recommendations are: 1. A history and physical as quickly as possible due to the limited time window to perform treatment. 2. Manage oxygenation and ventilation during treatment of AIS. Tracheal intubation is not required if adequate spontaneous oxygenation and ventilation can be maintained and adequate cooperation can be sustained under mac anesthesia. 3. Periprocedural Hemodynamic Management. Systolic blood pressure should be maintained >140 mmHg via fluids and vasopressors and <180 mmHg with or without IV tPA. The key is to avoid hypotension. 4. Fluid management. Maintain euvolemia and avoid fluids containing glucose (unless the blood sugar is <50). 5. Temperature management. Maintain a target temperature range between 35 C and 37 C. If the patient is febrile treat with antipyretics and a cooling blanket. Meperidine has been used for shivering. 6. Intraprocedural Monitoring. Place an arterial line as soon as possible. If it will delay the start of the procedure, then do noninvasive blood pressures Q three minutes until theneurointervention team can place a femoral arterial line. 7. Glycemic Management. Hyperglycemia is associated with a larger infarct size, higher risk of mortality, and poor clinical outcome. Maintain glucose levels between 70 and 140 mg/dL. Glucose above 140 should be treated with insulin. 8. Post procedure care. These patients should go to a dedicated ICU specializing in stroke and neurovascular care. If standard extubation criteria are met, the patient should be extubated.

4

Case Summary A 47-year-old man presented to a local hospital emergency room complaining of severe headache and left sided weakness. His wife, around 1040, picked up the patient from work. During the drive home, he developed an acute onset of left sided weakness and a severe headache. He was driven to the hospital. On admission, he stated a headache x 3 days, which was bitemporal but now, feels the pain behind his eyes. Vital signs in the emergency department were: BP 128/84, P 90, RR 16, T 97.0, SpO2 97% on room air. His medical history included helicobacter pylori H. pylori) infection, migraines, motor vehicle accident, stab wound to the neck, former smoker, former cocaine abuse (quit 10 years ago). A CT scan was performed which showed right middle cerebral artery (MCA) territory hypodensity, CTA with filling defect in right M2 (M2 extending anteriorly on the insula, also known as the insular segment). His National Institutes of Health Stroke Scale (NIHSS) score was 14 on a scale of 0-42. tPA was given at 1141 and he was then transferred to a local university hospital, which functions as a stroke code center. On arrival to the university hospital his NIHSS score was 9. Upon arrival, a MRI was performed which showed a clot in the M1 (also known as the sphenoidal segment), M2 bifurcation. A stroke code was called and the patient was taken to Interventional Radiology (IR). Patient was seen and examined by anesthesia. A review of the systems yielded an awake, alert, and oriented to person, place, and time. He was noted to have left sided weakness in his hand and leg. All other physical examinations were within normal limits. He was classified as an ASA class 3. The anesthesia care plan was for conscious sedation with general anesthesia as a backup. The emergency department performed blood typing and screening. A discussion with the neuroradiologist and the anesthesia team was performed to keep the patient’s SBP between 140-180. The patient was transferred to the operating table. A 16-gauge IV catheter was already in place in the left ante cube, a right lateral arm 20-gauge IV, and an 18- gauge IV was placed in the right hand. The patient’s hands were secured with wrist restraints, and his head was taped to the bed. The procedure was explained to the patient who verbalized understanding. During the two and half hour procedure, he received a total of fentanyl 200mcg, versed 2mg, labetalol

CRNA Today

15mg, zofran 4mg, lactated ringers solution 600ml, and nasal cannula 02 at 3L/min. During the entire procedure, a second neuroradiologist was present who performed neuro checks every 10-15 minutes. The patient’s hemodynamic status was stable with BPs ranging from 138/76- 190/99. During the brief period when his SBP being greater than 180, labetalol was given. During the last 10 minutes of the procedure the patient became agitated and wanted to move. He was calmed with gentle verbal reassurance. A 1 cm clot was removed from the distal M1, M2 bifurcation at 1845. The time to recanalization was 8 hours. At the end of the case the neuroradiologist did a thorough examination, which continued to show left sided weakness. The patient was transferred to the neurosurgical intensive care unit (NICU). The hospital course was unremarkable and the patient was discharged to home on 1/22/16 with outpatient physical therapy and occupational therapy. A 24-hour post tPA head CT showed no hemorrhagic transformation, and a repeat MRI/MRA of the brain showed evolution of his previous stroke. At discharge patient was noted to have left pronator drift, and was unable to perform left fine finger movements. On 2/8/16 patient was discharged from PT and OT with complete resolution of all deficits.

