Jallo / Urtecho The Jefferson Manual for Neurocritical Care

1. Auflage 2021
ISBN: 978-1-63853-459-4
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 326 Seiten, ePub

Medical management of patients in the neurocritical care unit (NCCU) often spells the difference between life or death and return to normal function or a lifetime disability. As such, it is vital that patients with life-threatening neurological and neurosurgical illnesses receive prompt diagnosis and rapid interventions in the NCCU.

by renowned neurosurgeon Jack I. Jallo, neurointensive care physician Jacqueline S. Urtecho, and distinguished colleagues is a high-yield pocket resource ideal for the bedside care of patients with serious, life-altering diseases. Nineteen concise chapters encompass cerebrovascular, neuromuscular, oncologic, and traumatic conditions, as well as core clinical topics applicable to the care of neurocritical patients.

Key Highlights

• Evidence-based management strategies created at Thomas Jefferson University's Vickie and Jack Farber Institute for Neuroscience presented in reader-friendly algorithms, pictures, and charts
• General chapters cover brain death, sodium dysregulation, nutrition, sedation, pain management, neuromonitoring, and ventilation strategies
• Disease-specific chapters featuring succinct, bulleted format include epidemiology, causes, diagnostic tests, treatment options, symptoms, common clinical presentation, risk factors, differential diagnoses, and more

This manual is an indispensable resource for neurocritical care residents and fellows, NCCU nurses, nurse practitioners, physician assistants, general intensive care physicians, and neurointensivists.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Autoren/Hrsg.

Jallo, Jack I.

Urtecho, Jacqueline

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Neurologie, Klinische Neurowissenschaft
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Pflege Intensivpflege
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizinische Fachgebiete AINS Intensivmedizin

Inhaltsverzeichnis

1. Encephalopathy and Delirium
2. Cerebrovascular Emergency: Acute Stroke Diagnosis and Management
3. Cerebrovascular Emergency: Spontaneous Intracerebral Hemorrhage (ICH)
4. Cerebrovascular Emergencies: Aneurysmal Subarachnoid Hemorrhage (SAH)
5. Transfusion Medicine and Anticoagulation
6. Cerebral Edema and Elevated Intracranial Pressure
7. Fevers and Infections in the Neuro-ICU
8. Treatment of Status Epilepticus in Adults
9. Trauma
10. Neuromuscular and Other Neurologic Emergencies
11. Brain Tumor Postoperative Management
12. Brain Death in Adults
13. Sodium Dysregulation
14. Nutrition
15. Sedation
16. Pain Management in the Neuro-Intensive Care Unit (ICU)
17. Advanced Hemodynamic and Neurological Monitoring in the Neuro-ICU
18. Neuroimaging
19. Ventilation Strategies in Neuro-ICU

Leseproben

1 Encephalopathy and Delirium

Abstract

Encephalopathy is characterized by the National Institute of Neurological Disorders and Stroke as “any diffuse disease of the brain that alters brain function or structure,”1 and can be classified as acute or chronic. The definition, diagnosis, and treatment of encephalopathy is reviewed here, along with one of its most common symptoms, delirium.

: encephalopathy, delirium, confusion, agitation, arousability, Ramsay score, Riker score

1.1 Encephalopathy

1.1.1 Definition

The National Institute of Neurological Disorders and Stroke (NINDS) defines encephalopathy as “a term for any diffuse disease of the brain that alters brain function or structure”1 with the hallmark of encephalopathy being an altered mental state. Encephalopathy can be categorized by chronicity2:

• Acute

? Toxic: due to medications, illicit substances, or toxins

? Metabolic: due to a metabolic disturbance

? Toxic-metabolic: due to a combination of both

• Chronic: characterized by a slowly progressive alteration in mental status resulting from permanent structural changes within the brain2

1.1.2 Causes of Encephalopathy3

See ? Table 1.1.

1.1.3 Diagnosis of Encephalopathy

Diagnosis is guided by the history and physical examination of the patient. It is considered on a case-by-case basis.

