Preliminary guideline- and pathophysiology-based protocols for neurocritical care
Because of the complex pathophysiological processes involved, neurocritical care has been driven by anecdotal experience and physician preferences, which has led to care variation worldwide. Standardization of practice has improved outcomes for many of the critical conditions encountered in the intensive care unit.
In this review article, we introduce preliminary guideline- and pathophysiology-based protocols for (1) prompt shivering management, (2) traumatic brain injury and intracranial pressure management, (3) neurological prognostication after cardiac arrest, (4) delayed cerebral ischemia after subarachnoid hemorrhage, (5) nonconvulsive status epilepticus, and (6) acute or subacute psychosis and seizure.
These tentative protocols may be useful tools for bedside clinicians who need to provide consistent, standardized care in a dynamic clinical environment. Because most of the contents of presented protocol are not supported by evidence, they should be validated in a prospective controlled study in future. We suggest that these protocols should be regarded as drafts to be tailored to the systems, environments, and clinician preferences in each institution.
KeywordsNeurocritical care Protocols Guidelines Pathophysiology Shivering Neurological prognostication Delayed cerebral ischemia Nonconvulsive status epilepticus Psychosis Seizure
Delayed cerebral ischemia
Nonconvulsive status epilepticus
Traumatic brain injury
Targeted temperature management
The art of neurocritical care requires an understanding of the pathophysiology of the highly complex central nervous system. Because of its complexity and the lack of evidence, the approach to neurocritical care is often clinician-dependent, i.e., driven by anecdotal experience and physician preferences, which leads to care variation. Overall, standardization of practice has improved outcomes for many critical conditions in the intensive care unit; thus, greater emphasis should be placed on reducing variation in neurocritical care practice.
Guideline- and pathophysiology-based protocols are concise yet comprehensive and are useful for bedside clinicians who need to provide consistent, standardized practice in a dynamic clinical environment. We introduce five preliminary protocols in this article. Because most of the text of the protocols addresses management in neurocritical care fields that lack firm evidence, and because of the varied availability of medical resources among institutions, we recommend that these protocols be used as drafts to be customized for the systems, environments, and clinical preferences of each institution.
Prompt shivering management (Fig. 1)
Traumatic brain injury and ICP management (Fig. 2)
Neurological prognostication after cardiac arrest (Fig. 3)
Delayed cerebral ischemia after subarachnoid hemorrhage (Fig. 4)
Diagnosis of nonconvulsive status epilepticus (Fig. 5)
Acute or subacute psychosis and seizure (Fig. 6)
The present guideline- and pathophysiology-based protocols that can be customized for particular clinical environments may help providing consistent, standardized care in neurocritical care. Because most of the contents of presented protocol are not supported by evidence, they should be validated in a prospective controlled study in future.
YN is the guarantor of the manuscript content and protocols. YF and KN substantially contributed to the manuscript and protocols. All authors read and approved the final manuscript.
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The authors declare that they have no competing interests.
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- 3.Fishman RA. Cerebrospinal fluid in diseases of the nervous system. Philadelphia: London: Saunders; 1980.Google Scholar
- 11.Lee K. The neuroICU book. 2nd ed. New York: McGraw-Hill Medical; 2017.Google Scholar
- 13.Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European Resuscitation Council guidelines for resuscitation 2015. Resuscitation. 2015;95:202–22.CrossRefPubMedGoogle Scholar
- 14.Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S, Quality Standards Subcommittee of the American Academy of N. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 67(2):203–210.Google Scholar
- 18.Etminan N, Vergouwen MD, Ilodigwe D, Macdonald RL. Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Cereb Blood Flow Metab. 2011;31(6):1443–51.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Tejada JG, Taylor RA, Ugurel MS, Hayakawa M, Lee SK, Chaloupka JC. Safety and feasibility of intra-arterial nicardipine for the treatment of subarachnoid hemorrhage-associated vasospasm: initial clinical experience with high-dose infusions. AJNR Am J Neuroradiol. 2007;28(5):844–8.PubMedGoogle Scholar
- 23.Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES Jr, Citerio G, Gress D, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211–40.CrossRefPubMedGoogle Scholar
- 32.Leitinger M, Beniczky S, Rohracher A, Gardella E, Kalss G, Qerama E, Hofler J, Hess Lindberg-Larsen A, Kuchukhidze G, Dobesberger J, et al. Salzburg consensus criteria for non-convulsive status Epilepticus––approach to clinical application. Epilepsy Behav. 2015;49:158–63.CrossRefPubMedGoogle Scholar
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