Discussion The therapeutic reference for acute ischemic stroke is intravenous thrombolysis with tPA within 4.5 hours of stroke onset according to the National Stroke Association. When the occluded artery is large or proximal, tPA may not always work and recanalization is highly correlated with the patient’s prognosis. Endovascular techniques have been developed to mechanically remove the clot, thus restoring blood flow. Intra-arterial thrombectomy (IAT) have been performed under general anesthesia as well as conscious sedation with varying degrees of results. A 36-patient study by Soize, et al. (2013) showed mechanical thrombectomy while under CS (86.1%) is associated with a high percent of good functional outcomes at 3 months. There are a number of potential complications that may occur during this procedure. The most serious and feared complication is symptomatic intracerebral hemorrhage. Others potential complications are vessel perforation, arterial dissection, and issues with the groin access site. There is a paucity of literature directly looking at the various products on the market that is used for the procedure. A retrospective study of 190 patients by John et al. 2014 showed GA being associated with poorer outcomes and higher mortality in patients undergoing IAT. Many of the studies identified limitations to their findings such as patient level of conscious at presentation, retrospective, selection bias, and the particular device used to remove the clot.

Conclusion In this case, the patient’s initial presentation of awake, alert and the ability to protect his own airway made him an ideal candidate for CS. The activation of the stroke code and staff members working quickly to stabilize the patient are key factors in getting the patient to IR for clot removal. The importance of communication between the neuroradiologist and the anesthesia team played a critical role in a favorable outcome for this patient. Anesthesia providers will always have a major place in stroke code therapy by choosing the most appropriate and least harmful anesthesia to patients with acute stroke treated by mechanical thrombectomy. Further studies comparing general anesthesia versus conscious sedation on patient outcomes would be useful.

May 2017

5

References Davis, M. J., Menon, B. K., Baghirzada, L. B., Campos-Herrera, C. R., Goyal, M., Hill, M. D., . . . Calgary Stroke Program. (2012). Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology, 116(2), 396-405. doi:10.1097/ALN.0b013e318242a5d2 [doi] Jellish, W. S., & Edelstein, S. B. (2015). General anesthesia versus conscious sedation for the endovascular treatment of acute ischemic stroke. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association, 24(9), 1957-1960. doi:10.1016/j.jstrokecerebrovasdis.2015.05.037 [doi] John, N., Mitchell, P., Dowling, R., & Yan, B. (2013). Is general anaesthesia preferable to conscious sedation in the treatment of acute ischaemic stroke with intra-arterial mechanical thrombectomy? A review of the literature. Neuroradiology, 55(1), 93-100 8p. doi:10.1007/s00234-012-1084-y John, S., Thebo, U., Gomes, J., Saqqur, M., Farag, E., Xu, J., . . . Hussain, M. S. (2014). Intra-arterial therapy for acute ischemic stroke under general anesthesia versus monitored anesthesia care. Cerebrovascular Diseases (Basel, Switzerland), 38(4), 262-267. doi:10.1159/000368216 [doi] Schonenberger, S., Mohlenbruch, M., Pfaff, J., Mundiyanapurath, S., Kieser, M., Bendszus, M., . . . Bosel, J. (2015). Sedation vs. intubation for endovascular stroke TreAtment (SIESTA) - a randomized monocentric trial. International Journal of Stroke: Official Journal of the International Stroke Society, 10(6), 969-978. doi:10.1111/ijs.12488 [doi] Soize, S., Kadziolka, K., Estrade, L., Serre, I., Bakchine, S., & Pierot, L. (2013). Mechanical thrombectomy in acute stroke: Prospective pilot trial of the solitaire FR device while under conscious sedation. AJNR.American Journal of Neuroradiology, 34(2), 360-365. doi:10.3174/ajnr.A3200 [doi]

6

CRNA Today

Questions:

