1. Supportive Care Measures

Summary: Early optimization of airway, breathing, and circulation is essential to maintain cerebral perfusion and minimize secondary injury.

1.1 Mechanical Ventilation

• Indications:
  • Glasgow Coma Scale (GCS) ≤ 8
  • Inability to protect airway
  • Refractory hypoxemia or hypercapnia
• Ventilation strategy:
  • Lung-protective: tidal volume 6 mL/kg predicted body weight
  • Target PaCO₂ 35–45 mmHg (avoid hypo- or hypercapnia)
• Sedation/Analgesia:
  • Propofol or dexmedetomidine preferred for rapid titration and minimal ICP impact
  • Titrate opioids to comfort; avoid over-sedation to permit neurologic exams
• Weaning/Extubation:
  • Daily spontaneous awakening/breathing trials
  • Criteria: stable vitals, intact cough/gag, improving mental status

1.2 Hemodynamic Support

Summary: Maintain Cerebral Perfusion Pressure (CPP = Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP)) within optimal range to prevent delayed cerebral ischemia.

• Targets:
  • Pre-repair Systolic Blood Pressure (SBP) < 160 mmHg to reduce rebleeding risk
  • Post-repair MAP 80–100 mmHg (adjust for Delayed Cerebral Ischemia (DCI) risk)
• Agent Selection:
  • Norepinephrine first-line (alpha-1 > beta-1 effects; minimal tachycardia)
  • Add dopamine if inotropy needed
  • Avoid phenylephrine due to reflex bradycardia
• Monitoring & Titration:
  • Invasive arterial line for beat-to-beat BP monitoring
  • Start norepinephrine 0.01 mcg/kg/min; titrate by 0.01–0.05 mcg/kg/min
  • Assess urine output, lactate, mental status

2. Pharmacologic Prophylaxis of ICU-Related Complications

Summary: Pharmacologic prophylaxis must be timed and tailored to minimize bleeding and thrombotic risks.

2.1 Venous Thromboembolism (VTE) Prophylaxis

• Timing: Begin after aneurysm securing (clipping/coiling).
• Monitoring: Platelet count every 2-3 days (for Heparin-Induced Thrombocytopenia (HIT) surveillance), anti-Xa levels if extremes of weight or renal dysfunction.
• Contraindications: Active bleeding, platelet count < 100×10⁹/L, uncontrolled hypertension.

2.2 Stress-Related Mucosal Bleeding (SRMB) Prophylaxis

• Indications: Mechanical ventilation > 48 hours, coagulopathy, shock.
• Agents & Dosing:
  • Pantoprazole 40 mg IV daily
  • Ranitidine 50 mg IV q6–8h if Proton Pump Inhibitor (PPI) contraindicated
• Monitoring: Reassess daily; monitor magnesium with prolonged PPI use.
• Risks: PPI—Clostridioides difficile infection, pneumonia; H2-Receptor Antagonist (H2RA)—less potent acid suppression.

3. Infection Prevention

Summary: Bundled care approaches significantly reduce Ventilator-Associated Pneumonia (VAP), Central Line-Associated Bloodstream Infections (CLABSI), and Catheter-Associated Urinary Tract Infections (CAUTI) in neurocritical patients.

• VAP Prevention:
  • Elevate head-of-bed 30–45°
  • Daily sedation interruption and assessment of readiness to extubate
  • Oral care with chlorhexidine
• CLABSI Prevention:
  • Maximal sterile barrier precautions during insertion
  • Chlorhexidine skin preparation
  • Daily review of line necessity; remove if no longer needed
• CAUTI Prevention:
  • Early catheter removal
  • Aseptic insertion and maintenance techniques

4. Management of Iatrogenic Complications

Summary: Vigilant monitoring and prompt adjustment of therapies are key to preventing drug-induced organ dysfunction and other treatment-related harm.

4.1 Drug-Induced Organ Dysfunction

1. Nimodipine-Associated Hypotension

• Hold or reduce nimodipine dose if SBP < 90 mmHg.
• Ensure euvolemia before resumption of nimodipine.
• Monitor BP hourly after administration, especially with dose changes.

2. Osmotic Therapy-Induced Acute Kidney Injury (AKI)

• Agents: Mannitol 0.25–1 g/kg IV bolus; 23.4% NaCl infusion per local protocol.
• Monitor Blood Urea Nitrogen (BUN)/Creatinine, serum osmolality (target < 320 mOsm/kg).
• Adjust dose or switch agent if creatinine is rising or osmolality exceeds target.

3. Anticonvulsant Hepatotoxicity

• Phenytoin: Monitor Liver Function Tests (LFTs); switch to levetiracetam if hepatotoxicity or significant drug interactions occur.
• Levetiracetam dosing: 500–1000 mg IV q12h; adjust dose for renal function.

5. Multidisciplinary Goals of Care Conversations

Summary: Aligning treatment intensity with patient values and preferences is a critical component of high-quality care in severe SAH, which often carries a high burden of morbidity and mortality.

• Indications for formal discussion:
  • Poor neurologic prognosis despite maximal therapy
  • High burden of therapy with limited perceived benefit
  • Prolonged ICU stay without significant improvement
  • Patient or family request
• Core Team Members:
  • Neurocritical care physician
  • Neurosurgeon
  • Palliative care specialist (if available/indicated)
  • Bedside nurse
  • Social worker/Case manager
  • Ethics consultant (if complex ethical dilemmas arise)
• Framework for Discussion:
  1. Share prognosis clearly, including uncertainties.
  2. Elicit patient values, preferences, and any advance directives.
  3. Discuss the risks, benefits, and burdens of continued aggressive care versus a shift towards comfort-focused care.
  4. Collaboratively establish and document agreed-upon goals of care.
• Documentation: Ensure clear documentation of goals-of-care orders (e.g., DNR/DNI status, limitations on interventions) and plan for regular re-evaluations as the clinical situation evolves.