12 MARCH 2016 www.radiologynursing.

org 

Procedural Sedation/ Anesthesia 

Protocol Among Acute Ischemic 
Stroke Patients Undergoing 
Endovascular Revascularization 
Procedures: The Nursing Perspective 
on What Is Being Practiced 
Nationwide 
■ Margaret Korzewski, DNP, ANP-BC; Bonnie Raingruber, PhD, RN; and 
Karen Van Leuven, PhD, FNP-BC 
ABSTRACT: Background: The updated American Heart Association/American Stroke Association guidelines favor conscious 
sedation over general anesthesia but allow that choice of anesthesia modality during endovascular therapy for acute ischemic 
stroke (AIS) to be based on a specific clinical scenario taking patient risk factors into consideration. Little evidence is available 
on who is most suited to provide anesthesia management to AIS patients undergoing these emergent endovascular interventions. 
Given the limited data on sedation manage- ment and the nursing role during endovascular revascularization therapy, a 
nationwide survey was conducted. The purpose of this study was to gather data on current practice about anesthesia/sedation 
management and nursing involvement during endovascular revascularization procedures among AIS patients. Methods: A survey 
was presented in English and electronically distributed to all current and past Association for Radiologic and Imaging Nursing 
(ARIN) members via the ARIN List Serve with a 1-month timeline to respond to the survey questions. The survey consisted of 
17 multiple-choice questions with free-text response available when applicable. Some of the multiple-choice questions allowed 
choice of all applicable answers. Members were asked to participate if they worked in the interventional radiology/interventional 
neuroradi- ology department and were currently involved in the management of AIS patients during endovascular revas- 
cularization therapy. Recipients had the option of whether to complete the survey or to skip any question in the survey. To 
maintain confidentiality, response via SurveyMonkey was considered consent. Results: A total of 109 nurses responded to the 
survey questions. In most cases, the certified registered nurse anesthetist or the anesthesiologist was responsible for the 
anesthesia management of AIS patients undergo- ing endovascular revascularization procedures regardless of the anesthesia 
modality chosen (36.19%). If a registered nurse (RN) was responsible for sedation management, most of the time (33.33%) she 
or he felt comfortable in this role. Approximately 20% of responding RNs preferred to have the anesthesia team member in this 
role, 8.57% were somewhat uncomfortable in this role, and 1.90% reported being uncomfort- able. Approximately 47.66% of the 
survey respondents confirmed that the RN providing procedural sedation was qualified to administer vasoactive drips, whereas 
8.41% disagreed. 
 
Acute Ischemic Stroke JOURNAL OF RADIOLOGY NURSING 
Korzewski et al Conclusions: Randomized clinical trials are necessary to establish if there is truly a difference in clinical out- 
comes among AIS patients who are managed with general anesthesia versus conscious sedation during endo- vascular 
revascularization interventions, as well as comparing clinical outcomes of AIS patients from stroke centers where anesthesia is 
always provided by the anesthesia team versus stroke centers using a variety of providers. Large longitudinal studies are 
necessary as most facilities perform less than six procedures per month, and data will need to be correlated with National Institute 
of Health Stroke Scale scores and im- aging findings. (J Radiol Nurs 2016;35:12-18.) 
KEYWORDS: Acute ischemic stroke; Anesthesia; Sedation; Interventional radiology; Endovascular treatment; Endovascular 
revascularization; Mechanical thrombectomy; Nursing role. 
INTRODUCTION 
patients, who are beyond the 3- to 4.5-hr time 
window, In spite of medical advances, stroke remains a leading cause of death and disability worldwide with the 
high- est incidence of stroke being reported in low-income and middle-income countries (Truelsen et al., 2015). 
However, in 2008, stroke incidence dropped from the third to the fourth leading cause of mortality in the United 
States (Jauch et al., 2013). Currently available management options for acute ischemic stroke (AIS) include 
prevention and secondary risk management via blood pressure (BP) control, lipid management, an- 
tiplatelet/anticoagulation therapies, and smoking cessa- tion; tertiary disease management via intravenous (IV) 
administration of recombinant tissue-type plasminogen activator (r-tPA); and endovascular revascularization options 
(intra-arterial r-tPA administration and me- chanical thrombectomy). IV tPA treatment within 3 hr of AIS symptoms 
onset was approved by the Food and Drug Administration (FDA) in 1996 and re- mains the only FDA-approved 
treatment option for AIS patients. Its administration improves functional outcomes at 3 to 6 months, if delivered 
within 3 hr of AIS symptoms onset, and recently has been extended up to 4.5 hr (off-label use) in selected groups of 
AIS pa- tients (Powers et al., 2015). Intra-arterial fibrinolysis with r-tPA delivered within 6 hr of stroke onset is an 
off-label use and can be considered in carefully chosen 
and/or have contraindications to IV tPA (Powers et al., 2015). 
