From the Guidelines
A patient with subarachnoid hemorrhage presenting with high blood pressure, fever, and desaturation requires immediate comprehensive management to prevent further complications and improve outcomes. The most recent guideline from the American Heart Association/American Stroke Association, published in 2023 1, emphasizes the importance of prompt recognition and management of these symptoms.
Key Management Strategies
- Control blood pressure with titratable IV medications like nicardipine (5-15 mg/hr) or labetalol (2-8 mg/min) to maintain systolic BP below 160 mmHg, as recommended by the 2012 guidelines 1, to prevent rebleeding while ensuring adequate cerebral perfusion.
- Address fever promptly with acetaminophen 650 mg every 4-6 hours and external cooling measures, as hyperthermia worsens neurological outcomes.
- For desaturation, provide supplemental oxygen targeting SpO2 >94%, consider head elevation to 30 degrees, and assess for neurogenic pulmonary edema or aspiration pneumonia.
- Secure the airway if respiratory status deteriorates.
- Obtain urgent neurosurgical consultation, repeat head imaging, and monitor in an ICU setting with frequent neurological assessments.
- Administer nimodipine 60 mg every 4 hours to prevent vasospasm, as recommended by the 2012 guidelines 1.
Rationale
These symptoms may indicate neurogenic fever from blood irritating the hypothalamus, vasospasm development, or evolving hydrocephalus. The Canadian Stroke Best Practice Recommendations, updated in 2015 1, also highlight the importance of addressing blood pressure management, temperature, risk of venous thromboembolism, and vasospasm in caring for patients with subarachnoid hemorrhage.
Prioritization
The management of high blood pressure, fever, and desaturation in patients with subarachnoid hemorrhage should prioritize preventing further complications, such as rebleeding, vasospasm, and neurological deterioration, to improve patient outcomes. The most recent and highest-quality evidence, as outlined in the 2023 guideline 1, should guide clinical decision-making.
From the Research
Clinical Presentation and Management
- High blood pressure, fever, and desaturation in a patient with subarachnoid hemorrhage can be indicative of various complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities 2.
- The management of patients with subarachnoid hemorrhage should adhere to currently available treatment guidelines, which include admission to high-volume centers, early identification and management of the bleeding source, and management of patients in the neurocritical care unit with oral nimodipine, blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications 2, 3.
Complications and Treatment
- Delayed cerebral ischemia secondary to cerebral vasospasm should be treated with induced hypertension and endovascular therapies once confirmed 2.
- The critical care of aneurysmal subarachnoid hemorrhage prioritizes cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications 3.
- Standardized neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes 3.
Diagnosis and Prognosis
- Noncontrast brain computed tomography (CT) performed within 6 hours of symptom onset has sensitivity approaching 100% for diagnosing subarachnoid hemorrhage 4.
- Lumbar puncture may be considered after this period for definitive diagnosis if initial CT is normal 4.
- The overall outcome of subarachnoid hemorrhage has improved over recent decades, likely related to improvements in interventional options for ruptured cerebral aneurysms and in critical care management 5.