A client who has experienced a subarachnoid hemorrhage would be maintained in which position

  1. Shea AM, Reed SD, Curtis LH, Alexander MJ, Villani JJ, Schulman KA. Characteristics of nontraumatic subarachnoid hemorrhage in the United States in 2003. Neurosurgery. 2007;61(6):1131–7 discussion 7-8.

    Article  PubMed  Google Scholar 

  2. Labovitz DL, Halim AX, Brent B, Boden-Albala B, Hauser WA, Sacco RL. Subarachnoid hemorrhage incidence among Whites, Blacks and Caribbean Hispanics: the Northern Manhattan study. Neuroepidemiology. 2006;26(3):147–50.

    Article  CAS  PubMed  Google Scholar 

  3. Lahiri S, Mayer SA, Fink ME, Lord AS, Rosengart A, Mangat HS, et al. Mechanical ventilation for acute stroke: a multi-state population-based study. Neurocrit Care. 2015;23(1):28–32.

    Article  PubMed  Google Scholar 

  4. Mayer SA, Copeland D, Bernardini GL, Boden-Albala B, Lennihan L, Kossoff S, et al. Cost and outcome of mechanical ventilation for life-threatening stroke. Stroke. 2000;31(10):2346–53.

    Article  CAS  PubMed  Google Scholar 

  5. Udy AA, Vladic C, Saxby ER, Cohen J, Delaney A, Flower O, et al. Subarachnoid hemorrhage patients admitted to intensive care in Australia and New Zealand: a multicenter cohort analysis of in-hospital mortality over 15 years. Crit Care Med. 2017;45(2):e138–e45.

    Article  PubMed  Google Scholar 

  6. Gruber A, Reinprecht A, Gorzer H, Fridrich P, Czech T, Illievich UM, et al. Pulmonary function and radiographic abnormalities related to neurological outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg. 1998;88(1):28–37.

    Article  CAS  PubMed  Google Scholar 

  7. Busl KM, Bleck TP. Neurogenic pulmonary edema. Crit Care Med. 2015;43(8):1710–5.

    Article  PubMed  Google Scholar 

  8. Vespa PM, Bleck TP. Neurogenic pulmonary edema and other mechanisms of impaired oxygenation after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2004;1(2):157–70.

    Article  PubMed  Google Scholar 

  9. Solenski NJ, Haley EC Jr, Kassell NF, Kongable G, Germanson T, Truskowski L, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995;23(6):1007–17.

    Article  CAS  PubMed  Google Scholar 

  10. Veeravagu A, Chen YR, Ludwig C, Rincon F, Maltenfort M, Jallo J, et al. Acute lung injury in patients with subarachnoid hemorrhage: a nationwide inpatient sample study. World Neurosurg. 2014;82(1–2):e235–41.

    Article  PubMed  Google Scholar 

  11. Kahn JM, Caldwell EC, Deem S, Newell DW, Heckbert SR, Rubenfeld GD. Acute lung injury in patients with subarachnoid hemorrhage: incidence, risk factors, and outcome. Crit Care Med. 2006;34(1):196–202.

    Article  PubMed  Google Scholar 

  12. Marhong JD, Ferguson ND, Singh JM. Ventilation practices in subarachnoid hemorrhage: a cohort study exploring the use of lung protective ventilation. Neurocrit Care. 2014;21(2):178–85.

    Article  PubMed  Google Scholar 

  13. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Romner B, Brandt L, Berntman L, Algotsson L, Ljunggren B, Messeter K. Simultaneous transcranial Doppler sonography and cerebral blood flow measurements of cerebrovascular CO2-reactivity in patients with aneurysmal subarachnoid haemorrhage. Br J Neurosurg. 1991;5(1):31–7.

    Article  CAS  PubMed  Google Scholar 

  15. Ainslie PN, Duffin J. Integration of cerebrovascular CO2 reactivity and chemoreflex control of breathing: mechanisms of regulation, measurement, and interpretation. Am J Physiol Regul Integr Comp Physiol. 2009;296(5):R1473–95.

    Article  CAS  PubMed  Google Scholar 

  16. Diringer MN, Kirsch JR, Hanley DF, Traystman RJ. Altered cerebrovascular CO2 reactivity following subarachnoid hemorrhage in cats. J Neurosurg. 1993;78(6):915–21.