Recent  randomized  clinical  trials  have  demonstrated  the  benefit  of  endovascular  revascularization  therapy  with 
mechanical  thrombectomy  devices  with  retrievable  stents  as  the  most promising endovascular intervention for AIS, 
if  performed  within  the  first  6  hr  from  symp-  toms  onset  (Fargen  et  al.,  2015).  Moreover,  the  findings  of  these 
studies  led  to  an  update  of  the  2013  American  Heart  Association/American  Stroke  Association  (AHA/ASA) 
Guidelines  for  the  Early  Management  of  Patients  with  Acute  Ischemic  Stroke  (Powers  et  al.,  2015).  Available 
evidence  favors  conscious  sedation  over  general  anesthesia  during  endovascular  revascu-  larization  for  AIS; 
however,  the  evidence  is  weak  owing  to  limited  randomized  clinical  trials  supporting  this  practice  (Brinjikji  et  al., 
2015).  The  updated  AHA/  ASA  guidelines  (Powers  et  al.,  2015)  incorporate  the  available  evidence  and  favor 
conscious  sedation  over  general  anesthesia  but  allow the choice of anesthesia modality during endovascular therapy 
for  AIS.  This  choice  should  be  based  on  the  specific  clinical  scenario  taking  patient  risk  factors  into consideration 
(class  IIb;  level  of  evidence:  C).  Little  evidence  is  available  on  who  is  most  suited  to  provide  anesthesia 
management to AIS patients undergoing these emergent endovascular interventions. 
Recently published recommendations by the Society for Neuroscience in Anesthesiology and Critical Care Margaret 
Korzewski, DNP, ANP-BC, is from the University of 
(SNACC) on anesthetic management of AIS patients 
California Davis Medical Center, Sacramento, CA; Bonnie Raingruber, PhD, RN, is from the University of California Davis, 
Davis, CA; Karen Van Leuven, PhD, FNP-BC, is from the University of San Francisco, San Francisco, CA. 
undergoing these procedures are mostly based on expert opinion (Talke et al., 2014). SNACC recom- mends that the 
anesthesiologist/anesthesia team be pre- No grant or financial assistance received. 
sent to provide sedation and strict hemodynamic The 
manuscript has never been presented or submitted for publishing. 
monitoring of these patients given the emergent nature 
Corresponding author: Margaret Korzewski, University of California 
and complexity of patients with AIS, as well as the in- 
Davis Medical Center, 3435 Klevner Way, Rancho Cordova, CA 95670. E-mail: mkorzewski@ucdavis.edu; margaretkorzewski@ 
gmail.com 1546-0843/$36.00 Published by Elsevier Inc. on behalf of the Association for Radiologic & Imaging Nursing. 
tricacy of the procedure. At the same time, these rec- ommendations also state that other qualified nonanesthesia 
personnel, including registered nurses (RNs), may provide sedation under direct supervision of the responsible 
physician. SNACC rec- http://dx.doi.org/10.1016/j.jradnu.2016.01.002 
ommendations do not specify the training, skill set, 
VOLUME 35 ISSUE 1 www.radiologynursing.org 
13 
 
 Korzewski et al JOURNAL OF RADIOLOGY NURSING Acute Ischemic Stroke and knowledge required for RNs 
involved in the moni- was geared for a subset of these members who specif- toring and sedation management of this 
group of pa- 
ically work in a facility that offers endovascular 
revas- tients. Moreover, these recommendations do not 
cularization procedures for AIS patients. ARIN 
does specify who should act as the responsible physician 
not maintain data on the percent of members who 
fit who would provide direction for the nurse. 
these criteria; therefore, it would be difficult to 
estimate Given the limited data on sedation management and 
the survey response rate. A total of 109 nurses re- 
nursing roles during endovascular revascularization 
sponded to the survey questions. therapy, a 
nationwide survey was conducted. The pur- 
Currently, there are approximately 100 advanced 
pose of this study was to gather data on current prac- 
comprehensive stroke centers (CSCs) in the United 
tice about anesthesia/sedation management and 
States (Joint Commission, 2015). To be classified 
as a nursing involvement during endovascular revasculari- 
CSC, advanced imaging services including catheter 
zation procedures among AIS patients. 
