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The Critically Ill Neurological Patient: Why Neuro ICU Matters

The Critically Ill Neurological Patient: Why Neuro ICU Matters. Julia Durrant, MD Division of Neurosciences Critical Care Department of Neurology Oregon Health and Science University. Disclosures. No external sources of financial support to disclose. Outline. The Dedicated Neuro ICU

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The Critically Ill Neurological Patient: Why Neuro ICU Matters

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  1. The Critically Ill Neurological Patient: Why Neuro ICU Matters Julia Durrant, MD Division of Neurosciences Critical Care Department of Neurology Oregon Health and Science University

  2. Disclosures • No external sources of financial support to disclose

  3. Outline • The Dedicated Neuro ICU • The Art of the Neuro ICU • Cerebral edema/ICP management • Fever control • Seizure control • Does it work?

  4. Neuro ICU at OHSU • Founded in 2005 • 17 bed unit • 24 hour CT/MRI access • 24 Hour access to EEG techs, Epilepsy faculty • Proximity to OR and Angio suites • 24-7 Neuro-Intensivist coverage with 8 faculty

  5. Patient Population Severe ischemic stroke: at risk for cytotoxic edema Ischemic stroke following thrombolysis with tPA or thrombectomy Cerebral venous thrombosis

  6. Who should be admitted? • ICU admission: • Stroke complicated by respiratory failure, myocardial decompensation or uncontrollable hypertension. • Large mismatch between core infarction and territory • complex hemodynamic management.

  7. Patient Population • Intracerebral and intraventricular hemorrhage • Subdural and epidural hematoma

  8. Patient Population • Subarachnoid hemorrhage • Cerebral aneurysms • Cerebral and spinal vascular malformations • Brain tumors

  9. Patient Population • Status epilepticus • Meningitis and encephalitis • Neuromuscular disorders in crisis (myasthenia gravis, Guillain-Barre syndrome) and acute myelopathies

  10. Neuroprotection: the goal of neurocriticalcare • Assessment of end organ perfusion • No direct laboratory measurements • Physical exam • MRI/CT imaging • Interval to end-organ failure under adverse conditions can be rapid. • Further injury to even small regions of brain can have devastating consequences.

  11. What Can We Offer? • Cerebral resuscitation • “The Brain Code” • Disease-specific management • Full complement of subspecialists • Cutting-edge technology

  12. Cerebral Resuscitation: acute catastrophic neurologic injury • Catastrophic neurologic injury: ICP herniation

  13. csf blood brain normal 9% 150mL 4% 4% 75mL 4% 1% Saunders NR, Habgood MD, Dziegielewska KM (1999). "Barrier mechanisms in the brain, I. Adult brain". Clin. Exp. Pharmacol. Physiol. 26 (1): 11–9 Cranial Vault Mechanics • Monroe and Kellie • Skull is a rigid container • Cranial contents (brain, blood, CSF) are viscous gel and incompressible • Additional volume (pathologic or expansion of the 3 normal contents) will lead to the displacement of another content 87% 1400 mL abnormal 92% abnormal mass 20% 79%

  14. Cranial vault mechanics CPP = MAP - ICP CBF = CPP/CVR CD02 = CBF x Ca02 ICP<20, CPP>60 = mortality reduction by> 50% in TBI Bratton SL et al. J Neurotrauma 24 (S1): S59-S64, 2007 Narotam P, Morrison J et al. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. JNS (2009) 111 (4): 672-682 Rosner M J, Rosner S D & Johnson A H. "Cerebral perfusion: management protocol and clinical results." J.Neurosurgery 1985; 83: 949-962.

  15. Cerebral Resuscitation: herniation syndromes • SubfalcineHerniation • Cerebral cortex under falx • Ipsi/contra leg weakness •  mental status • Central Herniation • Brainstem down through tentorium •  mental status • Dilated pupil (CNIII), ophthalmoplegia • Ipsi paresis/posturing (contra cerebral crus) • Basilar stroke • Upward Herniation • Brainstem up through tentorium •  mental status • Dilated pupil (CNIII), ophthalmoplegia • Ipsi paresis/posturing (contra cerebral crus) • UncalHerniation •  mental status • Uncus over tentorial notch • Dilated pupil (CNIII), ophthalmoplegia • Ipsi paresis/posturing (contra cerebral crus) • PCA stroke • TonsillarHerniation • Cerebellar tonsils in foramen magnum • Awake, quadriparesis • Arrhythmia/cardiac arrest • Respiratory arrest

  16. Reduce Cranial Contents: Blood – vasodilation to constriction Venous Return Hyperventilation Reduction of CMR02 Brain water Osmolar therapy for edema Medical Interventions Airway: O2 sat>90% Breathing: normal CO2 Circulation CPP> 60mmHg Surgical Interventions Drain CSF Surgical removal of mass Break the rigid skull - craniectomy Brain Code • Head of Bed: • 30 degree, midline • Hyperventilation: • pCO2 30 +/- 2 mmHg • Hyperosmolar therapy • Mannitol IV 1 gm/kg IV • Hypertonic saline (CVL) • 3% NaCl or 23.4% NaCl • Normothermia/?Hypothermia • Pharmacologic Coma

