National survey on perioperative anaesthetic management in the endovascular treatment of acute ischaemic stroke

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Rev Esp Anestesiol Reanim. 2017;xxx(xx):xxx---xxx

Revista Española de Anestesiología y Reanimación www.elsevier.es/redar

ORIGINAL ARTICLE

National survey on perioperative anaesthetic management in the endovascular treatment of acute ischaemic stroke夽 O. Romero Kräuchi a,∗ , L. Valencia b , F. Iturri c , A. Mariscal Ortega d , A. López Gómez e , nola de Anestesiología R. Valero f , Sección de Neurociencias de la Sociedad Espa˜ y Reanimación a

Servicio de Anestesiología, Hospital Universitario de Son Espases, Palma de Mallorca, Spain Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain c Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, Spain d Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, Spain e Servicio de Anestesiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain f Servicio de Anestesiología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain b

Received 28 June 2017; accepted 5 July 2017

KEYWORDS Neuro-anaesthesia; Descriptive questionnaire; Ischaemic stroke; Endovascular treatment

Abstract Objective: To assess the anaesthetic management of treatment for endovascular acute ischaemic stroke (AIS) in Spain. Materials and method: A survey was designed by the SEDAR Neuroscience Section and sent to the Spanish anaesthesiology departments with a primary stroke centre between July and November 2016. Results: Of the 47 hospitals where endovascular treatment of AIS is performed, 37 anaesthesiology departments participated. Thirty responses were obtained; three of which were eliminated due to duplication (response rate of 72.9%). Health coverage for AIS endovascular treatment was available 24 h a day in 63% of the hospitals. The anaesthesiologist in charge of the procedure was physically present in the hospital in 55.3%. There was large inter-hospital variability in non-standard monitoring and type of anaesthesia. The most important criterion for selecting type of anaesthesia was multidisciplinary choice made by the anaesthesiologist, neurologist and neuroradiologist (59.3%). The duration of time from arrival to arterial puncture was 10---15 min in 59.2%. In 44.4%, systolic blood pressure was maintained between 140 and 180 mmHg, and diastolic blood pressure <105 mmHg. Glycaemic levels were taken in 81.5% of hospitals. Intravenous heparinisation was performed during the procedure in 66.7% with different patterns of action. In cases of moderate neurological deterioration with no added complications, 85.2% of the included hospitals awakened and extubated the patients.

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Please cite this article as: Romero Kräuchi O, Valencia L, Iturri F, Mariscal Ortega A, López Gómez A, Valero R, et al. Encuesta nacional sobre la atención anestesiológica perioperatoria en el tratamiento endovascular del ictus isquémico agudo. Rev Esp Anestesiol Reanim. 2017. https://doi.org/10.1016/j.redar.2017.07.005 ∗ Corresponding author. E-mail address: [email protected] (O. Romero Kräuchi). 2341-1929/© 2017 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.

REDARE-849; No. of Pages 11

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O. Romero Kräuchi et al. Conclusions: The wide variability observed in the anaesthetic management and the organisation of the endovascular treatment of AIS demonstrates the need to create common guidelines for anaesthesiologists in Spain. © 2017 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.

PALABRAS CLAVE Neuroanestesia; Encuesta descriptiva; Accidente cerebrovascular isquémico; Tratamiento endovascular

Encuesta nacional sobre la atención anestesiológica perioperatoria en el tratamiento endovascular del ictus isquémico agudo Resumen Objetivo: Conocer la práctica clínica habitual de los anestesiólogos espa˜ noles en el manejo del tratamiento endovascular del infarto isquémico cerebral agudo (IIA). Materiales y métodos: Encuesta dise˜ nada desde la Sección de Neurociencias de la SEDAR, enviada a todos los servicios de anestesiología en hospitales espa˜ noles con unidad de referencia de ictus, entre julio y noviembre de 2016. Resultados: De los 47 hospitales donde se realiza tratamiento endovascular del IIA, en 37 participa el servicio de anestesiología. Obtuvimos 30 respuestas, eliminándose 3 por duplicidad (tasa de respuesta del 72,9%). El 63% de los hospitales tiene cobertura asistencial para el tratamiento endovascular del IIA las 24 h del día. El anestesiólogo encargado es el de presencia física en el hospital en un 55,3%. Existe gran variabilidad interhospitalaria en la monitorización no estándar y el tipo de anestesia. El criterio más empleado para su elección, es una decisión consensuada entre anestesiólogo, neurólogo y neurorradiólogo (59,3%). El tiempo transcurrido desde el inicio de la técnica anestésica hasta la punción arterial en un 59,3% es de 10---15 min. En un 44,4%, se mantiene una presión arterial sistólica entre 140-180 mmHg y diastólica <105 mmHg. El control de la glucemia se realiza en un 81,5% de los hospitales. El 66,7% (18) lleva a cabo una heparinización endovenosa durante el procedimiento pero con un régimen muy variado. El 85,2% coincide en la educción y extubación del paciente al final del procedimiento en caso de deterioro neurológico leve o moderado sin complicaciones a˜ nadidas. Conclusiones: La gran variabilidad observada en el manejo anestésico y organización del tratamiento endovascular del IIA, pone de manifiesto la necesidad de crear unas pautas de actuación comunes entre los anestesiólogos de Espa˜ na. © 2017 Sociedad Espa˜ nola de Anestesiolog´ıa, Reanimaci´ on y Terap´ eutica del Dolor. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.