angiography must be available 24 hours per day and 7 days per week (Alberts et al., 2005). In addition, there 
METHODS After obtaining permission from the Association for Radiologic and Imaging Nursing (ARIN) Board of 
Di- rectors, and following the Institutional Review Board approval from the University of California, Davis Office 
of Research, a survey was presented in English and elec- tronically distributed to all current and past ARIN mem- 
bers via the ARIN List Serve with a 1-month timeline to respond to the survey questions. Each survey had a cover 
sheet (see Appendix 1 for SurveyMonkey Introduction) that explained the study purpose and its voluntary na- ture; 
recipients had the option of whether to complete the survey or to skip any question in the survey. To main- tain 
confidentiality, response via SurveyMonkey was considered consent. No names or identifying data were 
14 www.radiologynursing.org 
MARCH  2016  are  approximately  1,100  primary  stroke  centers  (PSCs)  in  the  United  States  (Joint  Commission, 
2015).  A  PSC  must  be  able  to  provide  a  head  computed  tomography  within  25  min  of  the  order  being  placed, and 
the  study  has  to  be  read by a physician experienced in CT inter- pretation within 20 min of its completion. Similarly 
to  CSCs, PSCs should be able to provide these imaging services 24 hr per day and 7 days per week. Moreover, PSCs 
can  provide  IV  thrombolytic  therapy,  when  needed,  must  have  a  designated  stroke  unit  for  contin-  uous  patient 
monitoring, and demonstrate application of and compliance with evidence-based clinical practice guidelines (Alberts 
et  al.,  2011).  Some  of the PSCs offer more advanced imaging options, including endovascu- lar treatment options as 
well. 
associated  with  the  responses;  only  aggregate  results  were  reported.  Survey  responses  were  stored  in  a 
password-protected computer. Data will be retained 
Demographics 
RESULTS 
for 3 years after publication as is required by the Amer- 
Of the respondents who supplied demographic data 
ican Psychological Association and then will be de- 
(N [ 106), 62.26% (N [ 66) had a bachelor of 
science stroyed by deleting computer files. 
in nursing (BSN) as their highest level of education, 
The survey consisted of 17 multiple-choice questions 
17.92% (N [ 19) were associate’s degree in nursing 
(Appendix 2) with free-text response available when 
(ADN) prepared, whereas 10.38% (N [ 11) held a 
applicable. Some of the multiple-choice questions al- 
master’s of science in nursing (MSN), 0.94% (N [ 
1) lowed choice of all applicable answers. Members were 
had earned a doctorate, and 8.49% (N [ 9) identified 
asked to participate if they worked in the interventional 
as having another educational background. Most of 
the radiology (IR)/interventional neuroradiology depart- 
study participants were experienced nurses (total of 
105 ment and were currently involved in the management 
responses); 60.95% had more than 21 years of 
experi- of AIS patients during endovascular revascularization 
ence as a nurse, followed by 11 to 20 years of 
experi- therapy. The survey gathered data on respondents 
ence (27.62%), 6 to 10 years of experience (9.52%), 
(questions 12-17), endovascular procedures performed 
and the smallest percentage of nurses had only 0 to 
(questions 3 and 6-8), and anesthesia practices during 
5 years of nursing experience (1.90%). However, 
endovascular procedures (questions 1, 2, 4, 5, and 
when considering nursing involvement in 
endovascular 9-11). Respondents were not compensated for partici- 
procedures (total of 109 responses), most of the 
respon- pation in this survey. Study responses were evaluated 
dents had 5 or less years of experience (38.53%), 
after the close of the 1 month posting. 
whereas 28.44% had 6 to 10 years of experience and 
The survey was placed on the ARIN List Serve on 
 27.52% reported 11 to 20 years of experience. 
Those June 2, 2015. Approximately 1,700 nurses were mem- 
with more than 21 years of experience constituted 
bers of ARIN at the time the survey was listed. 
