Gina Russo Article Summary 2 This article compares the two methods used for managing and monitoring

intracranial pressure in adult patients that have suffered a subarachnoid hemorrhage as a result of a ruptured cerebral artery aneurysm. A subarachnoid hemorrhage is described as a bleeding in the subarachnoid space in the brain. The resulting cerebral artery aneurysm is a weakened area in the vessel wall of the brain that can eventually rupture. The article references that each year in the United States approximately 25,000 people suffer a subarachnoid hemorrhage directly resulting from a ruptured cerebral artery aneurysm and only 5,000 people per year in the United Kingdom. A major complication following a subarachnoid hemorrhage is the development of a secondary brain injury that left untreated can lead to a stroke or death. There are currently two accepted methods for monitoring intracranial pressure following a subarachnoid hemorrhage. The aim of this study was to provide more data to research the differences in the two methods and observe how the two methods affect the outcome of the patients. The first method used is through intermittent cerebral spinal fluid drainage (CSF). This is accomplished by setting the monitoring of external ventricular drainage by a physician prescribed level for a specific period of time. The second method used is through continuous cerebral spinal drainage. The second method allows the nurse to continuously drain cerebral spinal fluid except when the external ventricular drain is closed to monitor the intracranial pressure at set intervals. In order for the physician and critical care staff to assess the severity of the subarachnoid hemorrhage and determine risk factors the physicians rely on 2 main tools called the Hunt & Hess Score (also called the Fisher grade) and the Modified Rankin Score. The

tools are used to determine the neurologic impairment and prognosis of the patient by classifying or grading the severity of the bleed from the hemorrhage. This can be determined by the amount of blood visible on a computerized tomography (CT) scan of the patients brain. The Modified Rankin Score evaluates a patients outcome after a stroke with 0 representing no disability and 5 marking severe disability. The study was conducted using a non-randomized convenience sample of patients in the Neuroscience Intensive Care Unit at a major university hospital. The Neuroscience Intensive Care Unit is a 16 bed unit for adult patients needing critical care following a neurological injury. This study was conducted over an 8 month period. Eligible patients consisted of patients 18 years of age or older with a primary diagnosis of subarachnoid hemorrhage and had external ventricular drainage. The critical care staff was provided information about the study. Upon admission to the intensive care unit (ICU) and after the decision has been made to insert an external ventricular drain the physician determines what method to use to drain the cerebral spinal fluid and monitor the patients intracranial pressure. The data collected for each of the 37 patients was from the hospitals electronic health care records. The study period is defined as admission to the ICU through discharge from the ICU. The patients were divided into two groups based on the method of drainage used. The article states that there is no current preferred method of cerebral spinal fluid drainage. The results of the study did not show a significant difference between the two methods observed for managing CSF drainage and monitoring intracranial pressure. Although the results of the observational study did not provide the researchers with the better method it did raise the question of whether a standard method of CSF drainage and intracranial pressure monitoring should exist.

There were several limitations found within the study that impacted the results. The major limitation is the small sample size and the lack of randomization with the patients observed. The lack of randomization could also lead to selection bias that influenced the results. The study only reported on the patients highest levels of measure for both CSF drainage and intracranial pressure, other levels collected for the patients were not recorded. The method of CSF drainage and intracranial pressure monitoring used for the patient was at the discretion of the physician. Some found fault with the way the use of electronic health records for gathering data. There is also no measure to determine fidelity or if the nurses and critical care staff are adhering to the medical order. What the results do show is the need for continued research into the two methods using a randomized clinical trial with a larger sample size. I really found this article very interesting and informative. It was very descriptive in explaining the medical terminology, procedures and measurements being tested. This article was also very personal for me. In April of 2011 I lost my mother to a subarachnoid hemorrhage. I found the statistic comparing the individuals diagnosed with a subarachnoid hemorrhage in the United States vs. United Kingdom very alarming. This article made me think about my own life, my day to day habits and how important it is to value your health by practicing a healthy lifestyle.

Works Cited: Amato, Anthony, Britz, Gavin W, Graffagino, Carmello, James, Michael L, Olson, DaiWai M, Zomardi, Ali R, Zomardi, Margaret E. An observational pilot study of CSF diversion in subarachnoid hemorrhage. British Association of Critical Care Nurses. Vol.16 issue 5 September/October 2011: p.252-260.