Medical Complications After ICH: Changes in the Last Decade
Current guidelines recommending deferral of subcutaneous anticoagulation for the initial few days following ICH may require reappraisal.
Researchers have found that 10-year trends in complications after intracerebral hemorrhage (ICH) show that acute renal failure (ARF) and deep venous thrombosis (DVT) have increased, while the risk of sepsis and pneumonia have decreased. The data was presented at the 2017 International Stroke Conference, February 22-24, 2017 in Houston, Texas.
Noting that data on medical complications after ICH are sparse, Fadar Oliver Otite, MD, SM, from the department of neurology at the University of Miami Miller School of Medicine, and colleagues identified 575,211 cases of adult ICH from the 2004 to 2013 Nationwide Inpatient Sample to examine the risk of complications and to assess their association with in-hospital mortality, cost, and length of stay.
The researchers found that the overall risk of the complications they examined were as follows:
- Urinary tract infection (UTI): 14.8%
- Pneumonia: 7.8%
- Sepsis: 4.1%
- DVT: 2.7%
- Pulmonary embolism: 0.7%
- ARF: 8.2%
- Acute myocardial mechanical ventilation status: 2.0%
However, risk differed by gender and by mechanical ventilation status.
All of the complications were associated with a >2.5-day increase in length of stay and a >$8000 increase in cost.
The researchers also found that from 2004 to 2013, the risk of DVT and ARF increased but the risk of pneumonia, sepsis, and mortality decreased.
ARF and acute myocardial infarction were associated with increased mortality in all patients, sepsis and pneumonia were associated with increased mortality only in nonmechanically ventilated patients, and UTIs and DVT were associated with reduced mortality in all patients. However, these differences in mortality may be partially due to survival bias.
“As more patients survive their ICH hospitalization, emphasis is slowly shifting from survival to improving ICH-related morbidity and optimization of functional recovery,” the researchers wrote. “Quantification of disparities and trends in complication burden is a crucial step in ameliorating ICH outcome because it highlights aspects of ICH care where marginal progress has been made and accentuates other areas where additional efforts are needed.”
The Exponential Increase in ARF
One major finding of this study is the exponential increase in ARF; the risk of ARF remained significantly high even after adjusting for hypertension, diabetes mellitus, and chronic kidney disease. It is possible that this increase may be caused by more aggressive lowering of blood pressure in the acute period of ICH to prevent hematoma expansion2,3 or by nephropathy from increased use of contrast imaging. However, no conclusions can be drawn from this study, and further prospective studies are needed to assess possible causes.
Increase in DVT Risk
Even though rates of DVT were consistent with the rates found in previous studies, the rising risk of DVT suggests that current measures for preventing DVT in patients with ICH are not adequate. “Innovative DVT preventive measures are needed, particularly in ventilated patients who accounted for all of the observed increase in risks,” the investigators wrote. “Current guidelines recommending deferral of subcutaneous anticoagulation for the initial few days may require reappraisal.”
Inverse Association Between DVT and UTIs with Mortality
The researchers offered several suggestions for the inverse association between DVT and UTIs with mortality:
- This may reflect early detection of nonfatal cases of these conditions
- The negative association with mortality in mechanically ventilated patients may be because these patients are generally closely monitored in an intensive care unit; therefore, sepsis and pneumonia may often be diagnosed early and treated aggressively
- Survival bias is a possibility; mechanically ventilated patients are more likely to have severe ICH and to die from it before they develop other complications
- The researchers cannot exclude potential coding errors.
- The true prevalence of comorbidities may be higher because a significant number of medical complications occur subacutely after ICH admission and contribute to morbidity and mortality. Outcome measures at 30 and 90 days may be more accurate indicators of complications.
- The finding that complications were all associated with higher costs and longer hospital stays should be interpreted with caution because the researchers were unable to show a temporal correlation between these outcomes.
- Reverse causation may also be a factor in the association between complications and longer hospital stays; for example, patients surviving and staying in the hospital for other reasons may be predisposed to DVT, rather than DVT causing a longer hospital stay.
- The impact of withdrawal of care on medical complications could not be evaluated because this information is not available in the Nationwide Inpatient Sample.
- Otite FO, Khandelwal P, Malik AM, Chaturvedi S, Sacco RL, Romano JG. Ten-year temporal trends in medical complications after acute intracerebral hemorrhage in the United States. Stroke. 2017;48:596-603. doi:10.1161/strokeaha.116.015746
- Hemphill JC 3rd, Greenberg SM, Anderson CS, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032-2060. doi:10.1161/STR.0000000000000069
- Anderson CS, Huang Y, Wang JG, et al; INTERACT Investigators. Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391-399. doi:10.1016/S1474-4422(08)70069-3