Neurocritical Care

Learning Objectives

Identify pertinent pathophysiologic and laboratory

changes that acutely occur after neurologic injuries

and require therapeutic intervention.

neurocritical care patients that help develop and

optimize treatment strategies.

Develop an evidence-based treatment strategy for

neurocritical care patients that optimizes patient out-

comes and reduces the risk of adverse drug effects

and drug interactions.

Recommend a monitoring plan to assess response to

therapeutic regimens and specific therapeutic goals

for neurocritical care patients.

Develop new plans of care for neurocritical care

patients according to therapeutic and adverse out-

comes and progress toward therapeutic goals.

Antidiuretic hormone

CNS

Central nervous system

CPP

Cerebral perfusion pressure

CSF

Cerebrospinal fluid

EEG

Electroencephalogram

GCS

Glasgow Coma Scale

ICH

Intracerebral hemorrhage

ICP

Intracranial pressure

ICU

Intensive care unit

MAP

Mean arterial pressure

epidermidis

PSH

Paroxysmal sympathetic hyperactivity

RSE

Refractory status epilepticus

SAH

Subarachnoid hemorrhage

SCI

Spinal cord injury

hormone

TBI

Traumatic brain injury

VTE

Venous thromboembolism

Self-Assessment Questions

Answers and explanations to these questions may be

found at the end of this chapter.

A 56-year-old woman is hospital day 4 after

her acute aneurysmal subarachnoid hemorrhage

(SAH). She is oriented and following commands.

Laboratory values reveal a serum sodium of 128

mmol/L. Other serum chemistry values include

potassium (K) 3.9 mEq/L, chloride 103 mEq/L,

bicarbonate 27 mEq/L, blood urea nitrogen (BUN)

10 mg/dL, and serum creatinine (SCr) 1.0 mg/dL.

Her urinary output is 1–2 mL/kg/hour, and her fluid

balance has been +435 mL during the past 24 hours

(currently receiving 0.9% sodium chloride at 125

mL/hour). Which is the best initial therapy for this

patient’s hyponatremia?

ventriculoperitoneal shunt failure and associated

infection. She has no significant medical history

and no allergies to medications. A lumbar punc-

ture reveals cerebrospinal fluid (CSF) white blood

cell count (WBC) 34 × 103 cells/mm3, red blood

cell count (RBC) 1 × 103 cells/mm3, protein 78

mg/dL, and glucose 21 mg/dL. The cultures grow

methicillin-resistant Staphylococcus epidermidis

(MRSE). Her shunt is externalized. Despite 4 days

of intravenous vancomycin (most recent vancomy-

cin trough was 17.7 mcg/mL), the CSF continues to

grow MRSE. Which is the most appropriate intra-

ventricular antimicrobial regimen to initiate for this

patient’s refractory ventriculitis?

daily.

ularly for this patient.