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Transdermal nicotine replacement is associated with lower mortality among active smokers admitted with spontaneous subarachnoid hemorrhage


Active smokers comprise 35–55% of patients admitted with acute spontaneous subarachnoid hemorrhage (SAH). Transdermal nicotine replacement is sometimes prescribed to these patients to prevent a withdrawal syndrome, but the safety of exogenous nicotine during the acute period after SAH is unknown.


We conducted a prospective, observational study from 2001 to 2007 in the neurological ICU of a major academic medical center. All active smokers admitted with SAH were included in the analysis, but we excluded patients who died within 7 days of admission to remove those whose death was due to discontinuation of life support. The primary endpoint was 3-month mortality. Secondary endpoints were delayed cerebral ischemia (DCI) and clinical vasospasm.


One hundred and ninety-two active smokers, including 104 (54%) who received transdermal nicotine, were well matched on demographics, gender, age, Hunt and Hess grade, SAH sum score, aneurism size, and smoking pack-year history, but a higher percentage of current heavy smokers (>10 cigarettes daily) received nicotine (67%, P < 0.001). There was no association of nicotine replacement and clinical vasospasm or DCI. After controlling for disease severity and cerebral edema on head CT (OR = 13.9, CI = 1.5–125.3), multivariable logistic regression revealed that heavy smokers were more likely than light smokers to die (OR = 6.0, CI = 1.11–32.7). Smokers who received nicotine had lower mortality (OR = 0.26, CI = 0.68–0.98), an effect that seemed on secondary analysis to be driven by high mortality among heavy smokers who did not receive nicotine.


Transdermal nicotine replacement is not associated with clinical vasospasm or DCI in smokers admitted with SAH, and is associated with lower mortality, particularly among smokers of more than 10 cigarettes daily. This may be due to prevention of the physiological derangements associated with nicotine withdrawal. Nicotine replacement after acute SAH is probably safe, and should be given to active heavy smokers at the time of admission. More research is needed to verify these findings and define the therapeutic role of nicotine in the ICU.


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Seder, D., Schmidt, M., Badjatia, N. et al. Transdermal nicotine replacement is associated with lower mortality among active smokers admitted with spontaneous subarachnoid hemorrhage. Crit Care 12 (Suppl 2), P111 (2008).

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