背景:动脉瘤性蛛网膜下腔出血(aSAH)患者的神经重症监护管理是影响患者短期和长期预后的最关键因素之一。基于2011年召开的共识会议,对以往的aSAH医疗管理建议进行了全面总结。在这份报告中,我们在文献评估的基础上,使用建议评级评估提供更新的建议,发展,和评价方法。
方法:与aSAH的医疗管理相关的人口/干预/比较/结果(PICO)问题是由小组成员达成共识而优先考虑的。小组使用定制设计的调查工具来优先考虑每个PICO问题的临床相关结果。要包括在内,研究设计合格标准如下:前瞻性随机对照试验(RCT),前瞻性或回顾性观察研究,病例对照研究,样本大于20名患者的病例系列,荟萃分析,仅限于人类研究参与者。小组成员首先筛选标题和摘要,随后对选定的报告进行全文审查。从符合纳入标准的报告中提取数据一式两份。小组成员使用了建议评级评估,发展,用于评估随机对照试验的偏差风险评估工具和用于评估观察性研究的“非随机研究中的偏差风险-干预措施”工具。每个PICO的证据摘要已提交给整个小组,然后小组对建议进行了投票。
结果:最初的搜索检索了15,107个独特的出版物,并包括74个用于数据抽象。进行了几项随机对照试验来测试药理学干预措施,我们发现,非药物问题的证据质量一直很差。五个PICO问题得到了强有力的建议的支持,一个PICO问题得到了有条件建议的支持,和六个PICO问题没有足够的证据来提供建议。
结论:这些指南为被证明有效的干预措施提供了建议,无效,根据对现有文献的严格审查,或对aSAH患者的医疗管理有害。它们还有助于突出应指导未来研究重点的知识差距。尽管随着时间的推移,aSAH患者的预后有所改善,许多重要的临床问题仍未得到解答.
The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on
consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology.
The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by
consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the \"Risk of Bias In Nonrandomized Studies - of Interventions\" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations.
The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation.
These
guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.