Thursday, October 30, 2014

For stroke patients, hospital bed position is a delicate balancing act

Bed position is an example of how attention to detail improves outcomes

MAYWOOD, Ill. (Oct. 30, 2014) – During the first 24 hours after a stroke, attention to detail - such as hospital bed positioning - is critical to patient outcomes.

Most strokes are caused by blood clots that block blood flow to the brain. Sitting upright can harm the patient because it decreases blood flow and oxygen to the brain just when the brain needs more blood.

Thus it’s reasonable to keep patients lying flat or as nearly flat as possible, according to a report in the journal MedLink Neurology by Loyola University Medical Center neurologist Murray Flaster, MD, PhD, and colleagues.

But strokes also can increase intracranial pressure (brain swelling) that can damage the brain. Sitting upright helps improve blood drainage and reduces intracranial pressure, but at a cost of reduced blood flow to the brain.

“There are few data to guide decision making in this difficult situation,” Flaster and his colleagues write.

Further complicating stroke care, some patients have orthopnea (difficulty breathing while lying flat). In such patients, the head of the bed should be kept at the lowest elevation the patient can tolerate.

Finally, frequent changes in body position, regardless of head position, may help patients tolerate lying flat, while also minimizing the risk of bed sores, the Loyola neurologists write.

Bed position is among the complex issues that Flaster and his colleagues address in their article, which summarizes the latest research on caring for ischemic stroke patients. (Most strokes are ischemic, meaning they are caused by blood clots.)

“The period immediately following an acute ischemic stroke is a time of significant risk,” the Loyola neurologists write. “Meticulous attention to the care of the stroke patient during this time can prevent further neurologic injury and minimize common complications, optimizing the chance of functional recovery."

The authors discuss stroke-care issues that can affect outcomes. For example, there is considerable evidence of a link between hyperglycemia (high blood sugar) and poor outcomes after stroke. The authors recommend strict blood sugar control, using frequent finger-stick glucose checks and aggressive insulin treatment, regardless of whether the patient has a known history of diabetes.

In addition, for each 1-degree Celsius increase in the body temperature of a stroke patient, the risk of death or severe disability more than doubles. Therapeutic cooling has been shown to help cardiac arrest patients, and clinical trials are under way to determine whether such cooling could also help stroke patients. Until those trials are completed, the goal should be to keep normal temperatures (between 95.9 and 99.5 degrees Fahrenheit).

The authors discuss many other issues in stroke care, including blood pressure management; blood volume; statin therapy; management of complications such as pneumonia and sepsis; heart attack and other cardiac problems; blood clots; infection; malnutrition and aspiration; brain swelling; seizures; recurrent stroke; and brain hemorrhages.

Studies have shown that hospital units that specialize in stroke care decrease mortality, increase the likelihood of patients being discharged to their homes and improve functional status and quality of life.

Approximately 15 million people in the world have a stroke each year and nearly 6 million people die. Every six seconds someone dies from a stroke. The World Stroke Organization has designated Oct. 29 World Stroke Day to help spread public awareness of the world's high stroke risk and stroke prevalence.

Flaster is a stroke specialist and an associate professor in the Department of Neurology of Loyola University Chicago Stritch School of Medicine. Co-authors are Sarkis Morales-Vidal, MD; Michael Schneck, MD; and José Biller, MD. Dr. Morales-Vidal is an assistant professor, Dr. Schneck is a professor and Dr. Biller is professor and chair in the Department of Neurology.

About Loyola University Health System

Loyola University Health System (LUHS) is a member of Trinity Health. Based in the western suburbs of Chicago, LUHS is a quaternary care system with a 61-acre main medical center campus, the 36-acre Gottlieb Memorial Hospital campus and more than 30 primary and specialty care facilities in Cook, Will and DuPage counties. Loyola University Medical Center’s campus is conveniently located in Maywood, 13 miles west of Chicago’s Loop and 8 miles east of Oak Brook, Ill. At the heart of the medical center campus is a 559-licensed-bed hospital that houses a Level 1 Trauma Center, a Burn Center and the Ronald McDonald® Children's Hospital of Loyola University Medical Center. Also on campus are the Cardinal Bernardin Cancer Center, Loyola Outpatient Center, Center for Heart & Vascular Medicine and Loyola Oral Health Center as well as Loyola University Chicago Stritch School of Medicine, Loyola University Chicago Marcella Niehoff School of Nursing and the Loyola Center for Fitness. Loyola's Gottlieb campus in Melrose Park includes the 255-licensed-bed community hospital, the Professional Office Building housing 150 private practice clinics, the Adult Day Care, the Gottlieb Center for Fitness, Loyola Center for Metabolic Surgery and Bariatric Care and the Loyola Cancer Care & Research at the Marjorie G. Weinberg Cancer Center at Melrose Park.

Trinity Health is a national Catholic health system with an enduring legacy and a steadfast mission to be a transforming and healing presence within the communities we serve. Trinity is committed to being a people-centered health care system that enables better health, better care and lower costs. Trinity Health has 92 hospitals and hundreds of continuing care facilities, home care agencies and outpatient centers in 21 states and 119,000 employees.