Management of acute stroke. Specific nursing care and treatments in the stroke unit.

OBJECTIVE: This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS: We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS: The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS: These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

Management of acute stroke. Specific nursing care and treatments in the stroke unit. / Manejo del ictus agudo. Tratamientos y cuidados específicos de enfermería en la Unidad de Ictus.

OBJECTIVE: This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS: We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS: The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS: These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.

[Thrombotic complication of severe COVID-19 pneumonia: stroke due to atypical paradoxical embolism]. / Complicación trombótica de neumonía grave por COVID-19: ictus por embolismo paradójico atípico.

INTRODUCTION: Severe infection by SARS-CoV-2 has shown to entail an increased risk of thrombotic, especially venous, events. Central venous catheters have also been associated with an increased risk of thrombotic complications. Paradoxical embolism as an aetiological mechanism of ischaemic stroke should be considered in a highly prothrombotic context, where it may be more frequent. CASE REPORT: A 40-year-old woman with a central venous catheter, with a large vessel ischaemic stroke, treated with mechanical thrombectomy for an atypical paradoxical embolism while in intensive care for bilateral COVID-19 pneumonia. In the aetiological study, analysis highlighted an elevation of the D-dimer and right-left shunt with massive passage of contrast directly from the central peripheral access pathway in the left upper extremity to the left atrium in the transoesophageal echocardiogram. Thoracic tomographic angiography showed an anomalous venous structure with its origin in the subclavian vein and drainage to the segmental vein of the left upper lobe with direct emptying into the left atrium. Treatment consisted in anticoagulation until removal of the central venous catheter and simple anti-aggregating medication on discharge. CONCLUSIONS: Paradoxical embolism due to intra- or extra-cardiac shunt should be considered in patients with COVID-19, given the high associated risk of venous thromboembolism. Further studies are needed to be able to define optimal prophylactic and therapeutic management.

TITLE: Complicación trombótica de neumonía grave por COVID-19: ictus por embolismo paradójico atípico.Introducción. La infección grave por el SARS-CoV-2 ha demostrado un incremento del riesgo de fenómenos trombóticos, especialmente venosos. Los catéteres venosos centrales también se han asociado a un mayor riesgo de complicaciones trombóticas. El embolismo paradójico como mecanismo etiológico del ictus isquémico debe tenerse en cuenta en un contexto protrombótico elevado, en el que puede ser más frecuente. Caso clínico. Mujer de 40 años, portadora de un catéter venoso central, con ictus isquémico de gran vaso, tratada con trombectomía mecánica por embolismo paradójico atípico durante el ingreso en cuidados intensivos por neumonía bilateral por COVID-19. Dentro del estudio etiológico, destacaba analíticamente una elevación del dímero D y shunt derecha-izquierda con paso masivo de contraste directamente desde la vía central de acceso periférico en la extremidad superior izquierda a la aurícula izquierda en el ecocardiograma transesofágico. Una angiotomografía torácica mostró una estructura venosa anómala con origen en la vena subclavia y drenaje a la vena segmentaria del lóbulo superior izquierdo con vaciado directo a la aurícula izquierda. Se decidió anticoagulación hasta la retirada del catéter venoso central y antiagregación simple al alta. Conclusiones. El embolismo paradójico por shunt intra o extracardíaco debe considerarse en pacientes con COVID-19, dado el elevado riesgo tromboembólico venoso asociado. Para definir el manejo profiláctico y terapéutico óptimo son necesarios más estudios.

Donor referral from outside the intensive care unit: A multidisciplinary cooperation model using communication apps and redefining refereal criteria.

OBJECTIVE: We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU). STUDY DESIGN: Cohort prospective study. SETTINGS: University hospital. PATIENTS AND INTERVENTION: In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate. RESULTS: A two-fold increase of referrals was noted in 2015 [n=46/74; (62%)] compared to 2014 [n=13/40; (32%)]; p<0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p<0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5±20.2 and 44.4±12.2h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p<0.05). CONCLUSION: The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death.