5.5% of the respondents. Most study participants 
(87 ARIN is a professional organization for nurses who 
of 108 responses) were older than 40 years (41-50 
years work in the field of radiology and imaging. The survey 
old [23.15%], 51-60 years old [50.93%], and older than 
 
Acute Ischemic Stroke JOURNAL OF RADIOLOGY NURSING Korzewski et al 60 years [6.48%]), and only 21 of 
108 participants were vey question allowed respondents to select all responses younger than 40 years (20-30 years 
old [4.63%], 31- 
that applied. As a result, it appears that facilities 
often 40 years old [14.81%]). Most study subjects were fe- 
have multiple providers who might be called on to 
pro- males (85.98%), and 14.02% were males (total of 107 
vide care during a procedure. Most respondents 
(80%) responses). Of the 101 respondents who supplied 
reported that the anesthesia team (certified 
registered ethnicity/cultural background, the majority were 
nurse anesthetist [CRNA] or anesthesiologist) is 
Caucasian (88.12%). The remainder were Asian 
responsible for managing sedation among AIS 
patients (6.93%), African American (2.97%), Hispanic, and 
undergoing endovascular revascularization therapy. 
As Native American (both groups, 1.98%). 
respondents also noted, sedation might be provided by the IR nurse in 56.19% of the hospitals. Neurocritical 
Procedural Statistics 
care RNs sometimes are involved in the sedation 
man- A total of 105 respondents provided data on the num- ber of endovascular revascularization procedures per- 
formed at their facilities. Respondents indicated that most stroke centers in the United States perform one to six 
endovascular revascularization procedures per month (one to three cases/month [31.43%] and four to six 
cases/month [32.38%]). Higher volume centers were less prevalent: 7 to 10 cases/month (23.81%), 11 to 15 
cases/month (6.67%), or more than 15 cases/ month (5.71%). Most frequently, a proceduralist trained in 
interventional neuroradiology (90.65%) per- forms the endovascular revascularization. Neurosur- geons trained in 
endovascular procedures were less likely to perform revascularizations (18.69% vs. 90.65%). A minority of 
procedures (5.61%) are per- formed by a neurologist or neurointensivist trained in endovascular procedures. 
Interventional cardiologists 
VOLUME 35 ISSUE 1 www.radiologynursing.org 
15  agement  of  AIS  patients  during endovascular proce- dures (5.71%), and cardiac catheterization laboratory nurses 
(3.81%),  in  addition  to  the  emergency  depart-  ment  (ED)  nurses  (3.81%).  Rarely,  the  procedural  sedation  in  these 
cases is managed by the neurointen- sivist (1.90%). 
According to 42.45% of the survey respondents, an arterial line is used for continuous BP monitoring dur- ing 
procedures with anesthesia team involvement (gen- eral anesthesia and monitored anesthesia care cases). Rarely 
(1.89%), a femoral arterial line placed by the neurointerventionalist is used for the continuous BP monitoring during 
the endovascular intervention for AIS. Most (72.38%) of the study participants believe that it is not routine practice 
to have blood glucose (BG) monitored during endovascular revascularization procedures. (2.80%) were noted to 
perform the least number of procedures. 
RN Role in Sedation 
Anesthesia Practices 
In most cases, the CRNA or anesthesiologist was responsible for the anesthesia management of AIS pa- A total of 
 31.48% of respondents reported that anes- 
tients undergoing endovascular revascularization 
pro- thesia technique choice is dependent on the clinical sce- 
cedures regardless of the anesthesia modality 
chosen nario. Clinical scenario factors include patient 
(36.19%). If an RN was responsible for sedation 
man- characteristics, such as neurological status, comorbid- 
agement, most of the time (33.33%) she or he felt 
ities, imaging findings, and time since onset of symp- 
comfortable in this role. Approximately 20% of re- 
toms, and facility factors such as anesthesia team 
sponding RNs preferred to have the anesthesia team 
availability. Approximately 56.48% of hospitals use 
member in this role, 8.57% were somewhat 
uncomfort- general anesthesia for AIS patients undergoing endo- 
able in this role, and 1.90% reported being vascular 
revascularization therapy (intra-arterial r- 
uncomfortable. tPA, mechanical thrombectomy, or 
combination of 
When an RN was charged with providing 
sedation, both), whereas 37.04% of respondents reported using 
she or he was responsible for the management of 
the conscious sedation as the anesthesia management mo- 
patient’s hemodynamics while following verbal 
orders dality at their facility. The survey question allowed re- 
of the neurointerventionalist performing the 
procedure spondents to select all responses that applied. As a 
in 55.24% of responses. In 36.19% of cases, this 
ques- result, there is overlap in response of choice and indica- 
tion was not applicable because the anesthesia team 
tion of specific anesthesia modalities. Endotracheal 
member was responsible for care. In 12.38% of 
cases, intubation for airway protection with pharmacological 
the anesthesiologist was always immediately 
available paralysis and sedation was reported as usual practice at 
to manage hemodynamics. The neurointensivist 
was 21.30% of facilities, whereas 9.26% of stroke centers 
available immediately in 5.71% of cases, and the 
use local anesthesia alone during endovascular therapy. 