    Article  CAS  PubMed  Google Scholar 

  17. Solaiman O, Singh JM. Hypocapnia in aneurysmal subarachnoid hemorrhage: incidence and association with poor clinical outcomes. J Neurosurg Anesthesiol. 2013;25(3):254–61.

    Article  PubMed  Google Scholar 

  18. Lang M, Raj R, Skrifvars MB, Koivisto T, Lehto H, Kivisaari R, et al. Early moderate hyperoxemia does not predict outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2016;78(4):540–5.

    Article  PubMed  Google Scholar 

  19. Westermaier T, Stetter C, Kunze E, Willner N, Holzmeier J, Kilgenstein C, et al. Controlled transient hypercapnia: a novel approach for the treatment of delayed cerebral ischemia after subarachnoid hemorrhage? J Neurosurg. 2014;121(5):1056–62.

    Article  PubMed  Google Scholar 

  20. Reinges MH. Pros and cons of permissive hypercapnia in patients with subarachnoid haemorrhage and ARDS. Acta Neurochir. 2010;152(12):2173–4.

    Article  PubMed  Google Scholar 

  21. Kapinos G, Chichra A. Lung-protective ventilation for SAH patients: are these measures truly protective? Neurocrit Care. 2014;21(2):175–7.

    Article  PubMed  Google Scholar 

  22. Stevens RD, Lazaridis C, Chalela JA. The role of mechanical ventilation in acute brain injury. Neurol Clin. 2008;26(2):543–63 x.

    Article  PubMed  Google Scholar 

  23. Mascia L. Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care. 2009;11(3):417–26.

    Article  PubMed  Google Scholar 

  24. Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.

    Article  Google Scholar 

  25. Roquilly A, Cinotti R, Jaber S, et al. Implementation of an evidence-based extubation readiness bundle in 499 brain-injured patients. a before-after evaluation of a quality improvement project. Am J Respir Crit Care Med. 2013;188(8):958-966. https://doi.org/10.1164/rccm.201301-0116OC.

  26. Asehnoune K, Mrozek S, Perrigault PF, Seguin P, Dahyot-Fizelier C, Lasocki S, et al. A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project. Intensive Care Med. 2017;43(7):957–70.

    Article  PubMed  Google Scholar 

  27. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, et al. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775–86.

    Article  CAS  PubMed  Google Scholar 

  28. Hodgson CL, Tuxen DV, Davies AR, Bailey MJ, Higgins AM, Holland AE, et al. A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome. Crit Care. 2011;15(3):R133.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kacmarek RM, Villar J, Sulemanji D, Montiel R, Ferrando C, Blanco J, et al. Open lung approach for the acute respiratory distress syndrome: a pilot, randomized controlled trial. Crit Care Med. 2016;44(1):32–42.

    Article  CAS  PubMed  Google Scholar 

  30. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial I, Cavalcanti AB, Suzumura EA, Laranjeira LN, Paisani DM, Damiani LP, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318(14):1335–45.

    Article  Google Scholar 

  31. Petridis AK, Doukas A, Kienke S, Maslehaty H, Mahvash M, Barth H, et al. The effect of lung-protective permissive hypercapnia in intracerebral pressure in patients with subarachnoid haemorrhage and ARDS. A retrospective study. Acta Neurochir. 2010;152(12):2143–5.

    Article  PubMed  Google Scholar 

  32. McHedlishvili GI, Ormotsadze LG, Nikolaishvili LS, Baramidze DG. Reaction of different parts of the cerebral vascular system in asphyxia. Exp Neurol. 1967;18(2):239–52.

    Article  CAS  PubMed  Google Scholar 

  33. Nemer SN, Caldeira JB, Azeredo LM, Garcia JM, Silva RT, Prado D, et al. Alveolar recruitment maneuver in patients with subarachnoid hemorrhage and acute respiratory distress syndrome: a comparison of 2 approaches. J Crit Care. 2011;26(1):22–7.

    Article  PubMed  Google Scholar 

  34. Muench E, Bauhuf C, Roth H, Horn P, Phillips M, Marquetant N, et al. Effects of positive end-expiratory pressure on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation. Crit Care Med. 2005;33(10):2367–72.