Introduction Cerebrovascular disease is the most common cause of disability in adults in developed countries. As such, it is one of the greatest public health problems due to its high morbidity and mortality and the burden it places on healthcare resources. The therapeutic goal of acute ischaemic stroke (AIS) is to restore perfusion to the ischaemic areas of the brain. The introduction of intravenous fibrinolysis in 1995 marked a turning point in the care of AIS patients.1 Intravenous tissue plasminogen activator (t-PA) administered within 4.5 h after onset of AIS has been shown to improve outcomes,1---3 although recanalization after thrombolysis was achieved in less than half of patients with large artery occlusions treated with t-PA.4 Intra-arterial treatment was first described by Furlan et al.5 in 1999, who initially showed that intraarterial administration of thrombolytics improved outcomes in patients with large artery occlusion. In 2004, following the MERCI6 study, the FDA approved the Merci Retriever, a mechanical thrombectomy device. Although the

first 3 studies comparing mechanical thrombectomy with tPA found no benefit,7---9 5 randomised multicentre controlled clinical trials have now provided class 1 level A evidence that endovascular mechanical thrombectomy is the gold standard for patients with large vessel occlusion.10---14 Stroke patients often present significant neurological impairment, which can range from altered level of consciousness, aphasia and various degrees of paresis, as well as dizziness, headache, ataxia and significant levels of distress. All this, aggravated by comorbidity and, in many cases, advanced age, limits the capacity of these patients to tolerate a procedure that requires prolonged immobility. Their inability to remain immobile will make the procedure technically challenging, or even impossible, to perform, and can even lead to catheter-induced neurovascular injury. Although the logical solution would be to perform these procedures under anaesthesia, choosing between general or local anaesthesia prior to thrombectomy continues to be a topic of debate.15,16 Literature and evidence on the anaesthetic management of endovascular treatment of acute

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Anaesthetic management in the endovascular treatment of ischaemic stroke ischaemic stroke is limited. Anaesthetic management during these procedures is still mostly dependent on individual or institutional preferences. Recently, the Society of NeuroInterventional Surgery and the Neurocritical Care Society published a consensus document with recommendations for the anaesthetic management of endovascular treatment of acute ischaemic stroke.17 During neurointerventional procedures, anaesthesiologists are intimately involved in: (a) maintaining the patient immobile during the procedure to allow the neuroradiologist to obtain accurate, good quality images; (b) immediate reversal of anaesthesia to facilitate neurological examination or to make intermittent intraprocedural evaluations of neurological function; (c) controlling coagulation; (d) avoiding and treating complications; (e) monitoring critical care patients during their transfer to and from the radiology room; and (f) applying radiation safety and protection standards. All these factors can be controlled to a greater or lesser extent according to the anaesthetic technique, which is why the choice of general or local anaesthesia is still controversial.2 In 2010, Abou-Chebl et al.18 found general anaesthesia to increase the risk of poor prognosis and mortality 2.3- and 1.7-fold, respectively, vs local anaesthesia or conscious sedation. Similarly, Jumaa et al.19 observed a 3fold increase in mortality in the general anaesthesia group with up to 5-fold increase in final infarct volume. More recent studies have attempted to address the limitations of previous retrospective studies, and since 2015 studies20---23 finding no significant differences in mortality and neurological prognosis between patients undergoing routine general anaesthesia and those receiving local anaesthesia/conscious sedation. The Neurosciences Section of the Spanish Society of Anaesthesiology and Critical Care periodically evaluates different aspects of anaesthesiology to reveal the different approaches used. It subsequently draws up a series of evidence-based recommendations based on these findings and the results of a systematic review of the literature. At the SEDAR conference held in October 2015 in Santander, we decided to evaluate the anaesthetic management of AIS patients undergoing mechanical thrombectomy. To the best of our knowledge, this is the first overall evaluation of the peri-procedural process of care and anaesthetic strategies used in the endovascular treatment of AIS.

Materials and methods The survey was carried out by a working group of anaesthesiologists belonging to the Neuroscience Section of SEDAR and subsequently re-evaluated by members of the Neuroscience Section board. The final questionnaire consisted of 38 multiple- or single-choice questions relating to the organisation of endovascular treatment of AIS and anaesthetic management during the procedure. An invitation to take part in the survey was sent by personalised email to the heads of the anaesthesiology departments of the 50 Spanish hospitals with a neurosurgery service between July and November 2016. A link to the survey questionnaire created on the Google Forms platform was included in the email.

