Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany.
Neurocrit Care. 2019 Aug;31(1):46-55. doi: 10.1007/s12028-018-00667-3.
Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT.
KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months.
Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups.
An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.
尽管近年来急性缺血性脑卒中（AIS）患者机械取栓（MT）的治疗窗口已被延长，但事实证明，再通治疗必须尽快进行。我们提出了一种新的标准操作程序（SOP），以减少内部延迟，规范围手术期管理并提高 MT 期间的患者安全性。
KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment（KEEP SIMPLEST）是一项前瞻性、单中心观察性研究，旨在比较根据我们新的 SOP 使用依托咪酯和氯胺酮联合镇静与 Sedation versus Intubation for Endovascular Stroke TreAtment（SIESTA）试验中随机接受清醒镇静（CS）的 AIS 患者的围手术期管理方面。主要结局是使用国立卫生研究院卒中量表（NIHSS）评估 24 小时时的早期神经功能改善，次要结局是门到再通时间、再通分级、转换率和改良 Rankin 量表（mRS）在 3 个月时。
门到再通时间（128.6 ± 69.47 分钟与 156.8 ± 75.91 分钟；p = 0.02）、MT 平均持续时间（92.01 ± 52 分钟与 131.9 ± 64.03 分钟；p < 0.001）、门到第一幅血管造影图像时间（51.61 ± 31.7 分钟与 64.23 ± 21.53 分钟；p = 0.003）和 CT 到第一幅血管造影图像时间（31.61 ± 20.6 分钟与 44.61 ± 19.3 分钟；p < 0.001）在新 SOP 治疗组中明显更短。两组之间早期神经功能改善、3 个月时的 mRS 或其他次要结局无差异。两组 CS 转为全身麻醉的转换率相似。
使用新型镇静方案和优化设备和程序的 SOP，针对更精简、更综合和更紧凑的围手术期管理，可以显著减少接受轻镇静下取栓的脑卒中患者的内部治疗延迟，并证明了我们改进方法的安全性和可行性。