  17. Cerebral Resuscitation: compartment approach to ICP management Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if appropriate (Vasogenic edema) Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents Arterial blood -Hyperventilate -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Lesion -Blood, tumor, pus -> surgery -Air-> 100% NRB, surgery CSF -Place IVC -Change popoff

  18. Cerebral Resuscitation: arterial compartment Arterial blood -Hypervent -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Kramer A, Zygun D. Anemia and red cell transfusion in neurocritical care. Critical Care 2009 13:R89

  19. Cerebral Resuscitation: compartment approach to ICP management Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if appropriate (Vasogenic edema) Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents Arterial blood -Hyperventilate -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Lesion -Blood, tumor, pus -> surgery -Air-> 100% NRB, surgery CSF -Place IVC -Change popoff

  20. Cerebral Resuscitation: venous compartment Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents If CVP exceeds ICP, CPP = MAP - CVP Ropper: n=19. 52% had ICP when HOB increased from 0->60°. 2% had ICP. Davenport: n=8. Median ICP from 18->15 with 20° elevation, no in CPP until > 60°. Lee: n=30. Trendelenburg positioning ICP from 20->24, but ICP in 20% of pts. (!) Davenport A, Will EJ, Davison AM. Effect of posture on intracranial pressure and cerebral perfusion pressure. Crit Care Med 1990; 18(3):286-289. Lee ST. Intracranial pressure changes during positioning of patients with severe head injury. Heart Lung 1989; 18(4):411-414. Ropper AH, O'Rourke D, Kennedy SK. Head position, intracranial pressure, and compliance. Neurology 1982; 32(11):1288-1291.

  21. Cerebral Resuscitation: compartment approach to ICP management Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if appropriate (Vasogenic edema) Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents Arterial blood -Hyperventilate -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Lesion -Blood, tumor, pus -> surgery -Air-> 100% NRB, surgery CSF -Place IVC -Change popoff

  22. Cerebral Resuscitation: CSF compartment CSF -Place IVC -Change popoff

  23. Cerebral Resuscitation: compartment approach to ICP management Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if appropriate (Vasogenic edema) Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents Arterial blood -Hyperventilate -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Lesion -Blood, tumor, pus -> surgery -Air-> 100% NRB, surgery CSF -Place IVC -Change popoff

  24. Cerebral Resuscitation: Brain parenchyma Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if vasogenic edema - Surgery (hemicrani, SOC) Cytotoxic Vasogenic Hydrostatic

  25. Cerebral Resuscitation: Brain parenchyma Reflection Coefficient

  26. Osmotic Load P.S. 1L of NS is 3.5g of Na+ in 1 liter of free water Hinson et al, J Intensive Care Med (2011)

  27. Cerebral Resuscitation: Brain parenchyma • Both improve rheology of erythrocytes increases deformability through small capillaries • Mannitol easier to give: no central line • HS increases vascular volume improves CBF up to 23% •  HS reduces inflammatory response by reducing PMN adhesion to microvasculature Pascual J et al. Hypertonic saline resuscitation of hemorrhagic shock diminishes neutrophil rolling and adherence to endothelium and reduces in vivo vascular leakage. Ann Surg. 2000 Nov; 236 (5): 634-642 Tseng M, Pippa G et al. Effect of hypertonic saline on cerebral blood flow in poor grade patients with subarachnoid hemorrhage. Stroke 2003;34:1389-1396

  28. Recent Trials Hinson et al, J Intensive Care Med (2011)

  29. Adverse Effects Hinson et al, J Intensive Care Med (2011)

  30. Cerebral Resuscitation: compartment approach to ICP management Brain parenchyma -Osmotherapy (mannitol, hypertonic saline) -Steroids only if appropriate (Vasogenic edema) Venous blood -HOB up -Neck straight -No IJ lines, do not lay flat for lines -Do no use venodilating BP agents Arterial blood -Hyperventilate -Avoid hyperemia: MAP target 60, Pa02>50 -Decrease metabolism: sedation, cooling Lesion -Blood, tumor, pus -> surgery -Air-> 100% NRB, surgery CSF -Place IVC -Change popoff

  31. Cerebral Resuscitation: Lesion • Surgical evacuation: STICH • Subjects with ICH (≥2cm) randomized to early (<24 hours) surgical evacuation v. medical management • No benefit to early surgery in general • Superficial lesions, large cerebellar lesions (≥3cm) may benefit • Summary: “Except for possibly those with superficial ICHs, craniotomy at 1 day or longer after onset is not better than initial conservative medical treatment with or without later craniotomy for patients who have deterioration.” Mendelow AD, et. al. STICH investigators. Lancet. 2005; 365 (9457): 387–97.

