BP Control During Transport Key to Improved Outcomes in Patients with ICH

The etiology of intracranial hemorrhage (ICH) is multifactorial and may include an aneurysm, head trauma or severe hypertension. According to Robbi Cwynar, MSN, ACNP, CCRN, “Intracranial hemorrhage is associated with high rates of mortality and morbidity.” Cwynar, who is a member of Cleveland Clinic’s Critical Care Transport (CCT) team, noticed that when the team arrived at a facility to transport a patient with ICH, the patient’s blood pressure was often not yet controlled.

Robbi Cwynar, MSN, ACNP, CCRN

Hematomas typically expand within six hours of initial hemorrhage, making it crucial that blood pressure management be achieved quickly. Although researchers reported that maintaining a systolic blood pressure of less than 160 mm Hg was associated with better patient outcomes, there is little in the literature comparing blood pressure levels during transit and final patient outcomes. Cwynar notes that Cleveland Clinic’s CCT team travels up to 250 nautical miles from Cleveland and that in the research study discussed below, the average transport time is about 50 minutes. This is an important period of time during which blood pressure management needs to be initiated.

The purpose of the study was to determine if management of systolic blood pressure by the CCT team during transport would impact outcomes, regardless of the initial systolic blood pressure. The study was conducted by Cwynar, Andrew P. Reimer, PhD, RN, of CCT; and Sandra L. Siedlecki, PhD, CNS, of Cleveland Clinic’s Office of Nursing Research and Innovation. Using a retrospective chart review, researchers assessed the records of 201 patients with the diagnosis of ICH who were transported by the CCT air team between January 2011 and January 2012.

According to Cwynar, findings from this study support those in earlier studies, suggesting that it is important to initiate interventions quickly that will keep the systolic blood pressure in the ideal range of 140 mm Hg to 160 mm Hg, as poor outcomes (mortality and morbidity) were associated with a systolic pressure greater than 160 mm Hg. They also found that a systolic blood pressure less than 100 mm Hg was associated with poor outcomes. Thus, it is not enough to worry about hypertension alone — it is also necessary to be aware of the dangers associated with hypotension in this population.

Cleveland Clinic’s CCT team is able to start medications or insert arterial lines to monitor blood pressure when in transit since the team includes a nurse practitioner, like Cwynar. “Not all transport teams have that capability,” she says. The ability to respond rapidly and efficiently while en route to a higher level of care results in better patient outcomes.

The study was presented as a poster at Cleveland Clinic’s 11th Annual Nursing Research Conference in April 2015. Cwynar hopes to submit the findings to a journal in the near future.