What are the recommendations for a patient undergoing a neurology exam while on a ventilator?

From the Guidelines

For a patient undergoing a neurology exam while on a ventilator, it is crucial to prioritize their positioning to minimize complications and ensure accurate assessment findings, as recommended by the latest guidelines from 2024 1. When performing a neurology exam on a ventilated patient, several factors must be considered to ensure the patient's safety and the accuracy of the examination findings.

• The patient's positioning is critical, and elevation of the upper body ≥ 40° is recommended in intubated patients, considering possible haemodynamic side effects and an increased risk of pressure ulcers 1.
• In patients with increased intracranial pressure (ICP), upper body elevation should be performed to achieve the most favourable effect on cerebral perfusion pressure 1.
• Regular modification of positioning to avoid the flat supine position is recommended as an inappropriate form of positioning 1.
• The exam should focus on assessing pupillary responses, eye movements, motor responses to painful stimuli, and brainstem reflexes such as corneal and gag reflexes, while maintaining continuous monitoring of vital signs.
• Prone positioning is recommended in invasively ventilated patients with ARDS and impaired arterial oxygenation (PaO/FiO2 < 150 mmHg), but its application during a neurology exam should be carefully considered based on individual patient risks and benefits 1.
• The head should be positioned in a centred position and lateral rotation should be avoided, especially in patients at risk of increased ICP 1.
• Adequate sedation should be temporarily reduced if possible to allow for accurate neurological assessment, and ventilator settings and sedation levels should be documented during the examination.
• The Glasgow Coma Scale assessment should be modified, noting the inability to assess verbal responses, and any asymmetry in motor responses should be noted as it may indicate focal neurological deficits.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Ventilator Settings for Neurology Exam

• The ideal ventilator settings for patients undergoing a neurology exam while on a ventilator are unclear, but maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight is recommended 2.
• This approach may reduce the rate of pulmonary complications, although it cannot be easily applied in a neuro setting due to the need for special care to minimize the risk of secondary brain damage 2.

Challenges in Ventilator Management

• Neurological patients often require invasive mechanical ventilation and have unique challenges pertaining to the assessment and securing of the airway, maintenance of mechanical ventilation, as well as weaning and extubation readiness 3.
• The weaning process from mechanical ventilation is particularly challenging in these patients, who cannot control brain respiratory patterns and protect airways from aspiration 2.

Importance of Neurologic Status

• Neurologic status is a major factor necessitating continued mechanical ventilation in critically ill patients, with diminished level of consciousness being the major cause of continued ventilatory support 4.
• Mortality is significantly lower in patients who continue to require mechanical ventilation after 48 hours because of neurologic factors as opposed to pulmonary factors 4.

Palliative Care Needs

• Advanced neurology patients on mechanical ventilator support have two types of needs: respiratory-related needs and non-respiratory related needs, including substantial nursing care, adequate nutrition, accessible communication, and psychological support 5.
• These needs are important to maintain the quality of life of these patients 5.