From the Guidelines
Not all suspected stroke patients require admission to the ICU for at least 24 hours, as the decision for ICU admission should be based on individual patient needs, including stroke severity, neurological status, and the need for intensive monitoring or interventions. The primary goal is to provide the appropriate level of care, and patients with minor strokes or transient ischemic attacks (TIAs) who are neurologically stable may be managed in a stroke unit or regular medical ward 1. However, patients with severe strokes, decreased level of consciousness, need for mechanical ventilation, those receiving thrombolytic therapy, or those with significant fluctuations in vital signs or neurological status would benefit from ICU monitoring.
Some key factors to consider when deciding on ICU admission include:
- Stroke severity, as measured by the NIHSS score, with higher scores indicating a greater need for ICU monitoring 1
- Neurological status, including the presence of decreased level of consciousness or significant fluctuations in neurological status
- Need for intensive monitoring or interventions, such as mechanical ventilation or thrombolytic therapy
- Presence of comorbidities, which may increase the risk of complications and the need for ICU care
In general, patients who receive thrombolytic therapy should be monitored closely for at least 24 hours after treatment, and care may be provided in a designated intensive care unit or a stroke unit with continuous cardiac telemetry 1. The nurse-patient ratio should be 1:2 for the first 24 hours, and then 1:4 as appropriate, with nurses trained in the care of patients after thrombolysis and aware of bleeding complications 1.
Overall, the decision for ICU admission should be individualized and based on the specific needs of each patient, with the goal of providing the appropriate level of care to optimize outcomes and minimize morbidity and mortality.
From the Research
Admission Requirements for Suspected Stroke Patients
- Not all suspected stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours 2
- The decision to admit a patient to the ICU should be based on the severity of the stroke and the patient's overall condition 3, 4
- Patients with mild strokes (National Institutes of Health Stroke Scale score <8) may not require ICU admission, as they may have fewer complications and more favorable discharge outcomes when admitted to a general ward 2
ICU Management of Stroke Patients
- The main goal of ICU management is to prevent secondary brain injury by optimizing systemic physiological homeostasis, controlling intracranial pressure, and managing cardiorespiratory parameters 3, 4
- Specialized neuro-intensive care teams can help improve functional outcomes after acute ischemic stroke 3
- ICU management may involve invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery, and specific cardiorespiratory management, nutrition, temperature management, and mobilization strategies 3, 4
Guidelines for ICU Admission
- Guidelines for the early management of stroke, commonly used in Stroke Units, should be followed, even in critically ill patients in an ICU setting 5
- The European Stroke Organisation, the American Stroke Association, and the U.K. National Institute for Health and Care Excellence provide general guidelines for the management of acute ischemic stroke, but robust evidence for specific ICU management principles is weak 4