neurologist was present during the procedure for the 
Sedation and monitoring of patients during revascu- 
management of the patient’s hemodynamics in 
4.76% larization procedures followed a similar path. The sur- 
of cases. 
 
Korzewski et al JOURNAL OF RADIOLOGY NURSING 
Acute Ischemic Stroke Approximately 47.66% of the survey respondents cular procedures for AIS. At some 
facilities, interven- (total number of responses to this question was 107) 
tional neuroradiology nurses do not have critical 
care confirmed that the RN providing procedural sedation 
competencies and have no intensive care 
background. was qualified to administer vasoactive drips, whereas 
Some respondents believe that standardization of 
a 8.41% disagreed. According to 37.38% of responses, 
nursing role via orientation and mentorship through 
this statement was not applicable given sole anesthesia 
a minimum number of AIS endovascular 
procedures team responsibility for the management of sedation and 
before independent functioning and maintenance of 
hemodynamics among AIS patients undergoing endo- 
neuroendovascular and neurocritical competencies 
vascular revascularization procedures at their facilities. 
would help to improve the AIS patients’ safety during 
Out of 109 survey respondents, 75 shared information 
these procedures. about training for their role in 
providing sedation for en- dovascular procedures. Thirty-six of 75 were required to undergo moderate sedation 
training. Twenty-one of the 
DISCUSSION study 
participants reported having critical care experi- 
Although the use of endovascular revascularization 
ence before providing sedation to AIS patients during 
therapy continues to expand, there is a paucity of 
endovascular revascularization procedures. In addition, 
data regarding current practice patterns and nursing 
of 75 who answered this question, 11 were required to 
involvement in caring for patients undergoing these 
obtain Advanced Cardiac Life Support (ACLS) certifi- 
procedures. This survey aims to shed light on 
current cation, and one was Pediatric Advanced Life Support 
practice in stroke centers nationwide, especially the 
(PALS) certified. Thirteen of the survey respondents 
nurse’s role during these interventions. received 
some type of neurological nursing education 
The recent update to AHA/ASA guidelines favor 
including completion of the National Institute of Health 
 conscious sedation over general anesthesia during 
endo- Stroke Scale (NIHSS) certification class (four of the 
vascular therapy for AIS (Powers et al., 2015). At 
the study participants). Only one participant mentioned a 
same time, the recommendations call for tailoring 
anes- requirement of 8-hr stroke-specific training before being 
thesia management to the clinical scenario taking 
into a procedural nurse for patients with AIS. Four of the 
account the patient’s risk factors and ability to 
tolerate respondents reported obtaining no additional stroke- 
the procedure. In some patients like those with 
airway specific training before providing sedation to AIS 
compromise, agitation, high NIHSS score, general 
anes- patients during endovascular therapy. 
thesia might be the only choice. This survey illustrates 
Out of 109 survey participants, 50 provided sugges- 
that anesthesia choice based on patient screening 
tions for improving safety. A total of 25 (50%) advocate 
occurred in 31.48% of reported revascularizations. 
Gen- for anesthesia team involvement in managing AIS 
eral anesthesia was the predominant anesthetic 
tech- patients during endovascular therapy, regardless of the 
nique used (56.48%). Conscious sedation, the type 
of anesthesia modality being used. Concerns 
recommended anesthesia choice, was used in only 
revolved around airway and BP management, especially 
37.04% of reported revascularizations. Without 
correla- for cases performed during the off shift. Also, the inter- 
tion with NIHSS score, it is unclear if the 
preponderance ventional neuroradiology nurses often had to perform 
of general anesthesia is warranted or a matter of 
routine. multiple tasks during the procedure, including sedation 
Based on the SNACC Expert Consensus 
Statement, management, hemodynamics management (e.g., vasoac- 
“an anesthesiologist must be involved for all proce- 
tive drips titration), circulating nurse duties (e.g., obtain- 
dures with general anesthesia;” however, “other 
quali- ing needed supplies and medications), and in some cases, 
fied personnel with expertise in management of 
research data collection. Respondents called for improved 
 critically ill neurology patients, including RNs may 
communication between the anesthesia team and the 
provide sedation” (Talke et al., 2014, p. e147). At 
the neurointerventionalist and clarification of the roles of 
same time, these experts advise following the 
American each stroke team member to improve patient safety and 
Society of Anesthesiologists recommendations as 
far as ensure timely and smooth flow during the procedure. 
