Vancouver Acute Department of Anesthesia

Stroke Activation - Preamble

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Preamble:

The acute stroke IR pager system will go live as of Jan 28th, 2019. Now, once an acute stroke is booked to go to the interventional radiology suite, both the first call and slating pagers will receive a "7111" page (in addition to the radiologists, techs, IR fellows, etc). Please call switchboard and you will be put through to the stroke neurologist or be given their number. At this point, you can discuss the case and the need for anesthesia involvement. I've attached a cheat sheet for anesthesia for acute stroke in IR as a guide if that's helpful.

Strongly consider anesthesia involvement with the following:
 

• vomiting/inadequate airway protection

• poor cooperation or deteriorating neurologic status

• OSA/obesity

• Difficult airway

• Hemodynamic instability

• Anticipated direct carotid puncture (vs femoral)

• Anticipated carotid stenting

• Posterior circulation strokes

It would also reasonable to have an anesthesiologist lay eyes on the patient initially and make a decision. These cases should be treated as stat, ie E0 priority. Blood pressure management should be discussed with the neurologist/neurointerventionalist as there may be specific patient considerations. 

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ANESTHETIC MANAGEMENT FOR ENDOVASCULAR TREATMENT OF ACUTE ISCHEMIC STROKE 

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1) STAT CASE (EO): Avoid any delays

 

2) Monitoring:

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• Standard monitors with NIBP q3 minutes

• Arterial line if does not delay procedure, insert prior to induction if GA

• If arterial line not possible consider T-ing off IR femoral artery sheath

 

3) Anesthesia:

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• Most patients will require minimal to mild sedation 

• A minority of patients will require a GA (e.g. posterior circulation or severe stroke; airway compromise vomiting/aspiration, uncooperative)

• If GA, aim for early extubation if possible

 

4) Blood pressure management: 

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• Target Blood Pressure:

  • SBP 140 - 180 mmHg if received IV TPA

  • Permissive HTN up to SBP 220 if no IV TPA

• **Avoid hypotension (SBP<140) prior to revascularization**

• Consider lowering BP target after successful revascularization due to risk of hyperperfusion and hemorrhagic conversion, discuss with stroke neurologist and radiologist

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5) End-tidal CO2 management:  Aim for normocapnea 

 

6) Glucose management: 

• Avoid hypoglycemia

• Treat blood glucose >10 mmol/L

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7) Disposition:

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• GA with immediate extubation will go PACU -> NICU

• MAC/Uncomplicated patients will go directly to NICU

• Intubated/unstable patients will go to the regular ICU

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Last updated: January 2019 by Dr. Flexman