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(https://docs.google.com/forms/d/1WF696700Q2lIPjT9vI 2sztZ7531HQnXeQ ZyIrSNoRI/closedform). Hospitals were also asked to inform the survey team by return email if they did not perform endovascular treatment of AIS or if the anaesthesiology service is not involved in the intra-procedural care and management of these patients. The questionnaire was also available through a link on the website of the Neuroscience Section of SEDAR during the aforementioned period, and an email was sent to each of the 99 members of the SEDAR Neuroscience Section inviting them to participate. If no response was received, the heads of service or members of the corresponding hospital section were again contacted personally. Finally, members of the Neurosciences Section undertook to contact non-responding hospitals within their autonomic community. Only 1 completed questionnaire was accepted from each anaesthesiology service. If several questionnaires were received from the same hospital, the anaesthesiology service was contacted again to confirm the usual practice followed in the centre. The data were analysed using the statistical utilities included in the Google Docs platform. The data are given as percentage of the total number of answers obtained, followed by the number of responses obtained (in absolute values) in brackets.

Results Of the 50 tertiary level stroke units in Spain polled, 3 did not provide AIS treatment, and accordingly were eliminated. Of the 47 centres where this procedure is performed, 21% (10) of anaesthesiology services did not participate in the care and management of AIS patients undergoing endovascular treatment. Of the remaining 37 hospitals in which the anaesthesiology service was involved in the anaesthetic management of endovascular treatment of AIS, 30 completed questionnaires were obtained, of which 3 were duplicated, and therefore eliminated, leaving a response rate of 72.9% (27 completed questionnaires).

Organisation of endovascular treatment of AIS The hospitals that responded to the survey cater for a very variable population (18.5% [5] had a catchment population of around 500,000 inhabitants, 25.9% [7] > 750,000 inhabitants, 29.6% [8] > 1 million inhabitants, and 25.9% [7] > 1.5 million inhabitants). Sixty-three percent (17) of the hospitals provide round-the-clock endovascular treatment for AIS, while in 29.6% (8) the procedure is provided as part of a rostering system involving various hospitals. In 1 hospital, the treatment was only provided in the morning. In 44.4% (12) of hospitals, over 100 endovascular procedures for AIS were performed per year, followed by 22.2% (6) of centres performing between 50 and 75 procedures per year 18.5% (5) performing between 75 and 100 endovascular treatments per year, and 11.1% (3) performing between 25 and 50. Only 1 hospital performed less than 25 procedures per year. Aside from the 10 hospitals that were excluded because the anaesthesiologist did not participate in stroke care, in all but 1 hospital (26/27) the physician responsible for

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O. Romero Kräuchi et al. Table 1

Monitoring during endovascular treatment of AIS.

Bispectral index (BIS) Spectral entropy Evoked potentials Regional cerebral oxygen saturation (NIRS) Capnography in spontaneous breathing Hourly urine output Temperature Placement of 2 large peripheral lines Central venous line Peripherally inserted central catheter Central venous line only if peripheral access is impossible Neuromuscular blockade monitoring

Always

Sometimes

Never

22.2% (6)

59.3% 3.7% 7.4% 44.5% 33.3% 37% 37% 44.5% 59.2% 51.8% 66.6% 44.5%

18.5% 96.3% 92.6% 51.8% 26% 14.8% 51.8% 14.8% 40.8% 48.2% 22.2% 51.8%

3.7% 40.7% 48.2% 11.2% 40.7%

(1) (11) (13) (3) (11)

11.2% (3) 3.7% (1)

(16) (1) (2) (12) (9) (10) (10) (12) (16) (14) (18) (12)

(5) (26) (25) (14) (7) (4) (14) (4) (11) (13) (6) (14)

Data expressed as percentages of answers obtained with absolute values in parentheses.

anaesthetic management during treatment is an anaesthesiologist, while in 11.1% (3) of centres polled, the neurologist may also occasionally take over the patient’s care and management (monitoring, haemodynamic control, administration of sedative drugs or anaesthetics, and treatment of systemic complications). In 7.4% (2) of hospitals, the other attending doctor is either the emergency room doctor or the intensive care specialist. In 1 of the hospitals, the neuroradiologist will sometimes take responsibility for the care and management of the patient. Regarding the organisation of endovascular treatment of AIS, in up to 55.5% (15) of the services polled the AIS anaesthesiologist is physically present in the hospital and always available, since it is considered an emergency procedure, while in 33.3% (9) an anaesthesiologist is on call for this procedure. In 1 centre, the duty anaesthesiologist physically present in the hospital only performs the procedure when he or she is available, and in another 2 hospitals (7.4%) the duty anaesthesiologist only participates when his or her assistance is requested in specific cases. Regarding staff available in addition to the anaesthesiologist, 48.1% (13) of centres only have interventional vascular radiology nurses. In 22.2% (6), the anaesthesiology resident is also present. In 14.8% (4), the resident doctor as well as the anaesthesia nurses participate, and in 11.1% (3) the attending anaesthesiologist is only accompanied by the anaesthesia nurse. In 1 hospital (3.7%), the resident doctor has no nursing support. The person in charge of contacting the anaesthesiologist is the neuroradiologist (48.1%), the neurologist (37%), or either (14.8%). In all cases, the anaesthesiologist treats the patient in the radiology room, without their presence being required before the procedure.