    Article  PubMed  Google Scholar 

  35. Weir B, Grace M, Hansen J, Rothberg C. Time course of vasospasm in man. J Neurosurg. 1978;48(2):173–8.

    Article  CAS  PubMed  Google Scholar 

  36. Boone MD, Jinadasa SP, Mueller A, Shaefi S, Kasper EM, Hanafy KA, et al. The effect of positive end-expiratory pressure on intracranial pressure and cerebral hemodynamics. Neurocrit Care. 2017;26(2):174–81.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Caricato A, Conti G, Della Corte F, Mancino A, Santilli F, Sandroni C, et al. Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance. J Trauma. 2005;58(3):571–6.

    Article  PubMed  Google Scholar 

  38. Reinprecht A, Greher M, Wolfsberger S, Dietrich W, Illievich UM, Gruber A. Prone position in subarachnoid hemorrhage patients with acute respiratory distress syndrome: effects on cerebral tissue oxygenation and intracranial pressure. Crit Care Med. 2003;31(6):1831–8.

    Article  PubMed  Google Scholar 

  39. Roth C, Ferbert A, Deinsberger W, Kleffmann J, Kastner S, Godau J, et al. Does prone positioning increase intracranial pressure? A retrospective analysis of patients with acute brain injury and acute respiratory failure. Neurocrit Care. 2014;21(2):186–91.

    Article  PubMed  Google Scholar 

  40. Nekludov M, Bellander BM, Mure M. Oxygenation and cerebral perfusion pressure improved in the prone position. Acta Anaesthesiol Scand. 2006;50(8):932–6.

    Article  CAS  PubMed  Google Scholar 

  41. Thelandersson A, Cider A, Nellgard B. Prone position in mechanically ventilated patients with reduced intracranial compliance. Acta Anaesthesiol Scand. 2006;50(8):937–41.

    Article  CAS  PubMed  Google Scholar 

  42. Daoud EG, Farag HL, Chatburn RL. Airway pressure release ventilation: what do we know? Respir Care. 2012;57(2):282–92.

    PubMed  Google Scholar 

  43. Marik PE, Young A, Sibole S, Levitov A. The effect of APRV ventilation on ICP and cerebral hemodynamics. Neurocrit Care. 2012;17(2):219–23.

    Article  PubMed  Google Scholar 

  44. Taplu A, Gokmen N, Erbayraktar S, Sade B, Erkan N, Karadibak K, et al. Effects of pressure- and volume-controlled inverse ratio ventilation on haemodynamic variables, intracranial pressure and cerebral perfusion pressure in rabbits: a model of subarachnoid haemorrhage under isoflurane anaesthesia. Eur J Anaesthesiol. 2003;20(9):690–6.

    Article  CAS  PubMed  Google Scholar 

  45. Davies SW, Leonard KL, Falls RK Jr, Mageau RP, Efird JT, Hollowell JP, et al. Lung protective ventilation (ARDSNet) versus airway pressure release ventilation: ventilatory management in a combined model of acute lung and brain injury. J Trauma Acute Care Surg. 2015;78(2):240–9 discussion 9-51.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Vergouwen MD. Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid H. Vasospasm versus delayed cerebral ischemia as an outcome event in clinical trials and observational studies. Neurocrit Care. 2011;15(2):308–11.

    Article  PubMed  Google Scholar 

  47. Gessler F, Mutlak H, Lamb S, Hartwich M, Adelmann M, Platz J, et al. The impact of tracheostomy timing on clinical outcome and adverse events in poor-grade subarachnoid hemorrhage. Crit Care Med. 2015;43(11):2429–38.

    Article  PubMed  Google Scholar 

  48. Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, et al. Impact of nosocomial infectious complications after subarachnoid hemorrhage. Neurosurgery. 2008;62(1):80–7 discussion 7.

    Article  PubMed  Google Scholar 

  49. Rondeau N, Cinotti R, Rozec B, Roquilly A, Floch H, Groleau N, et al. Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study. Neurocrit Care. 2012;17(2):183–90.

    Article  CAS  PubMed  Google Scholar 


Page 2

Head CT showing the unique challenges of an aneurysmal subarachnoid hemorrhage patient. a There is a significant amount of basilar cistern subarachnoid hemorrhage placing the patient at high risk for delayed cerebral ischemia. b There is prominent hydrocephalus needing CSF diversion to lower intracranial pressure