Anne M Rowat

Dehydration in Hospital-Admitted Stroke Patients Detection, Frequency, and Association

Background and Purpose— We aimed to determine the frequency of dehydration, risk factors, and associations with outcomes at hospital discharge after stroke. Methods— We linked clinical data from stroke patients in 2 prospective hospital registers with routine blood urea and creatinine results. Dehydration was defined by a blood urea-to-creatinine ratio >80. Results— Of 2591 patients registered, 1606 (62%) were dehydrated at some point during their admission. Independent risk factors for dehydration included older age, female gender, total anterior circulation syndrome, and prescribed diuretics (all P<0.001). Patients with dehydration were significantly more likely be dead or dependent at hospital discharge than those without (&khgr;2=170.5; degrees of freedom=2; P<0.0001). Conclusions— Dehydration is common and associated with poor outcomes. Further work is required to establish if these associations are causal and if preventing or treating dehydration improves outcomes.

Hypoxaemia in Acute Stroke Is Frequent and Worsens Outcome

Background: Hypoxaemia in the acute phase of stroke might damage the ischaemic penumbra and worsen clinical outcome. We determined the frequency of hypoxaemia on admission with stroke and assessed whether it was related to outcome. Methods: We measured arterial oxygen saturation (SaO2) and breathing effort with portable monitoring equipment in a large cohort of acute stroke patients, continually from arrival at hospital, during interdepartment transfer, in imaging and on the ward. Patients received best medical care according to current guidelines. Baseline neurological examination and 3-month outcome (Modified Rankin Scale) were assessed blind to other data. Hypoxaemia was defined as SaO2 <90% for ≧10% of each assessment stage. Results: Mean SaO2 was lowest during transfers (p < 0.01), but hypoxaemia was common in all assessment stages. Patients with hypoxaemia (30/153, 20%) were more likely to have a pre-existing respiratory disease on admission than those without hypoxaemia (p < 0.04). More patients with hypoxaemia (40%) died than those without hypoxaemia (20%) (hazard ratio, 2.0; 95% CI, 1.0–4.1), though after adjusting for National Institute of Health Stroke Scale and age this association was not statistically significant (hazard ratio, 1.5; 95% CI, 0.7–3.1). There were similar numbers of dependent survivors in both groups. Conclusion: Hypoxaemia during acute stroke assessment was associated with increased risk of death. Although SaO2 is lower during transfers, hypoxaemia occurs in all stages of the admission process. Further research is necessary to determine whether strategies to avoid hypoxaemia during acute assessment improve stroke survival.

Patient positioning influences oxygen saturation in the acute phase of stroke.

We evaluated arterial oxygen saturation (SaO2) and heart rate in acute stroke patients to determine whether routine positioning affected these physiological parameters. Measurements were recorded at the bedside non-invasively in five different positions assigned in random order each maintained for 10 min. One hundred and twenty-nine patients examined within a median of 72 h, lying on the left side resulted in slightly lower SaO2 than lying on the right side, which was statistically significant in the patients with a right (n = 66), but not left, hemiparesis. Patients able to sit in a chair (n = 65), who mostly had less severe strokes, had a significantly higher mean SaO2 and heart rate when sitting in the chair than when placed in any other position. About 10% of patients, especially those with a severe stroke, with right hemiparesis and concomitant chest disease, experienced falls in SaO2 to 90% or less for ≧2 min in certain positions; the hypoxia was more likely when they were lying on their left side. These results may have implications for current practice and for future patient positioning strategies to improve outcome after stroke.

Central periodic breathing observed on hospital admission is associated with an adverse prognosis in conscious acute stroke patients.