Preoperative assessment of endovascular treatment of AIS Approximately 90% of patients require a complete workup, including coagulation tests, 59.3% require 12-lead electrocardiogram, and 22.2% chest radiography. In 1 hospital, no additional tests are requested because it is considered an emergency procedure.

Regarding informed consent, half of the centres (51.9%) always obtain consent, provided doing so does delay the procedure, In 33.3% (9) it is not routinely obtained because it is considered an emergency procedure, and in 11.1% (3) it is bundled with the informed consent obtained for the endovascular procedure. Obtaining informed consent is an absolute prerequisite in only 1 hospital.

Intraoperative anaesthetic management of endovascular treatment of AIS Half of the centres polled (51.9%) have a specific protocol for the anaesthetic management of endovascular treatment of AIS. The time from the start of anaesthesia to arterial puncture by the neuroradiologist is 10---15 min in 59.3% (16) of hospitals, while in the rest (40.7%) (11) it can range from 15---30 min. Several different monitoring techniques are used, as shown in Table 1. Specifically, blood pressure monitoring varies according to the centre: in 63% (17) the femoral arterial introducer placed by the neuroradiologist is used to measure mean arterial pressure. A similar percentage (59.3%) (16) use noninvasive techniques to measure blood pressure at various intervals, and 11.1% (3) performed continuous non-invasive blood pressure monitoring. Only 25.9% (7) of centres used a peripheral arterial line for this purpose, provided this did not delay the procedure, while 7.4% (2) of centres polled always placed an arterial line. The type of anaesthesia used also varied greatly between centres (Fig. 1). The choice of anaesthesia in most hospitals is determined by consensus between the anaesthesiologist, neurologist and neuroradiologist (59.3%) (16). In 25.9% (7) of hospitals, the clinical status of the patient (haemodynamic, respiratory and neurological parameters) is also taken into consideration. In 14.8% (4), the decision is taken by the neuroradiologist, and in no case is the decision taken exclusively by the anaesthesiologist. Regarding the drugs administered when sedation is chosen, the most widely used is propofol (50%), followed by midazolam (38.5%), and remifentanil (11.5%). The second choice among anaesthesiologists is fentanyl (33.3%), remifentanil (29.2%), midazolam (20.8%) and propofol

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Anaesthetic management in the endovascular treatment of ischaemic stroke 25.9%

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25.9% 22.2%

14.8%

7.4% 3.7% General anaesthesia General anaesthesia 50% of cases general General anaesthesia always. or usually. chosen given in 75% of cases anesthesia and 50% given sedation in only 25% of cases

Figure 1 obtained.

General anaesthesia General anaesthesia or sedation are rarely used is rarely used; sedation is nearly always used

Types of anaesthesia administered during endovascular treatment of AIS. Data expressed as percentage of responses

44.4%

37%

25.9%

3.7%

No target BP

3.7%

Avoid hypotension

SBP 140 – 180

20% baseline

MAP > 70

Figure 2 Objective blood pressure levels during endovascular treatment of AIS. Data expressed as percentage of responses obtained. BP: blood pressure; MAP: mean blood pressure; SBP: systolic blood pressure. No target BP: defined target blood pressure levels are never used. Avoid hypotension: we always use defined target blood pressures, especially in general anaesthesia, in order to avoid hypotension. SBP140-180: regardless of the anaesthetic technique, we try to maintain SBP between 140 and 180 mmHg and diastolic BP <105 mmHg. 20% baseline: regardless of the anaesthetic technique, blood pressure is kept to within 20% of the patient’s usual blood pressure. MAP > 70: we use MPB > 70 mmHg.

(10.7%). Other drugs are used as a third option (in 2 hospitals ketamine, in 1 dexmedetomidine, and in 2 others sufentanil). When general anaesthesia is performed, propofol (88.8%) is usually used for anaesthetic induction (24). The second option is etomidate (55.5%) (15), while 3 centres also used midazolam, and 2 others used thiopental. Most hospitals (92.6%) (26) opted for rapid sequence intubation. The anaesthesiologists from 1 hospital used a supraglottic device. The most used commonly used neuromuscular blocking agent is rocuronium (55.6%) (15), followed by succinylcholine (22.2%) (6), while 22.2% (6) used either succinylcholine or rocuronium. During conventional orotracheal intubation, rocuronium is still the blocking agent of choice, except in a 1 centre where cisatracurium is used. General anaesthesia is usually maintained with sevoflurane (74%) (20), followed by propofol (22.2%) (6). Only 1 hospital used desflurane as first choice blocking agent. In hospitals administering an opioid, remifentanil is the most widely used (75%), followed by fentanyl (12.5%), and sufentanil (12.5%). With regard to maintenance of neuromuscular blockade, rocuronium is the drug of choice when boluses are administered (74%) (20), except in 1 centre where cisatracurium is used. When continuous neuromuscular blockade (48.1%) (13) is used, rocuronium is also usually

