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Caring for patients in the neurological intensive care unit involves managing and preventing complications, monitoring disease status and other body functions, administering treatments, and providing other life-sustaining interventions all at the same time.
Dr. Stephan Mayer, director of neurocritical care and emergency neurological services at Westchester Medical Center, says that challenges usually increase when patients are in the Neuro ICU for a longer period, whether it’s eight days or 20.
“Our top challenges in the Neuro ICU can be split into two categories: critical care issues and neurological issues,” agrees Dr. Jefferson W. Chen, director of neurotrauma in neurological surgery at the University of California, Irvine. “Patients who are in the Neuro ICU for a longer time have a higher risk of experiencing additional problems related to their disease process.”
As an example, Dr. Chen describes a patient who was in the Neuro ICU for longer than five days and had a stroke during his stay due to disease progression. The patient then developed additional complications due to the stroke, including the inability to move one side of his body, speech and language problems, high blood pressure and secondary brain injury.
Critical Care Challenges and Extended Stays in Neuro Intensive Care Units
Patients may have major pulmonary issues in the Neuro ICU that present a challenge because respiratory failure is common, so they may require intubation and mechanical ventilation to protect the airway and support normal gas exchange. For example, although about 1 in 15 patients in the neurological intensive care unit with stroke require mechanical ventilation, the 30-day mortality rate of ventilated patients ranges from 46% to 75%.
Nutrition and Hydration
Nutrition and hydration concerns are common in the neurological intensive care unit, especially for longer stays. “Feeding problems are some of the common issues that we have to deal with in the Neuro ICU. For instance, a patient with TBI needs nutritional support with more energy and protein to sustain them because of an increased metabolic rate,” says Dr. Chen.
Parenteral and enteral nutrition management is necessary to prevent malnutrition, and adequate nutrition may also prevent an increase in the amount of fluid entering the brain and elevated intracranial pressure.
Infections affect 36% of patients in the Neuro ICU who stay for longer than 48 hours. Infection rates for pneumonia range from 5% to 47%, for urinary tract infections from 7% to 27%, and for meningitis and ventriculitis from 1% to 20%. Infections develop in both post-operative and non-post-operative patients. There is a higher risk of infection because of invasive monitoring devices, traumas and critical illnesses.
A 2001 study by Attia et al. found a 30% incidence rate of deep vein thrombosis (DVT) during the first week in the ICU, and a 60% incidence rate among patients within the first two weeks. Neurosurgical patients who did not get prophylaxis had DVT rates ranging from 22% to 35%.
DVT can cause a pulmonary embolism, and patients in the Neuro ICU are at a higher risk of DVT because of immobility, dehydration, and injuries. Prevention and treatment of DVT can be challenging due to the possibility of anticoagulation medications causing intracranial bleeding.
An estimated 80% of patients in the ICU will develop some type of neuromuscular dysfunction during their stay, and the risk of ICU-induced weakness increases with prolonged stays. ICU-induced weakness may cause muscle weakness, muscle atrophy, neuropathy and myopathy.
Mobilization is another challenge that requires a delicate balance in the neurological intensive care unit. Immobility creates complications like muscle weakness. However, mobilization requires stopping sedation, which carries its own risks.
“Mobilization goes a long way toward promoting wellness and recovery, including maintaining physical strength and preventing accelerated muscle atrophy,” says Dr. Mayer. “In our medical center, we hired three physical therapists to work with Neuro ICU patients to improve mobilization because it is such an important issue.”
For more approaches to these challenging cases, read our special report on caring for long-term patients in the neurological intensive care unit.