From the Guidelines
Management of subarachnoid hemorrhage (SAH) with concurrent renal failure requires a careful multidisciplinary approach, prioritizing strict blood pressure control and euvolemia to minimize morbidity, mortality, and improve quality of life. Initial management should focus on stabilizing the patient with systolic blood pressure below 140-160 mmHg using titratable agents like nicardipine or clevidipine that can be adjusted based on renal function, as recommended by the American Heart Association/American Stroke Association guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1.
Key Considerations
- Nimodipine 60 mg every 4 hours for 21 days should be administered to prevent vasospasm, with dose adjustments in severe renal impairment, as early initiation of enteral nimodipine is beneficial in preventing delayed cerebral ischemia and improving functional outcomes after aSAH 1.
- Fluid management is critical, maintaining euvolemia rather than the traditional "triple-H" therapy (hypertension, hemodilution, hypervolemia), as hypervolemia can worsen renal function.
- For patients requiring renal replacement therapy, continuous venovenous hemofiltration is often preferred over intermittent hemodialysis to avoid rapid fluid shifts that could increase intracranial pressure.
- Medication dosing must be adjusted for renal clearance, particularly antibiotics, antiseizure medications, and analgesics.
- Contrast studies should be minimized, but when necessary, iso-osmolar contrast agents with appropriate pre-hydration should be used.
- Close monitoring of electrolytes is essential, as both SAH and renal failure can cause dangerous imbalances, particularly hyponatremia.
Multidisciplinary Approach
A multidisciplinary team approach, including neurocritical care and nephrology teams, is essential for optimal management, as it allows for early identification of discharge needs and design of rehabilitation treatment, improving long-term outcomes 1. Neurosurgical intervention for aneurysm securing (clipping or coiling) should not be delayed due to renal dysfunction, though the anesthesia approach may need modification. This combined condition carries high mortality, making early involvement of both teams crucial for minimizing morbidity, mortality, and improving quality of life.
From the Research
Management of Subarachnoid Hemorrhage
- The management of subarachnoid hemorrhage (SAH) involves a multidisciplinary approach, including admission to high-volume centers, early identification and management of the bleeding source, and evaluation and treatment of unsecured aneurysms 2.
- Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities 2.
- The use of nimodipine has been shown to be effective in relieving ischemic symptoms due to cerebral vasospasm after SAH 3, 4.
Renal Failure in Subarachnoid Hemorrhage
- There is limited information available on the management of renal failure in patients with subarachnoid hemorrhage.
- However, it is known that patients with SAH are at risk for developing medical complications, including renal failure, due to the systemic effects of the hemorrhage 5.
- The management of SAH should include close monitoring for signs and symptoms of vasospasm, as well as prevention of subsequent medical complications, including renal failure 5.
Treatment of Subarachnoid Hemorrhage
- The treatment of SAH involves a combination of medical and surgical interventions, including endovascular coiling or microsurgical clipping of the aneurysm, as well as management of cerebral vasospasm and delayed cerebral ischemia 6, 4.
- The use of nimodipine has been shown to be effective in reducing the rate of cerebral vasospasm and delayed cerebral ischemia in patients with SAH treated with endovascular coiling 4.
- The management of SAH should be individualized and based on the patient's specific needs and medical history 2, 5, 6.