the first choice (76.9%). Interestingly, less than 4% (1) of respondents systematically monitor the depth of neuromuscular blockade. Nearly all hospitals polled monitored blood glucose (81.5%), while in 7.4% (2) it is only monitored in known diabetics, and 11.1% (3), it is never monitored. Blood glucose levels are usually corrected by rapid intravenous bolus of insulin (53.8%). Other forms of administration are bolus plus continuous intravenous insulin infusion (11.5%), or continuous infusion alone (11.5%). Only some centres (15.4%) administered insulin subcutaneously. Half of anaesthesiologists (53.8%) maintain blood glucose between 140 and 180 mg dL−1 , some (23.1%) between 80 and 140 mg dL−1 , while a minority (11.5%) maintained a level of less than 200 mg dL−1 . The results of the survey show that physiological saline solution (77.8%) (21) is the first choice for fluid management, while 3 centres used Ringer’s lactate (11.1%) and another 3 (11.1%) used balanced isotonic solutions. Haemodynamic management targets varied among centres polled (Fig. 2). The most commonly used antihypertensive drug is urapidil (85%) (23) and, to a lesser extent, labetalol (22.2%) (6). Esmolol and clevidipine are the first choice in only 1 hospital. When vasopressors are required, ephedrine (62.9%) (17) is usually used, followed by phenylephrine (40.7%) (11) and noradrenaline (18.5%) (5).

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O. Romero Kräuchi et al. Table 2

Approach taken to endovascular treatment of AIS in patients previously taking anticoagulants and antiplatelets. No correction Prior correction regardless of procedure Prior correction according to procedure

Coumarin derivatives (INR > 2) 63% Coumarin derivatives (INR 2---4) 44.5% Coumarin derivatives (INR > 4) 44.5% Dabigatran 59.3% Apixaban 66.7% Rivaroxaban 66.7% ASA + clopidogrel 74.1% Other antiplatelet agents 74.1%

(17) (12) (12) (16) (18) (18) (20) (20)

7.4% 22.2% 33.3% 11.1% 3.7% 3.7% 3.7% 3.7%

(2) (6) (9) (3) (1) (1) (1) (1)

29.6% 33.3% 22.2% 29.6% 29.6% 29.6% 22.2% 22.2%

(8) (9) (6) (8) (8) (8) (6) (6)

Data expressed as percentages of answers obtained with absolute values in parentheses. ASA: acetylsalicylic acid; INR: international normalised ratio.

Table 3

Administration of antiplatelet agents during endovascular treatment of AIS, depending on the procedure performed.

Intraarterial thrombolysis Mechanical thrombectomy Suction thrombectomy Angioplasty and stent Thrombectomy with stent retriever

Not given

Intravenous ASA

ASAPO/NG tube

ClopidogrelPO/NG tube

Abciximab

74.1% 66.7% 63% 22.2% 51.9%

18.5% 18.5% 22.2% 48.1% 22.2%

3.7% 3.7% 7.4% 3.7% 3.7%

3.7% 11.1% 7.4% 26% 18.5%

3.7% (1)

(20) (18) (17) (6) (14)

(5) (5) (6) (13) (6)

(1) (1) (2) (1) (1)

(1) (3) (2) (7) (5)

Data expressed as percentages of answers obtained with absolute values in parentheses. ASA: acetylsalicylic acid; NG: nasogastric; PO: oral administration

Coagulation, heparin and antiplatelets in the endovascular treatment of AIS When endovascular treatment of AIS is proposed in a patient on chronic antiplatelet or anticoagulant therapy, our survey shows that the approach taken varies greatly among centres polled (Table 2). Only 14.8% (4) do not administer intraoperative intravenous heparin, while in 18.5% (5) the use of intravenous heparin will depend on the type of intravascular procedure undertaken. The remaining centres (66.7%) (18) administer intravenous heparin in different ways (7 centres administered weight-adjusted single bolus, another 6 administered multiple scheduled weight-adjusted boluses, and only 4 adjusted the dose to laboratory findings). According to anaesthesiologists, reversal of the residual effect of intravenous heparin is independent of the type of endovascular treatment performed. In 51.9% (14) of centres, anticoagulation is not reversed, and in the remainder it is reversed according to different criteria: 22.2% (6) according to analytical levels, in 18.5% (5) it is reversed at the request of the neuroradiologist, and finally, in 7.4% (2) it is reversed according to the time since the last administration of heparin. Regarding the administration of antiplatelets during the endovascular treatment of AIS, the responses varied according to the type of procedure performed (Table 3).

