Procedures and Protocols in the Neurocritical Care Unit

Description

This practical book covers neuro-critical care procedures performed in medical or surgical ICU and different procedures dedicated to acute neurological care.   The book's format allows for quick decisions about care and protocols while treating neurologically injured patients. Divided into two sections, the first focuses on procedures. The outlines of these chapters include indication, technique, types of kits available, and challenges. The second section covers the protocols; these chapters feature flowcharts, drugs/device, doses of drugs, description of device, indication, evidence, and future prospects.   This succinct guide will serve as a go-to reference for residents, fellows, intensivists, or any healthcare personnel within neuro-critical care unit. Foreword Preface Acknowledgements Contents Contributors Part I: Procedures Vascular Access 1 Peripheral Vascular Catheters 1.1 Introduction 1.2 Method of Insertion [6] 1.3 Technique [6, 13] 1.4 Pitfalls 2 Central Vascular Catheters 2.1 Introduction 2.2 Indications 2.2.1 Non-tunneled CVCs (Fig. 5) 2.2.2 Tunneled CVCs 2.3 Technique of Insertion for Non-tunneled Catheters [6, 13] (Fig. 6) 2.4 Pitfalls 3 Specialty Catheters 3.1 Hemodialysis Catheters: (Fig. 7) 3.2 Introducer Sheaths: (Fig. 8) 3.3 Technique 3.3.1 Hemodialysis Catheter 3.3.2 Introducer Sheath [36] References Pulmonary Artery Catheters 1 Introduction 2 Indications 3 Technique/Methods 4 Types of Kits Available 5 Pitfalls and Troubleshooting References Arterial Catheters 1 Introduction 2 Indications 3 Technique/Methods 4 Types of Kits Available 5 Pitfalls and Troubleshooting Airway Access Introduction Airway Anatomy 1 Supraglottic Devices 1.1 Oropharyngeal and Nasopharyngeal Airways 1.2 Laryngeal Mask Airway (LMA) 2 Infraglottic Devices 2.1 Direct Laryngoscopy 2.2 Video Laryngoscopy 3 Surgical Airway 4 Percutaneous Dilatation Tracheostomy (PDT) 5 Bronchoscopy 6 Summary Bibliography Thoracocentesis 1 Introduction 2 Indications 3 Technique/Methods 3.1 Prepare the Patient 3.2 Prepare Equipment and Yourself 3.3 Procedure Walkthrough 4 Pitfalls/Troubleshooting References Chest Tube Thoracostomy 1 Introduction 2 Indications 3 Technique/Methods 3.1 Prepare the Patient 3.2 Prepare Equipment and Yourself 3.3 Procedure Walkthrough 4 Pitfalls/Troubleshooting References Pericardiocentesis 1 Introduction 2 Indications 3 Equipment 4 Technique/Methods 5 Management After Pericardiocentesis 6 Complications 7 Tips to Avoid Complications References Paracentesis 1 Introduction 2 Indications for Abdominal Paracentesis 3 Contraindications 4 Steps Involved in Performing Abdominal Paracentesis 5 Analyzing Peritoneal Fluid 6 Complications 7 Types of Kits Available 8 Pitfalls of Paracentesis References Lumbar Puncture and Intrathecal Drug Administration 1 Introduction 2 Indications 3 Contraindications 4 Anatomy, Positioning, and Needle Location 4.1 Anatomy 4.2 Position Techniques 4.3 Spine Level Location 5 Needle Variants 5.1 Needle Type 5.2 Needle Gauge 6 Imaging Guided 6.1 Ultrasound Guidance 6.2 Fluoroscopy Guidance (Fig. 2) 6.3 CT Guidance 7 Complications 7.1 Intrathecal Lidocaine 7.2 Epidural Hematoma 7.3 Infection 7.4 Post Lumbar Puncture Headache 7.5 Needle Deformation 8 Conclusion References Intracranial Access 1 Introduction 2 Intracranial Pressure Monitoring 2.1 External Ventricular Drain Placement 2.2 Fiberoptic Intracranial Pressure Monitor (Camino, or “bolt”) 2.3 Brain Oxygenation Monitoring (Licox®, Integra; San Diego, CA, USA) 