choice of the anesthesia type and the respective choice 
Of 50 respondents who provided improvement sug- 
of the provider managing it. Respondents noted that 
gestions, six (12%) recommended a second nurse in 
the anesthesia team is involved in up to 80% of all 
en- the room (one for sedation management, and another 
dovascular revascularization procedures performed 
assigned to circulating nurse’s duties and hemodynamic 
with sedation. management), believing this practice 
would improve 
Nurses who are involved in managing conscious 
the AIS patients’ safety during endovascular revascu- 
sedation during endovascular interventions for AIS 
pa- larization procedures. Neurocritical care expertise was 
tients are provided with training in moderate 
sedation; also felt to be essential for nurses involved in endovas- 
however, the majority felt that they received inadequate 
16 www.radiologynursing.org 
MARCH 2016 
 
 Acute Ischemic Stroke JOURNAL OF RADIOLOGY NURSING Korzewski et al preparation for managing 
neurocritically ill patients dents) do not follow the SNACC expert consensus with AIS during these cases. 
Moreover, not all stroke 
recommendation as far as routine BG monitoring. 
centers have two nurses assigned to these procedures 
The management of AIS patients during 
endovascu- as was recommended by survey participants. 
lar therapy becomes even more complex when 
acute Frequently, the nurses have multiple responsibilities, 
complications arise. Nurses have to be prepared for 
including management of sedation, patient hemody- 
this possibility to support the neurointerventionalist 
namics (frequent BP and heart rate checks, electrocar- 
who should be focused on controlling the 
demanding diographic monitoring, and vasoactive drip titration), 
situation with limited distractions (McDonagh et 
al., and the responsibilities of the circulating nurse (deliv- 
2010). In case of intracranial hemorrhage, 
protamine ering supplies needed during the procedure, patient 
should be readily available to reverse the heparin 
effect, positioning, restraining, and sometimes even research 
and the parameters of the BP adjusted accordingly. 
The data collection). This is contrary to the recommenda- 
nurse should be able to recognize the symptoms of 
tions of the Association of periOperative Registered 
intracranial hypertension (Cushing’s triad 
[increased Nurses (AORN), which dictates that a nurse who is 
systolic and pulse pressure, bradycardia, and 
irregular responsible for providing and managing sedation 
respiration]). Airway compromise is also a potential 
should solely focus on this task and not be involved 
complication. Aspiration coupled with a lack of 
knowl- in any other activities (Spruce, 2015). 
edge of the patient’s fasting status, and/or patient Per 
AHA/ASA recommendations (Jauch et al., 
agitation, may make it necessary to convert 
sedation 2013), optimal BP during and after reperfusion therapy 
to general anesthesia, which carries risks of injury 
should be 180/105 mm Hg or lower. However, per 
and delays reperfusion therapy. Therefore, having 
im- SNACC expert consensus, the BP should be maintained 
mediate access to a provider experienced in 
emergency above 140 mm Hg, and sudden drops in BP should be 
airway management is crucial (Talke et al., 2014). 
Fear avoided to prevent hypoperfusion injury. After success- 
of potential procedure-related complications could 
be ful recanalization of an occluded blood vessel, the BP 
the reason why approximately 56.48% of stroke 
centers range might be lowered to prevent reperfusion injury; 
use general anesthesia during endovascular 
revascular- however, there are no specific guidelines available. 