Postoperative destination In patients with mild (NIHSS 2---5) or moderate (NIHSS 6---15) post-AIS neurological deterioration in whom endovascular treatment is uneventful, 85.2% (22) of hospitals reverse anaesthesia and extubate the patient. Postoperative desti-

nations differ according to patient status and circumstances, and are shown in Table 4. If the patient is transferred to one of the anaesthesiology department’s units, 57.9% of hospitals provide a specific post-endovascular treatment of AIS management protocol.

Discussion The results of the survey highlight the different approaches taken in AIS patients scheduled for endovascular treatment, in terms of both process of care and anaesthetic management. One of the factors that contribute to this wide variability is the lack of studies and guidelines on anaesthetic management during the procedure. In total, 72.9% of tertiary hospitals with a stroke unit attended by an anaesthesiologist completed our survey questionnaire. This high participation rate suggests that there is a growing interest among anaesthesiologists in participating in and improving clinical care in these procedures. Endovascular treatment is performed in tertiary hospitals located in each Spanish autonomous region with a stroke management unit.24 Spain has 50 stoke referral units located in high-tech or tertiary hospitals distributed among the different autonomous regions. To qualify as a referral unit, stroke units must be equipped with the staff, infrastructure and care programmes needed to diagnose and treat stroke patients requiring highly specialised medical and surgical care. Tertiary hospitals often provide round-the-clock care, however, in those situated in large cities with several referral hospitals, stroke management is part of a rostering system provided by a group of hospitals. This is the case in 33% of tertiary hospitals.

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Table 4 Postoperative destination according to type of anaesthesia, neurological deterioration and appearance of intraoperative complications. Stroke Unit (Neurology) Patient with mild or moderate 37% (10) neurological impairment under general anaesthesia with no complications Patient with mild or moderate 63% (17) neurological impairment under sedation or local anaesthesia with no complications Patient requiring orotracheal intubation due to severe neurological deterioration or complications

PACU (Anaesthesiology)

CCU (Anaesthesiology)

CCU (Intensive Care Medicine)

18.5% (5)

14.8%(4)

29.7% (8)

11.1% (3)

11.1% (3)

14.8% (4)

37% (10)

63% (17)

Neurological impairment, mild NIHSS 2---5, moderate NIHSS 6---15, severe NIHSS >15. Data expressed as percentages of answers obtained with absolute values in parentheses. CCU: Critical Care Unit; NIHSS: National institute of Health Stroke Scale; PACU: Post Anaesthesia Care Unit.

In most cases, the anaesthesiologist is responsible for administering anaesthesia, as would be expected, especially when dealing with patients classified as ASA IV (American Society of Anesthesiologists). It is both striking and disturbing that in some hospitals anaesthesia is occasionally administered by other specialists. Twenty one percent of the hospitals that completed our questionnaire performed endovascular treatment of AIS without the assistance of an anaesthesiologist, suggesting that in these cases sedation, if required, is always administered by another specialist. In this respect, it is interesting to note that according to the Spanish National Health System24 guidelines for stroke, specialised units are required to include a neurologist specialised in cerebrovascular diseases and an endovascular neurointervencionist, but no mention is made of the presence of an anaesthesiologist during the procedure.25 True enough, endovascular procedures performed by neurointerventional radiologists were not among the objectives of the National Health System Stroke Strategy, since at that time these procedures were in their infancy and there was scant scientific evidence for their use in acute stroke. Nonetheless, they are among the objectives of the updated version of the Health Care Plan for Stroke26 and the 2014 Guidelines for the Care of Stroke Patients in the Community of Madrid.27 According to Spanish National Health System objectives,28 any hospital that treats stroke patients must implement a clinical pathway, protocol or care process for stroke. According to our results, only about half of the hospitals that completed the questionnaire have guidelines on anaesthetic management in these cases. Prior to starting any anaesthetic procedure, an assessment, which may include a series of tests, must be performed. Most Spanish hospitals require general lab tests, including coagulation, and an electrocardiogram. The tests required in these patients are not clearly defined in the medical literature, but during workup it is essential to bear in mind that time is of the essence. Guidelines recommend that anaesthesiologists follow American Society of Anesthesiologists (ASA) standards for emergency procedures.17 In

