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The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review

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Abstract

The use of standardized management protocols (SMPs) may improve patient outcomes for some critical care diseases. Whether SMPs improve outcomes after subarachnoid hemorrhage (SAH) is currently unknown. We aimed to study the effect of SMPs on 6-month mortality and neurologic outcomes following SAH. A systematic review of randomized control trials (RCTs) and observational studies was performed by searching multiple indexing databases from their inception through January 2019. Studies were limited to adult patients (age ≥ 18) with non-traumatic SAH reporting mortality, neurologic outcomes, delayed cerebral ischemia (DCI) and other important complications. Data on patient and SMP characteristics, outcomes and methodologic quality were extracted into a pre-piloted collection form. Methodologic quality of observational studies was assessed using the Newcastle–Ottawa scale, and RCT quality was reported as per the Cochrane risk of bias tool. A total of 11,260 studies were identified, of which 37 (34 full-length articles and 3 abstracts) met the criteria for inclusion. Two studies were RCTs and 35 were observational. SMPs were divided into four broad domains: management of acute SAH, early brain injury, DCI and general neurocritical care. The most common SMP design was control of DCI, with 22 studies assessing this domain of care. Overall, studies were of low quality; most described single-center case series with small patient sizes. Definitions of key terms and outcome reporting practices varied significantly between studies. DCI and neurologic outcomes in particular were defined inconsistently, leading to significant challenges in their interpretation. Given the substantial heterogeneity in reporting practices between studies, a meta-analysis for 6-month mortality and neurologic outcomes could not be performed, and the effect of SMPs on these measures thus remains inconclusive. Our systematic review highlights the need for large, rigorous RCTs to determine whether providing standardized, best-practice management through the use of a protocol impacts outcomes in critically ill patients with SAH.

Trial registration Registration number: CRD42017069173.

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Acknowledgements

Thank you for considering this manuscript for publication in the Journal of Neurocritical Care. On behalf of my co-authors, I, Dr. Shaurya Taran, confirm that the following manuscript complies with all instructions to authors as outlined in the submission information package. I additionally confirm that the authorship requirements have been met and that all co-authors have reviewed and approved the final manuscript for submission.

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Authors and Affiliations

  1. Division of Internal Medicine, Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, USA

    Shaurya Taran

  2. Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada

    Vatsal Trivedi

  3. Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada

    Jeffrey M. Singh & Victoria A. McCredie

  4. Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada

    Jeffrey M. Singh & Victoria A. McCredie

  5. Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON, Canada

    Shane W. English

  6. Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Shane W. English

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  1. Shaurya Taran
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  3. Jeffrey M. Singh
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  4. Shane W. English
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Contributions

ST participated in study planning, data screening, acquisition, and analysis, appraising the quality of studies, manuscript preparation and proofreading, and critical revisions. VT participated in data screening, acquisition, and analysis, and manuscript proofreading. JMS participated in study planning and manuscript proofreading. SWE participated in study planning and manuscript proofreading. VAM participated in study planning, develo** the search strategy, manuscript preparation and proofreading, and critical revisions.

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Correspondence to Shaurya Taran.

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Taran, S., Trivedi, V., Singh, J.M. et al. The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review. Neurocrit Care 32, 858–874 (2020). https://doi.org/10.1007/s12028-019-00867-5

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