Background: Central periodic breathing (CPB) is common following acute stroke, but its prognostic significance is uncertain. We determined the frequency of CPB on admission with stroke and assessed whether it was related to outcome. Methods: We measured arterial oxygen saturation (SaO2), chest wall movements and nasal airflow continually with portable monitoring equipment in a large cohort of acute stroke patients, from arrival at hospital through acute assessment to reaching the ward. Baseline neurological examination and 3-month outcome (modified Rankin scale, MRS) were assessed blind to recordings. CPB was defined as cyclical rises and falls in ventilation, with intermittent reduced respiratory airflow or total apnoea. Results: CPB was common in acute stroke (33/138, 24%), but was poorly recognised by clinical staff. Patients with CPB were more likely to have a total anterior circulation syndrome and higher National Institutes of Health Stroke Scale scores than those without (both p < 0.01). Patients with CPB had significantly higher median SaO2 than those without (p < 0.01), unrelated to whether they received oxygen or not. At 3-month follow-up: 91% of patients with CPB were dead or dependent (MRS ≧3) compared with 53% of those without (OR 8.8; 95% CI 2.5–30.5); the association remained statistically significant after adjusting for covariates (OR 5.9; 95% CI 1.4–25.4). Conclusion: CPB is independently associated with poor outcome after stroke, but is not by association with hypoxia. Further work is required to identify causes, effects and interventions that might improve effects of CPB.

Does Feeding Alter Arterial Oxygen Saturation in Patients With Acute Stroke

Background and Purpose We measured arterial oxygen saturation (Sao2) during eating in acute stroke patients to establish the frequency of any meal-related hypoxemia, which could further damage already vulnerable brain tissue. Methods Stroke patients (≤12 days from stroke onset) classified as “safe to feed orally” were compared with elderly hospitalized (for nonneurological causes) and young healthy controls. Sao2 was measured noninvasively at the bedside by pulse oximetry continuously for 10 minutes before the patient ate a meal, during the meal, and for 10 minutes after completion of the meal. Results The median baseline Sao2 was significantly lower in stroke patients (n=106, 95.7%) than elderly (n=50, 96.7%) or young control subjects (n=20, 97.9%;P <0.001). There was a small decrease in the median Sao2 during eating in stroke and elderly patients (95.6%, P =0.08, and 96.3%, P =0.004, respectively) but not in young controls. Only stroke patients had a significantly lower median Sao2 after completion of the meal (95.4%, P <0.001). Sao2 of ≤90% during and after eating occurred in 24% of stroke and 16% of elderly patients but not in young controls, and it was significantly more common in those who had Sao2 of ≤90% during the baseline recordings (P ≤0.003). Conclusions Eating a meal was associated with a small fall in median Sao2 among stroke and elderly patients, but only in stroke patients did this persist for at least 10 minutes after eating. A quarter of stroke patients had episodes in which the Sao2 fell to ≤90% saturation (ie, hypoxemia) during or after eating, although this rarely coincided exactly with swallowing and was more common in patients who also experienced desaturation during the baseline recordings. Further studies are required to establish whether these changes are clinically important.

A pilot study to assess if urine specific gravity and urine colour charts are useful indicators of dehydration in acute stroke patients

AIM The purpose of this pilot study was to examine whether urine specific gravity and urine colour could provide an early warning of dehydration in stroke patients compared with standard blood indicators of hydration status. BACKGROUND Dehydration after stroke has been associated with increased blood viscosity, venous thrombo-embolism and stroke mortality at 3-months. Earlier identification of dehydration might allow us to intervene to prevent significant dehydration developing or reduce its duration to improve patient outcomes. METHODS We recruited 20 stroke patients in 2007 and measured their urine specific gravity with urine test strips, a refractometer, and urine colour of specimens taken daily on 10 consecutive days and compared with the routine blood urea:creatinine ratios over the same period to look for trends and relationships over time. The agreement between the refractometer, test strips and urine colour were expressed as a percentage with 95% confidence intervals. RESULTS Nine (45%) of the 20 stroke patients had clinical signs of dehydration and had a significantly higher admission median urea:creatinine ratio (P = 0·02, Mann-Whitney U-test). There were no obvious relationships between urine specific gravity and urine colour with the urea:creatinine ratio. Of the 174 urine samples collected, the refractometer agreed with 70/174 (40%) urine test strip urine specific gravity and 117/174 (67%) urine colour measurements. CONCLUSIONS Our results do not support the use of the urine test strip urine specific gravity as an early indicator of dehydration. Further research is required to develop a practical tool for the early detection of dehydration in stroke patients.