addition, if the procedure requires some type of anaesthesia, informed consent must be obtained.29,30 In the case of IAS patients scheduled for an endovascular procedure, the possibility of obtaining informed consent will be determined by various factors: the procedure is urgent, the neurological deterioration presented by these patients can limit ability to communication, and in many case no family members are present at the start of the procedure. For this reason, the requirement to obtain informed consent varied greatly among our respondent centres: it is obtained from approximately half of all patients, in 33.3% of hospitals it is not required due to the urgency of the procedure, and in 11.1% consent for endovascular procedure is bundled with consent for anaesthesia. The performance of any anaesthetic procedure outside the operating room not only increases the risk of complications, but is also more stressful for the anaesthesiologist, who is required to work without the usual operating room facilities. This is why the presence of an anaesthesiologist during non-operating room anaesthesia is all the more important. Contrary to expectations, our results show that 48% of anaesthesiologists are assisted solely by radiology nurses who, in most cases, are not trained in urgent anaesthetic procedures or in treating the possible complications that can arise. The need to rapidly recanalise the occluded vessel after onset of the stroke is one of the factors that has contributed to the current controversy regarding the most appropriate anaesthetic approach in these procedure.31 Studies comparing general anaesthesia and sedation have shown that one of the drawbacks of the former is the potential for induction to delay the start of the endovascular procedure. In contrast, our survey shows that the time from arrival at the radiology room to start of the femoral puncture does not exceed 10---15\,min in the majority of cases, and is between 15 and 30\,min in 40.7% of patients. This time includes the general preparations required for a neuroradiology intervention. This suggests that the administration of anaesthesia, whether general or sedation, may take no longer than the

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8 time required for preparing the interventional neuroradiology material and equipment. In their meta-analysis, Brinjikji et al.32 observed no difference in the time required for either anaesthesia induction and sedation. Implementing an anaesthesia protocol to be followed in these cases could reduce the anaesthesiologist’s reaction time and minimise the time needed to start the procedure.33 We found great variability in the use of non-standard monitoring during the procedure. It is surprising how little monitoring is used; for example, capnography is rarely used in spontaneous ventilation, depth of neuromuscular blockade is scarcely monitored during general anaesthesia, and finally, the specific neuromonitoring is rarely performed. In the case of blood pressure monitoring,17 current guidelines recommended the use of continuous invasive blood pressure monitoring throughout the procedure, provided the arterial line can be placed without delaying the start of the procedure. If invasive blood pressure monitoring is ruled out, non-invasive measurements should be taken every 3 min, and the arterial line placed by the neuroradiologist should be used when available. Our survey shows the extent to which these recommendations are followed. Over half (63%) of respondent centres use the femoral artery catheter to estimate mean arterial pressure. A similar percentage (59.3%) use noninvasive blood pressure monitoring, at various intervals; 25.9% (7) of centres used a peripheral arterial line for this purpose, provided this did not delay the procedure, and only 7.4% (2) of centres polled always placed an arterial line. The diversity of responses in respect of the type of anaesthesia used is merely a reflection of the sedation vs general anaesthesia controversy that has arisen due to the lack of evidence from randomised studies. Despite this, some clinical guidelines suggest that sedation is preferable in these procedures.17,32,34 Other,17,35 however, recommend that the choice of anaesthetic technique and pharmacological agents will depend on the characteristics of each patient. Powers et al.36 suggest that the choice should be individualised on the basis of patient risk factors, tolerance of the procedure, and other clinical characteristics. Two recent studies (ANSTROKE22 and GOLIATH23 ) suggest that general anaesthesia can be considered as safe as conscious sedation. In addition, the anaesthetic procedure should be decided in consensus with the neuroradiologist. According to the results of the McDonagh study,37 interventional neuroradiologists usually prefer general anaesthesia. It is interesting to draw attention to the general consensus among respondent centres with regard to the use of propofol as first choice in both sedation and anaesthesia induction. In terms of anaesthesia maintenance, sevoflurane was most widely used, with rocuronium as the muscle relaxant of choice. Interestingly, dexmedetomidine, a drug with great potential in anaesthesia under spontaneous ventilation, was rarely used. The literature available today makes no specific recommendation about the drugs to be used,17 and merely underlines the importance of taking steps to avoid, and when these fail treat, hypotension secondary to the administration of sedative/hypnotic drugs. The aim of periprocedural anticoagulation and administration of antiplatelet drugs during endovascular treatment is to reduce the risk of thromboembolic events secondary to the thrombus to be removed or to the use of catheters, stents, while minimising the risk of haemorrhage. There are