POST TEST 1. Current protocols states intra-venous tissue plasminogen activator (IVTPA) should be given within 6 hours of stroke onset. A. True B. False 2. Systolic blood pressure should be kept less than 140mm Hg at all times during the procedure. A. True B. False 3. Patients who present that are cooperative and can protect their own airway should have the procedure performed with conscious sedation. A. True B. False 4. Anesthetic management for endovascular treatment of acute ischemic stroke has no effect on patient outcome. A. True B. False 5. Time to reperfusion and arterial pressure are critical in maximizing survival of the ischemic penumbra. A. True B. False 6. The use of local anesthesia with conscious sedation for endovascular treatment of acute ischemic attack is associated with lower mortality and better neurological outcomes compared with general anesthesia. A. True B. False

May 2017

7. Heparin is used during the procedure to reduce catheter-induced embolic and thrombotic events. A. True B. False 8. Patients should receive IV fluids of at least 250cc/ hr to keep SBP >140. A. True B. False 9. Patients presenting for acute ischemic attack should not have an arterial line placed. A. True B. False 10. Hyperglycemia is associated with a larger infarct size, higher risk of mortality, and poor clinical outcome. A. True B. False 11. When the occluded artery is large or proximal, TPA typically works toremove theclot. A. True B. False 12. Early revascularization has been associated with pooroutcomes. A. True B. False 13. Performing this procedure under general anesthesia potentially offers neuro protection from the inhaled anesthetics. A. True B. False

7

14. Recent studies show there is no real difference in out comes in general anesthesia versus conscious sedation. A. True

18. Glucose levels should be maintained between: A. 70 and 140mg/dl. B. 100 and 150mg/dl. C. 70 and 100mg/dl.

B. False 15. Conscious sedation has the benefit of better brain mapping of images. A. True

D. 160 and 200mg/dl. 19. If the procedure is performed under general anesthesia the patient should: A. remain intubated overnight.

B. False 16. The anterior circulation stroke victims usually present with an intact airway and A. cooperative B. agitated C. uncooperative. 17. The posterior circulation stroke victims usually present as agitatedand A. cooperative B. uncooperative

B. Extubated if standard criteria are met. C. Remain intubated if SBP are>180. D. Extubated if SBP are<140. 20. The most serious and feared complication for mechanical thrombectomy is: A. vessel perforation B. arterial dissection C. bleeding at the groin site D. symptomatic intra-cerebral hemorrhage

C. neither

Test questions must be completed online, visit CRNAToday.com 8

CRNA Today

1. American Heart Association (AHA) http://www.heart.org/HEARTORG/Conditions/Arrhythmia/ AboutArrhythmia/What-is- Atrial-Fibrillation-AFib-or-AF_UCM_423748_Article.jsp#.VkFLu4Tl7zI. Retrieved on Nov 9, 2015. 2. Hall, JE, and AC Guyton. “Textbook of Medical Physiology.” Saunders London (2011) 3. Silbernagl, S, and A Despopoulos. “Color Atlas of Physiology.” Thieme (2009) 4. Narouze, S, HT Benzon et al. “Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications” Reg Anesth Pain Med 40.3 (2015): 182-212.

Across 1. Substance found inAcross liver lungs and other tissues

Down 1. Decreased or lowered blood pressure

1. pacemaker of the heart (two words) 2. Relating to the brain or cerebrum 3. A clot of blood that forms in the blood vessel 3. the surgical removal of body tissue hollow part 5. Calming of mental4. excitement 5. the process

6. 7. 8.

of the organ 4. When a medical instrument is inserted of being interrogated one thatthat takes the lead example a blood vessel to treat a vascular Inactive precursor 8. to plasmin is found in or sets an through 11. ischemic condition disease body fluids and blood 12. plasma lodestone or attraction Down 5. A throb of the heart Excited or disturbed 2. insert or engraft 6. relating to the heart Aware of something 7. depolarizing the heart cells 9. open roofed entrance hall 10. regular repeated pattern of sound

CRNA Today is owned/operated by CRNAs and is committed to the CRNA community. We strive everyday to build a vibrant, interactive, inspiring framework that will bring CRNAs together and help them be successful in their careers. A percentage of all sales is returned to the CRNA community by giving to deserving organizations, sponsoring events and training opportunities.

9

CRNA Today