• Laboratory testing

? Serum electrolytes

? Renal function

? Glucose

? Calcium

? Complete blood count

? Urinalysis

? Hepatic function

? Thyroid function

? Drug levels (if applicable), i.e., phenytoin

? Drugs of abuse screen

? Vitamin levels—B-12, folate

? Arterial blood gas

• Imaging

? Computed tomography (CT) of brain

? Magnetic resonance imaging (MRI) of brain

Table 1.1 Common causes of encephalopathy

Drugs and toxins

Idiopathic Withdrawal states Medication side effects Poisons

Infections

Sepsis Systemic infections Fever

Metabolic derangements

Electrolytes Endocrine disturbance Hypercarbia Hyperglycemia and hypoglycemia Hyperosmolar and hypo-osmolar states Hypoxemia Inborn errors of metabolism Nutritional

Brain disorders

CNS infection Seizures Head injury Hypertensive encephalopathy Psychiatric disorders

Systemic organ failure

Cardiac failure Hematologic Hepatic encephalopathy Pulmonary disease Renal failure

Abbreviation: CNS, central nervous system.

• Evaluation for infections

? Lumbar puncture

? Blood cultures

• Seizure evaluation

? Electroencephalography (EEG)

1.1.4 Treatment of Encephalopathy

• Acute encephalopathy

? Based on treatment of the underlying pathophysiology, i.e., treatment of sepsis and hypothyroidism with the potential for reversal of encephalopathy.

• Chronic encephalopathy

? Often not amenable to treatment as the inciting insult has caused permanent brain changes, i.e., anoxic encephalopathy.

1.1.5 Relationship to Delirium

Delirium can be characterized as the symptom of the underlying abnormal brain function, i.e., encephalopathy.2

1.2 Delirium

Delirium is a common disorder in hospitalized patients that has significant societal and economic impact.4 In-hospital mortality rates reportedly associated with delirium range from 22 to 33%.5,6 Currently patients aged 65 years and older account for more than 48% of hospital care; therefore, the impact of delirium on hospitalized patients will continue to grow as our population ages.4

1.2.1 Definition

The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 defines delirium under Neurocognitive Disorders7 which encompasses “the group of disorders in which the primary clinical deficit is in cognitive function, and that are acquired rather than developmental.” The diagnostic criteria are as follows:

• A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

• The disturbance develops over a short period of time (usually from hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

• An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

• The disturbances are not explained by another pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

• There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiologic consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or a medication), or exposure to a toxin, or is due to multiple etiologies.

As outlined in the DSM 5, Delirium can be further subdivided into:

• Substance intoxication

• Substance withdrawal

• Medication induced

• Another medical condition

• Multiple etiologies

1.2.2 Duration of Symptoms

• Acute: Lasting for a few hours or days

• Persistent: Lasting for weeks or months

1.2.3 Level of Activity (? Table 1.2)

• Hyperactive: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.

• Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.

• Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.

Table 1.3 Risk factors for delirium

Predisposing factors10

Precipitating factors11

Targeted interventions12

• Cognitive impairment • Severe underlying illness • Advanced age • Functional impairment • Chronic renal insufficiency • Dehydration • Malnutrition • Depression • Substance abuse • Vision or hearing impairment

• Use of physical restraints • Malnutrition • More than three medications • Use of bladder catheter • Psychoactive medication use • Any iatrogenic event • Immobilization • Dehydration

• Noise reduction • Reality orientation program • Early mobilization • Minimize medications • Provision of visual and hearing aids • Volume repletion and proper nutrition • Optimize nonpharmacologic protocols

A description of a patient in terms of the DSM 5 criteria could look like “acute, hypoactive delirium due to sepsis.”

1.2.4 Risk Factors for Delirium

Delirium involves a multifactorial etiology ranging from patient vulnerability to delirium at the time of admission and the occurrence of noxious insults during hospitalization.9 See ? Table...