O. Romero Kräuchi et al. no specific recommendations on anticoagulation management in these procedures, and the only data available come from expert recommendations and case-studies; therefore, the optimal dose of anticoagulation agents has yet to be determined in these patients. We also observed great variability in anticoagulation management, heparinisation and administration of antiplatelet agents. In the latter, we observed the greatest agreement among respondents in the context of angioplasty and stent implantation. Numerous research studies have been published on the detrimental effect of hyperglycaemia on brain function after AIS.38 Debate is ongoing about the optimal blood glucose levels in these patients, since both hyperglycaemia and hypoglycaemia are equally detrimental to the brain. Blood glucose levels should be monitored routinely and frequently,39 and the development and implementation of a treatment protocol is recommended. It is currently recommended to maintain blood glucose at between 110 and 180 mg dL−1 .40 Most hospitals monitor blood glucose and maintain it within recommended ranges by administering insulin. There are no studies that show the most effective and safest fluid therapy in these patient.41,42 One of the most important clinical issues after an AIS is haemodynamic management of the patient due to the serious neurological complications arising from both severe arterial hypertension and hypotension. Severe arterial hypertension must be treated in order to prevent the onset of cerebral oedema and prevent haemorrhagic transformation. However, maintaining a certain level of arterial hypertension could benefit cerebral perfusion pressure in the ischaemic penumbra and thus prevent progression and neurological deterioration. Before starting intravenous thrombolysis, blood pressure should be below 185/110 mmHg; systolic blood pressure should remain below 180 mmHg and diastolic blood pressure below 105 mmHg in patients who have received thrombolytic therapy or interventionist therapy in the immediate postprocedural period.43---47 In these patients, a fast-acting, easily adjustable antihypertensive agent should be used. The current American Heart Association43 guidelines for the management of AIS patients recommend labetalol and nicardipine as first-line drugs. The most widely used antihypertensive drug in our setting is urapidil, even though there is no evidence to support its use in the control of hypertension after ischaemic stroke. The brain is extremely vulnerable to hypotension, which can alter its self-regulatory system. Hypotension has not been clearly defined in these patients, although it is usually accepted that the lower limit of systolic pressure should not fall below 140 mmHg. However, hypotension must be assessed individually, taking into account the presence of chronic arterial hypertension. In routine practice, ephedrine and phenylephrine are first and second choice, respectively, and vasoactive drugs such as noradrenaline can also be used in continuous infusion. Our results show that in order to maintain adequate cerebral blood flow, most hospitals try to either maintain systolic blood pressure between 140 and 180 mm Hg and diastolic blood pressure <105 mmHg, or to maintain the patient’s blood pressure to within 20% of their normal values.

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Anaesthetic management in the endovascular treatment of ischaemic stroke After the end of the procedure, all patients who meet clear extubation criteria should be extubated, since early, serial neurological examinations are the most important monitoring tool for patients with AIS.48 Evidence also suggests that short mechanical ventilation times are associated with a lower risk of pneumonia and better clinical outcomes,49 a recommendation that is followed by most respondent centres, where 85% of anaesthesiologists attempt to extubate patients meeting extubation criteria. The criteria for admission to a Critical Care Unit (CCU) vary among respondent hospitals, although there are evidently some universal criteria for admission, such as decreased alertness, the need for mechanical ventilation, intensive haemodynamic management or invasive monitoring. However, since optimising clinical parameters in these patients appears to significantly benefit mortality and functional recovery, thus reducing the risk of new complications and progression of the infarction,50 a great many stroke patients could benefit from admission to a CCU.51 These benefits are achieved by improving and maintaining blood flow in the ischaemic penumbra using reperfusion therapies, optimisation of neuroprotective strategies, and the support of other organs during neurological recovery.52 Our survey shows that only 43% of patients that do not meet absolute criteria for admission to a CCU are ultimately admitted to these care units. In summary, our survey characterises the anaesthesia management of AIS patients undergoing endovascular procedures. Predictably, the organisational systems in place in respondent centres vary widely, as do their catchment area. Contrary to what might be expected, anaesthesiologists are seldom assisted by specialised healthcare personnel when performing these procedures outside the operating room. It is also interesting to note the different approaches to anaesthesia in these patients, a situation that illustrates the ongoing debate surrounding this topic in the literature, and the frequency with which the type of anaesthesia is decided in consensus with the neuroradiologist. The limited use of specific neuromonitoring in these patients is striking. This may be due to various factors: the use of continuous neurological evaluation; the difficulty involved in performing radiological studies in some of these patients; or time constraints that prevent these protocols from being introduced. However, we observed widespread consensus on criteria such as medication, fluid management, haemodynamic management and blood glucose control. Anesthesiologists are aware of the need to start the interventional procedure as soon as possible, and make every effort to do so. This is evidenced by the short interval between entry into the interventional radiology room and start of femoral artery puncture. We were surprised to observe that in many hospitals the Anaesthesiology service is not systematically involved in the perioperative care of these patients, and that in 1 of every 5 hospitals, critically ill patients are sedated by other specialists. This overview of the current situation, which highlights the widely differing approaches taken, should form the basis for drawing up recommendations for standardised anaesthesia management of endovascular revascularization of AIS. Our ultimate goal is to provide the best patient care, and this can only be achieved with the introduction of clinical practice protocols drawn up in consensus by the different specialists involved. We can unify

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objectives and criteria if we all apply the evidence-based guidelines recommended by different scientific societies. We should be able to work as a multidisciplinary team, not only in each centre, but also in each scientific society --- a difficult, though not impossible, goal.

Ethical disclosures Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation. Confidentiality of data. The authors declare that no patient data appears in this article. Right to privacy and informed consent. The authors declare that no patient data appear in this article.

Conflict of interest The authors declare they have no conflicts of interest.

Acknowledgments The authors would like to thank all the anaesthesiologists who participated in the survey for their selfless collaboration.

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