ization procedures among AIS patients, and 
approxi- Additionally, SNACC recommendations during endo- 
mately 36.19% of these cases are managed by the 
vascular procedures include continuous BP monitoring 
CRNA or an anesthesiologist regardless of the anes- 
via arterial line, or in the absence of an arterial line, the 
thesia modality chosen. Potential procedural 
complica- BP should be checked manually every 3 min (Talke 
tions could also justify assigning two RNs to these 
et al., 2014). Although the use of an arterial line is 
procedures with at least one of them with a strong 
neu- strongly recommended for continuous BP monitoring 
rocritical background in case of neuroanesthesia ex- 
during these procedures, its insertion should not delay 
pert’s shortage. the reperfusion therapy (Talke et 
al., 2014). In spite of 
This survey was undertaken to establish a 
baseline on these recommendations, only 26.42% of respondents 
common practice during endovascular 
revascularization confirmed using arterial lines for patients with AIS 
procedures for AIS. Limitations of this survey 
include during endovascular procedures. Given the need for 
small sample size and potential selection bias 
and/or almost continuous BP management, an arterial line or 
accuracy of the responses provided by the nurses 
partici- a nurse responsible for ongoing assessment of hemody- 
pating in this study. There is some discrepancy in 
the namics is essential. Yet, data from this survey demon- 
results pertaining to the percentage of the 
institutions us- strate that RNs were often called to perform multiple 
ing the anesthesia team for all AIS endovascular 
therapy tasks, which has the potential to jeopardize patient 
procedures regardless of the anesthesia type chosen 
(sur- safety during these revascularization procedures. 
vey question 4 and 5 [36.19%] vs. survey question 9 
Tarlov, Nien, Zaidat, and Nguyen (2012) noted that 
[37.38%]); however, most likely, it is related to the 
study hyperglycemia might lead to a larger infarct size and 
design, which allowed participants to skip a 
response to subsequently result in a poor clinical outcome after en- 
some questions. Another limitation of this survey 
was its dovascular revascularization therapy. As a result, BG 
distribution among ARIN members only, as this did 
not levels should be monitored during the acute phase of 
include all providers who are potentially involved 
in ischemic stroke. Adding routine hourly BG checks 
managing the anesthesia among AIS patient during 
en- combined with the management of hyperglycemia 
dovascular revascularization. Thus, the voice of 
nurses (BG O 140 mg/dL) as recommended by SNACC 
who work in IR but are not members of the ARIN 
orga- experts (Talke et al., 2014) adds another responsibility 
nization and nurses who work elsewhere 
(neurocritical to the already busy list of nursing tasks. This survey re- 
care nurses, ED nurses, cardiac catheterization 
labora- veals that most of the stroke centers (72.38% of respon- 
tory nurses, and float pool critical care nurses) but may 
VOLUME 35 ISSUE 1 www.radiologynursing.org 
17 
 
 Korzewski et al JOURNAL OF RADIOLOGY NURSING Acute Ischemic Stroke 18 www.radiologynursing.org 
MARCH 2016 be involved with these procedures is not presented. In SUPPLEMENTARY DATA addition, the 
survey was voluntary, and the responses of ARIN members who completed the survey may have differed from those 
who selected not to participate. 
Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jradnu.2016.01.002. 
References CONCLUSION Randomized clinical 
trials are necessary to establish, if 
Alberts, M.J., Latchaw, R.E., Jagoda, A., Wechsler, L.R., Crocco, T., George, M.G., et al. (2011). Revised and updated 
recommendations for the establishment of primary there is truly a difference in clinical outcomes among 
stroke centers. A summary statement from the 
brain attack AIS patients who are managed with general anesthesia versus conscious sedation during endovascular 
revascu- larization interventions, as well as comparing clinical outcomes of AIS patients from stroke centers where 
coalition. Stroke, 42, 261-265. Albers, M.J., Latchaw, R.E., Selman, W.R., Shephard, T., Hadley, M.N., Brass, L.M., et al. 
(2005). Recommendations for comprehensive stroke centers: A consensus statement from the brain attack coalition. Stroke, 36, 
1597-1616. anesthesia is always provided by the anesthesia team 
Brinjikji, W., Murad, M.H., Rabinstein, A.A., Cloft, 
H.J., Lan- versus stroke centers using a variety of providers (anes- thesiologist, IR nurse, neurocritical care nurse, 
neuro- intensivist, etc.). Large longitudinal studies are necessary as most facilities perform less than six proce- 
zino, G., & Kallmes, D.F. (2015). Conscious sedation versus general anesthesia during endovascular acute ischemic stroke 
treatment: A systematic review and meta-analysis. American Journal of Neuroradiology, 36, 525-529. Fargen, K.M., Neal, D., 
Fiorella, D.J., Turk, A.S., Froehler, M., dures per month, and data will need to be correlated 
& Mocco, J. (2015). A meta-analysis of prospective 
random- with NIHSS scores and imaging findings. 