3 Subdural Drainage 3.1 Subdural Drain 3.2 Subdural Evacuating Port System (SEPS) Placement References Point of Care Ultrasound 1 Introduction 2 Basics of Ultrasonography 2.1 Echogenicity 2.2 Probe Selection 2.3 Positioning and Probe Control 3 Vascular Ultrasound 3.1 Vascular Access 3.2 Deep Venous Thromboembolism Screening and Diagnosis 3.3 Two-Point DVT Screen 4 Lung Ultrasound 4.1 Normal Lung Ultrasound Patterns 4.1.1 Lung Sliding 4.1.2 A-Lines 4.2 Abnormal Lung Ultrasound Patterns 4.2.1 Pneumothorax 4.2.2 B-Lines 4.2.3 Pleural Effusions 4.2.4 Consolidation 4.2.5 BLUE Protocol 5 Cardiac Ultrasound 5.1 Transthoracic Views 5.1.1 Parasternal Long-Axis View 5.1.2 Parasternal Short-Axis View 5.1.3 Apical Four-Chamber View 5.1.4 Subcostal Long-Axis View 5.1.5 Inferior Vena Cava Longitudinal View 5.2 Utility of Cardiac POCUS 5.2.1 Left Ventricular Systolic Function 5.2.2 Fluid Responsiveness 5.2.3 Tamponade 5.3 Right Ventricular Function and Pulmonary Embolism 6 Focused Assessment Sonography in Trauma (FAST) 7 Conclusion References Transcranial Doppler Ultrasound 1 Introduction 2 Doppler Ultrasound Concepts 3 TCD Equipment and the Technique 3.1 Comparison of TCD to TCCD 4 Technique 5 Clinical Applications of TCD 5.1 Vasospasm 5.2 Stenosis 5.3 Acute Ischemic Stroke 5.4 Traumatic Brain Injury 5.5 Brain Death Evaluation 5.6 Sickle Cell Disease 6 Conclusion References Cervical Traction 1 Introduction 2 Indications, Contraindications, and Caveats 3 Procedure: Cervical Traction/Closed Reduction with Garner-Wells Tongs 4 Post-procedural Care 5 Case Presentation References Part II: Protocols Sedation and Analgesia Management 1 Introduction 2 Indications 3 Drug Selection 4 Pharmacological Agents for Sedation and Analgesia 5 Tools for Objective Measuring of Sedation and Analgesia 6 Sedation Interruptions 7 Pitfalls 8 Summary References Intracranial Hypertension in Intensive Care Unit 1 Introduction 1.1 Pathophysiology of Raised ICP 1.2 Etiology of Elevated ICP: [8–12] 1.3 Clinical Features: Table 2 [13–15] 1.4 ICP Monitoring: [1, 2, 8, 13, 16] 1.5 Indications for ICP Monitoring Devices [3] 1.6 Role of Fundoscopy: [17–22] 1.7 Management: [3, 23–28] 1.8 Surgery [30–32] 1.9 Mannitol [33–35] 1.10 Sedation: [16, 27, 39] 1.11 Temperature Modulation 2 Lumbar Drain (LD) 2.1 Future Directions References Sepsis and Fever in the Neuro-Critical Care Unit (NCCU) 1 Introduction 1.1 Definitions 2 Measurement of Body Temperature [9, 10] 3 Causes of Fever in Intensive Care Unit (ICU) 4 Infectious Causes of Fever (Table 3) 5 Management of Bacterial Meningitis 6 AMP-C Group of Organisms 7 Non-infectious Causes of Fever in NCCU 8 Protocol for Fever Management in NCCU References Status Epilepticus 1 Introduction 2 Treatment Algorithm for Management of Convulsive Status Epilepticus 3 Drugs Used for Treatment of Status Epilepticus 4 Current Evidence 5 Future Directions References Targeted Temperature Management 1 Introduction 2 Indications and Contraindications (Table 1) 3 Techniques for Targeted Temperature Management 4 Conventional Methods 5 Surface Cooling (SFC) 6 Endovascular Cooling 7 Other Methods 8 Protocol 8.1 Induction 8.2 Maintenance 8.3 Rewarming 9 Shivering (Fig. 4) References Original Bibliography Mechanical Ventilation and Weaning In ICU 1 Introduction 2 Airway Assessment 3 Predictors of Difficult Ventilation 4 Predictors of Difficult Intubation – Table 1 5 Modes of Ventilation References Tracheostomy Care 1 Introduction 2 Tracheostomy Care 3 Post-placement Care 4 Tracheostomy Weaning to Decannulation 4.1 Downsizing 