Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
Date
2017
Type:
Artículo
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10
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Publisher
Massachusetts Medical Society
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Abstract
BACKGROUND: The role of supine positioning after acute stroke in improving cerebral blood flow
and the countervailing risk of aspiration pneumonia have led to variation in head positioning in
clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke
could be improved by positioning the patient to be lying flat (i.e., fully supine with the back
horizontal and the face upwards) during treatment to increase cerebral perfusion.
METHODS: In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we
assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in
either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees,
according to the randomization assignment of the hospital to which they were admitted; the
designated position was initiated soon after hospital admission and was maintained for 24 hours.
The primary outcome was degree of disability at 90 days, as assessed with the use of the modified
Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of
6 indicating death).
RESULTS: The median interval between the onset of stroke symptoms and the initiation of the
assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were
less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%,
P<0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day
disability outcomes on the global modified Rankin scale between patients in the lying-flat group and
patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores
on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10;
P=0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4%
among the patients in the sitting-up group (P=0.83). There were no significant between-group
differences in the rates of serious adverse events, including pneumonia.
CONCLUSIONS: Disability outcomes after acute stroke did not differ significantly between patients
assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the
head elevated to at least 30 degrees for 24 hours. (Funded by the National Health and Medical
Research Council of Australia; HeadPoST ClinicalTrials.gov number, NCT02162017.)
Description
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Citation
Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, Muñoz Venturelli P, Brunser A, Peng B, Cui L, Song L, Rogers K, Middleton S, Lim JY, Forshaw D, Lightbody CE, Woodward M, Pontes-Neto O, De Silva HA, Lin RT, Lee TH, Pandian JD, Mead GE, Robinson T, Watkins C; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017 Jun 22;376(25):2437-2447. doi: 10.1056/NEJMoa1615715
Keywords
head position, cluster-randomized, Acute stroke