Current  guidelines  state  that  “other  qualified  personnel  with  expertise  in  management  of  critically  ill  neurology 
patients, including RNs may provide 
ized controlled trials evaluating endovascular therapies for acute ischemic stroke. Journal of Neurointerventional Surgery, 7, 
84-89. Jauch, E.C., Saver, J.L., Adams, H.P., Bruno, A., Connors, J.J., Demaerschalk, B.M., et al.; on behalf of the American 
Heart sedation” (Talke et al., 2014, p. e147). However, most 
Association Stroke Council, Council on 
Cardiovascular nurses involved in providing conscious sedation to pa- tients with AIS during endovascular 
revascularization procedures lack neurocritical experience and specific stroke-related training. Furthermore, in some 
stroke 
Nursing, Council on Peripheral Vascular Disease, and Coun- cil on Clinical Cardiology (2013). Guidelines for the early 
management of patients with acute ischemic stroke: Execu- tive summary. Stroke, 44, 870-947. McDonagh, D.L., Olson, D.M., 
Kalia, J.S., Gupta, R., Abou-Chebl, centers, only one staff nurse is assigned to manage all 
A., & Zaidat, O.O. (2010). Anesthesia and 
sedation practices aspects of care during endovascular therapy. It is rec- ommended that all nurses involved in the 
care of pa- tients with AIS during endovascular revascularization procedures receive education focused on the 
procedure, 
among neurointerventionalists during acute ischemic stroke en- dovascular therapy. Frontiers in Neurology, 1, 1-6. Mocco, J., 
Fargen, K.M., Goyal, M., Levy, E.I., Mitchell, P.J., Campbell, B.C.V., et al. (2015). Neurothrombectomy trial re- sults: Stroke 
systems, not just devices, make the difference. conscious sedation, current SNACC, and AHA/ASA 
International Journal of Stroke, 10, 990-993. 
recommendations, which are specifically related to the management of the patients with AIS. However, a neu- 
rocritical background should be a prerequisite to this new nursing role. Additionally, frequent active partici- 
Powers, W.J., Derdeyn, C., Biller, J., Coffey, C.S., Hoh, B.L., Jauch, E.C., et al.; on behalf of the American Heart Associ- ation 
Stroke Council (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute 
ischemic stroke regarding endovascular treatment. pation in these procedures, redundancy in problem 
Stroke, 46, 3020-3035. solving training, 
especially at low-volume stroke cen- ters, is important (Mocco et al., 2015). 
Hospital policies and procedures must be developed and standardized detailing the role of each partici- 
Spruce, L. (2015). Back to basics: Procedural sedation. Associa- tion of periOperative Registered Nurses Journal, 101(3), 
346-350. Talke, P.O., Sharma, D., Heyer, E.J., Bergese, S.D., Blackham, K.A., & Stevens, R.D. (2014). Republished: Society for 
pating practitioner. Should further randomized clinical 
Neuroscience in Anesthesiology and Critical 
Care expert trials reveal no difference between outcomes when pa- tients are managed by the anesthesiologist versus 
non- anesthesiologist, there will be a need for a new nursing specialty, the interventional neuroradiology nurse. This 
consensus statement: Anesthetic management of endovascu- lar treatment for acute ischemic stroke. Stroke, 45, e138-e150. 
Tarlov, N., Nien, Y.L., Zaidat, O.O., & Nguyen, T.N. (2012). Periprocedural management of acute ischemic stroke inter- vention. 
Neurology, 79(13 Suppl. 1), S182-S191. nurse, however, should be trained in endovascular ther- 
The Joint Commission Quality Check. (2015). 
Retrieved apy and sedation, in addition to having strong prior neurocritical care experience maintained with ongoing 
competency training, as well as NIHSS and ACLS cer- tifications. Only then, we can provide the AIS patients 
from http://qualitycheck.org/StrokeCertificationList.aspx. Accessed October 31, 2015 Truelsen, T., Krarup, L.H., Iversen, H.K., 
Mensah, G.A., Feigin, V.L., Sposato, L.A., et al. (2015). Causes of death data in the Global Burden of Disease estimates for 
ischemic and hemor- with the care they deserve. 
rhagic stroke. Neuroepidemiology, 45, 152-160.