Rehabilitation in Neurocritical Care

Rehabilitation is a process that should begin in the neurointensive care unit. Once a rough prognosis has been made within the context of goals of care discussions, and a decision has been made to proceed with measures geared toward recovery, the focus of clinical care should begin to shift toward the transition to rehabilitation in order to maximize functional gains. In the acute care setting, this necessitates the collaboration of a multidisciplinary team, including physical medicine and rehabilitation, physical and occupational therapy, speech and language pathology, neuropsychology, social work, and nursing. Among the most challenging issues facing intensivists and the rehabilitation team in the critical care setting is the management of the various rehabilitation-related medical complications associated with acquired brain injury, including decreased level of arousal, agitation, sleep disturbances, depression, dysautonomia, bowel and bladder dysfunction, and spasticity. This chapter highlights current management strategies for dealing with these issues.

Brain Death, Organ Donation, and Transplantation

This chapter reviews the history of brain death determination, current guidelines for performing the brain death examination including the apnea test, details of apnea testing, the role of brain dead donors in organ donation, physiologic changes seen in brain dead patients, and the relevant challenges in intensive care unit management of such patients for donor organ optimization. The goal of this chapter is to provide clear guidance for a critical care provider to perform an accurate and thorough brain death examination and to further the reader’s understanding of the historical and legal context surrounding brain death and organ donation in the United States.

Prognostication and Ethics

This chapter provides an overview of prognostication and key topics in ethics as they relate to the practice of neurocritical care. Challenges with prognostication are summarized. Outcome prognostication tools for ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury are outlined along with a discussion of their limitations. Best practices for communicating prognosis are reviewed. Shared decision-making with surrogate decision-makers in intensive care units is discussed in detail, with attention to advance care planning documentation and resolution of situations in which clinicians may have conscientious objections to potentially inappropriate treatment.

External Ventricular Drainage

External ventricular drainage, or ventriculostomy, refers to surgical placement of a catheter into the ventricle to achieve temporary cerebrospinal fluid diversion and remains one of the most frequently performed neurosurgical interventions. External ventricular drainage is an essential therapeutic strategy for a myriad of neurological disease processes causing hydrocephalus or increased intracranial pressure including traumatic brain injury, subarachnoid hemorrhage, and intracranial hemorrhage with intraventricular extension. In select cases, lumbar drains may provide a suitable alterative to an external ventricular drain (EVD). Complications related to both EVD and lumbar drain placement include malfunction, infection, and hemorrhage. This chapter reviews the indications, surgical technique, postoperative management strategies, and potential complications associated with external ventricular drainage.

Multimodality Monitoring

Advancements in the critical care of patients with various forms of acute brain injury (traumatic brain injury, subarachnoid hemorrhage, stroke, etc.) in its current evolution recognizes that in addition to the initial insult, there is a secondary cascade of physiological events in the injured brain that contribute significantly to morbidity and mortality. Multimodality monitoring (MMM) in neurocritical care aims to recognize this secondary cascade in a timely manner. With early recognition, critical care of brain-injured patients may then be tailored to preventing and alleviating this secondary injury. MMM includes a variety of invasive and noninvasive techniques aimed at monitoring brain physiologic parameters such as intracranial pressure, perfusion, oxygenation, blood flow, metabolism, and electrical activity. This chapter provides an overview of these techniques and offers a practical guide to their integration and use in the intensive care setting.

The Management of Traumatic Spinal Cord Injury

The management of traumatic spinal cord injury (SCI) requires thorough neurologic assessment and injury classification to guide treatment as well as inform prognosis. Initial radiographic evaluation is aimed at efficiently determining spinal column stability and should begin with high-quality multislice helical computed tomography imaging, including coronal and sagittal reconstructions. The primary objective of clinical SCI management is to prevent or ameliorate secondary injury caused by cardiovascular instability and/or pulmonary insufficiency, in addition to other comorbid processes common to this disease. Vigilant monitoring and treatment in the critical care setting is one of the most important means of reducing morbidity and mortality following SCI.

Anoxic Brain Injury

Cardiac arrest is common and deadly. Fortunately, with advances in care, short- and long-term outcomes of those resuscitated after cardiac arrest are steadily improving. Initial management focuses on general critical care support of multisystem organ dysfunction and diagnostic workup to identify the etiology of cardiac arrest. Thereafter, provision of a comprehensive bundle of care including active temperature management, coronary revascularization, delayed multimodal neurological prognostication, and best practice neurocritical care can result in a substantial proportion of patients experiencing favorable recovery despite patterns of injury once thought to be incompatible with survival.

Management of Intracranial Hypertension in Fulminant Hepatic Failure

Fulminant hepatic failure (FHF) leads to a spectrum of pathophysiologic derangements including multisystem organ failure, cerebral edema, intracranial hypertension, and cerebral herniation with associated high mortality. Orthotopic liver transplantation is currently the only definitive therapy that can improve outcome. The critical care physician must be familiar with the various monitoring tools and therapeutic strategies to support patients with FHF who develop intracranial hypertension. Methods of monitoring include electroencephalography, transcranial doppler, jugular venous oximetry, and intracranial pressure monitoring. Therapies to manage intracranial hypertension include propofol sedation, hypertonic saline, induced therapeutic hypothermia, and barbiturate coma. This chapter reviews the pathophysiology of intracranial hypertension including the multimodal neuromonitoring techniques and therapeutic strategies that are currently available in managing these patients in the critical care setting.

Neuromuscular Conditions

Neuromuscular disorders in an intensive care unit (ICU) setting may manifest as (a) an exacerbation of a previously known neuromuscular disorder, (b) a new onset of a previously undiagnosed neuromuscular disorder, or (c) a neuromuscular complication of a critical illness. Examination limitations, complex comorbidities, and technical difficulties associated with electrodiagnostic testing in an ICU setting also create unique challenges during evaluation of patients with possible neuromuscular disorders. Respiratory failure may occur as an initial sign of an underlying neuromuscular disorder, as a chronic respiratory insufficiency, or as an inability to wean the patient from mechanical ventilation. Respiratory function is often closely related to dysphagia, which may also lead to aspiration and sudden worsening of respiratory function. In addition to weakness, progressive cardiomyopathy associated with myopathies can precipitate cardiac failure and arrhythmias and even necessitate heart transplantation. This chapter reviews clinical manifestations of neuromuscular disorders in the ICU.

The Management of Traumatic Brain Injury

The management of traumatic brain injury necessitates a multidisciplinary approach with medical and surgical therapies employed based on rapid clinical assessment of injury severity and imaging characteristics. Therapy aims to prevent secondary brain injury through multifactorial interventions primarily focusing on prevention of cerebral hypoxemia and aggressive control of intracranial pressure (ICP). This chapter covers epidemiology, pathophysiology, clinical assessment, and both medical and surgical management of traumatic brain injury. Management topics include appropriate monitoring, first- and second-line therapy for ICP and cerebral perfusion pressure, hypoxia, seizure prophylaxis, hyperpyrexia, glycemic control, fluids and electrolytes, nutrition, and prophylaxis for venous thromboembolism and the gastrointestinal system.