4.2 Passy-Muir Valve or Speaking Valve 4.3 Capping Trials 4.4 Decannulation Bibliography Hemodynamic Monitoring 1 Introduction 2 Basic Principles of Fluid Resuscitation 2.1 Frank-Starling Curve 2.2 Diastolic Volume-Pressure Curve (Fig. 1) 2.3 Contractility (Fig. 1) 2.4 Mean Systemic Filling Pressure (Pms) 2.5 Venous Return 3 Hemodynamic Profiles of Shock 3.1 Methods of Assessment 4 Role of Ultrasound in Hemodynamic Assessment 4.1 Method 4.2 Basic Principles of Lung Ultrasound and Image Acquisition 4.3 Method 5 Artifacts 6 Real Images 6.1 Utility in Neuro-Science Intensive Care Unit 7 Future Directions 8 Application References Endotracheal Intubation via Direct Laryngoscopy 1 Introduction 2 Indications and Contraindications 3 Medications 4 Choosing the Medications for ETI in a Neurocritical Patient 5 Anatomy 6 Preparation 7 Technique 8 Confirming Proper Placement of Endotracheal Tube 9 Protocol for ETI (Fig. 2) References Vasospasm 1 Introduction 1.1 Incidence and Pathophysiology 1.2 Diagnostic Modalities 2 Prevention of Vasospasm 3 Treatment of Vasospasm (Table 5) 4 Pharmacological Treatment 5 Endovascular Therapy 6 Protocol for Vasospasm Management 7 Future Directions References Phenobarbital for Alcohol Withdrawal Syndrome 1 Introduction 2 Management of Alcohol Withdrawal 3 Pharmacotherapy 4 Literature Review References Diabetic Ketoacidosis and Hyperglycemia 1 Introduction 2 Glucose Homeostasis in the Brain 3 Hyperglycemia and Hypoglycemia in the Neurocritical Care Unit (NCCU) 4 Management of Hyperglycemia in the NCCU References Electrolyte Management 1 Introduction 2 Calcium Management 3 Magnesium Management 4 Phosphorus Management 5 Potassium Management 6 Sodium Management 7 Summary References Plasmapheresis 1 Introduction 2 Basic Nomenclature 3 Indications of Therapeutic Plasma Exchange (Table 1) 3.1 Principles 3.2 Mechanisms of Action 4 Technique (Fig. 1) 4.1 Vascular Access for Therapeutic Plasma Exchange 4.2 Anticoagulation 4.3 Replacement Fluids 5 Prescription of Therapeutic Plasma Exchange 6 Summary of Recommendations for Use of TPE in Neurology Intensive Care 7 Complications and Monitoring 8 Contraindications 9 Conclusion References Intravenous Immunoglobulin 1 Introduction 2 Composition 3 Mechanism of Action 4 Immunoglobulin in Neurological Diseases 4.1 Neurological Dose of IVIG 4.2 Neurological Disorders Treated with IVIG 5 Adverse Effect and Management 6 Conclusion and Future Directions References Brain Death 1 Introduction 2 Procedure for Declaration of Death by Neurological Criteria 3 Current Evidence and Guidelines 4 Special Case Scenarios 5 Future Prospects References Continuous Renal Replacement Therapy 1 Introduction 2 Risk Factors for Renal Injury in the ICU 3 Diagnosing Acute Kidney Injury in Critically-Ill Patients (Table 1) 4 Indications of Renal Replacement Therapy (Table 2) 5 Timing of RRT- Is Early Initiation of RRT Beneficial? 6 Renal Replacement Therapies in NCCU 7 Types of Renal Replacement Therapy (RRT) (Table 3) 8 CRRT 8.1 Principles of CRRT 8.2 Modes of CRRT 9 Is CRRT Superior Than Other Modalities? 10 CRRT Dosing 11 Dialysis Access 12 Anticoagulation 13 Types of Anticoagulation for CRRT [17] 13.1 Regional Anticoagulation (Table 6) 13.2 Systemic Anticoagulation (Table 7) 14 Special Considerations for CRRT Prescription in Neurocritical Care Patients 15 Prevention of AKI 16 Novel Approaches 17 Conclusion References Delirium 1 Introduction 2 Epidemiology 3 Risk Factors 4 Diagnosis 4.1 Clinical Presentation 5 Prevention 6 Management 7 Outcomes References Index