  32. Malignant Middle Cerebral Artery Stroke • 1-10% of patients with supratentorialinfarcts • life-threatening edema with peak edema on day 2-5 • Mortality of entire MCA territory is 78%, thus “malignant MCA infarction” • Including maximal medical intervention • Midline shift peaked after 2-4 days for those who died, • 3-7 days for survivors.

  33. Cerebral Resuscitation: Lesion • Hemicraniectomy in stroke: DECIMAL, DESTINY, HAMLET • All small trials showed non-significant trend toward benefit of hemicraniectomy • Meta-analysis suggests an absolute risk reduction of 13% • Patient selection? • Non dominant hemisphere • Age of patient Jüttler E. Stroke. 2007 Sep;38(9):2518-25.

  34. Disease Specific Management: Ischemic Stroke • Hemorrhagic Transformation • CT study shows ~1-5% hemorrhagic transformation • ranges from minor petechial bleeding to major mass-producing hemorrhage • Use of antithrombotics, anticoagulants, thrombolyticsincrease risk • NINDS ICH: 6.4% of tPA treated patients versus 0.6% in the placebo group, and mortality was 47%

  35. Disease Specific Management: Subarachnoid Hemorrhage • Feared Complications: • Hydrocephalus • Aneurysm re-rupture • Seizures • Vasospasm • Stressed myocardium • Neurogenic pulmonary edema

  36. Disease Specific Management: Subarachnoid Hemorrhage • Blood pressure management • Use of intermittent labetalol boluses or continuous infusion of nicardipine to maintain SBP less than 140 mmHg (unsecured) • Vasospasm prophylaxis • Nimodipine 60 mg every 4 hours for 21 days • Vasospasm monitoring • Daily transcranialdopplersonography for 14 days • Hydrocephalus treatment • Extraventricular Drain (EVD) placement

  37. Cardiac Support after SAH • Reduced Ejection Fraction or Symptomatic Vasospasm • Fluids, vasopressors • Hemodynamic monitoring

  38. Fever • ~50% of stroke patients develop fever1 • Body temp > 37.5°C significantly correlates with poor outcomes2 • Fever in first 24 hours linked to infarct volume3 • Induced normothermia may reduce metabolic stress4 1. Stroke 1998;29: 2455–60. 2. Stroke1995;26:2040–3. 3. Acta Neuropathol 1991;81:615–25. 4. Stroke2009;40:1913–16

  39. Fever and Hypothermia • Fever treatment • Acetaminophen • Cooling blankets • Intravascular cooling devices • Hypothermia • Not Standard of Care • No clinical evidence yet to support its use • National Acute Brain Injury Study: Hypothermia II terminated early for futility1 1. GL Clifton, A Valadka, D Zygun et al. Lancet Neurol, 10 (2011), pp. 131–139

  40. Glucose • Elevated serum glucose increases tissue necrosis and edema. • Hyperglycemia >200mg/dl is a predictor of poor outcome in ICU patients. • Hypoglycemia (<60mg/dl) can result in focal neurological deficits. • The goal of care is to achieve normoglycemia(80-140 mg/dl) with insulin infusion.

  41. Seizures after Stroke • Seizures occur in ~ 9% of patients1 • Greater risk after hemorrhagic stroke • ~2.5% have recurrent seizures • Stroke location modifies risk • Routine prophylaxis not recommended2 • Seizure always on differential in depressed mental status • Continuous EEG helpful in making diagnosis 1. ArchNeurol. 2000 Nov;57(11):1617-22. 2. Stroke. 2010; 41: 2108-2129

  42. Cardiac management • ST-T changes can be seen in large ischemic strokes • Diffuse or confined to a cardiovascular territory • Myocardial ischemia should always be excluded • “Brain T-wave changes” do not predict cardiac morbidity • Autonomic reciprocal innervation to the temporal lobes may produce arrhythmias in patients without pre-existing coronary disease

  43. Does Neurocritical Care matter? • Improved Mortality for ICH patients Critical Care Medicine. 29(3):635-640, March 2001.

  44. Does Neurocritical Care matter? • Reduced Mortality • Shorter LOS • More discharges to home/rehab Journal of Neurosurgical Anesthesiology. 13(2):83-92, April 2001.

  45. Does Neurocritical Care matter? • Reduction in mortality after Neuro-intensivist appointed Critical Care Medicine. 32(11):2191-2198, November 2004.

  46. Cerebral Resuscitation: outcomes Long-term outcome after medical reversal of transtentorialherniation in patients with supratentorial mass lesions Qureshi,,Geocadin,Suarez, Ulatowski, CRITICAL CARE MEDICINE 2000;28:1556-1564 11/28 (40%) survived to discharge 7/11 (59%) survivors functionally independent

  47. Does Neurocritical Care matter? YES!

  48. Thank you! • Questions?

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