Enteral tube feeding for dysphagic stroke patients

Enteral feeding tubes, a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG), are commonly used to provide nutrition, hydration and essential medications to stroke patients who cannot swallow. Early tube feeding is associated with improved survival after stroke and it is recommended that patients start tube feeding within 24 hours of hospital admission. NGT feeding is the preferred method for short-term feeding in the acute phase of stroke as it has the advantage of being easily placed at the bedside. However, there are often difficulties inserting the NGT and it can be easily dislodged by agitated and confused patients, leading to potentially fatal complications. A PEG tube is considered a more secure method of feeding stroke patients who require longer-term nutritional support, but it is an invasive procedure that can result in complications that are associated with an increased risk of morbidity and mortality after stroke. The aim of this article is to review the complications associated with enteral feeding tubes and discuss their prevention and management for stroke patients.

Top 10 research priorities relating to stroke nursing: a rigorous approach to establish a national nurse‐led research agenda

AIM To determine the top 10 research priorities specific to stroke nursing. BACKGROUND It is important that stroke nurses build their research capability and capacity. This project built on a previous James Lind Alliance prioritization project, which established the shared stroke research priorities of stroke survivors, carers and health professionals. DESIGN Research priority setting project using James Lind Alliance methods; a survey for interim prioritization and a consensus meeting for final priority setting. METHODS Between September - November 2014, stroke nurses were invited to select their top 10 priorities from a previously established list of 226 unique unanswered questions. These data were used to generate a list of shared research priorities (interim priority setting stage). A purposefully selected group of stroke nurses attended a final consensus meeting (April 2015) to determine the top 10 research priorities. RESULTS During the interim prioritization stage, 97 stroke nurses identified 28 shared priority treatment uncertainties. At the final consensus meeting, 27 stroke nurses reached agreement on the top 10 stroke nursing research priorities. Five of the top 10 questions relate to stroke-specific impairments and five relate to rehabilitation and long-term consequences of stroke. CONCLUSIONS The research agenda for stroke nursing has now been clearly defined, facilitating nurses to undertake research, which is of importance to stroke survivors and carers and central to supporting optimal recovery and quality of life after stroke.

The effect of concentration and duration of normobaric oxygen in reducing caspase-3 and -9 expression in a rat-model of focal cerebral ischaemia.

The aim of this study was to determine the effect of different concentrations of normobaric oxygen (NBO) on neurological function and the expression of caspase-3 and -9 in a rat model of acute cerebral ischaemia. Sprague-Dawley rats (n=120) were randomly divided into four groups (n=30 per group), including 3 groups given NBO at concentrations of 33%, 45% or 61% and one control group given air (21% oxygen). After 2h of ischaemic occlusion, each group was further subdivided into six subgroups (n=5) during reperfusion according to the duration (3, 6, 12, 24, 48 or 72h) and concentration of NBO (33%, 45% or 61%) or air treatment. The Fluorescence Quantitative polymerase chain reaction (PCR) and immunohistochemistry were used to detect caspase-3 and -9 mRNA and protein relative expression respectively. The Neurologic Impairment Score (NIS) was significantly lower in rats given 61% NBO ≥3h after reperfusion when compared to the control group (P<0.05, Mann-Whitney U). NBO significantly reduced caspase-3 and -9 mRNA and protein expression when compared to the control group at all NBO concentrations and time points (P<0.05, ANOVA). The expression of caspase-3 and -9 was lower in the group given 61% NBO compared any other group, and this difference was statistically significant when compared to the group given 33% NBO for ≥48h and the control group (both P<0.05, ANOVA). These findings indicate that NBO may inhibit the apoptotic pathway by reducing caspase-3 and -9 expression, thereby promoting neurological functional recovery after stroke.

Risk Factors for Suicide and Suicidal Behavior Relevant to Emergency Health Care Settings: A Systematic Review of Post-2007 Reviews

Suicide is a global public health problem, and with recent economic and societal changes, there may be emerging risk factors unrecognized by health care professionals. The aim of this systematic review was to update existing suicide risk factor literature applicable to emergency health care settings. A total of 35 articles identified from PsycINFO, CINAHL, and Medline met the inclusion criteria. Results supported the significance of existing suicide risk factors and identified emerging risk factors. The review provides a high-quality update of risk factor literature that could be applied to emergency health care settings; however, further research is needed to confirm emerging risk factors.