What is the recommended approach for evaluating and managing a patient in the Neurosurgical Intensive Care Unit (NSICU)?

From the Guidelines

The recommended approach for evaluating and managing a patient in the Neurosurgical Intensive Care Unit (NSICU) involves a systematic, multidisciplinary process focused on neurological assessment, hemodynamic stability, and prevention of secondary injury, with initial management prioritizing rapid neuroimaging with CT or MRI to distinguish ischemic stroke from intracerebral hemorrhage (ICH) 1.

Key Components of Evaluation and Management

• Initial evaluation should include a baseline severity score, such as the National Institutes of Health Stroke Scale (NIHSS) or the ICH Score, to help streamline assessment and communication between providers 1.
• Rapid admission to a stroke unit or neuroscience intensive care unit is crucial, with early management initiated while the patient is awaiting this bed 1.
• Urgent treatment of time-sensitive issues, including blood pressure lowering and reversal of coagulopathy, should be initiated in the emergency department rather than waiting until after transfer to an intensive care unit or other hospital 1.

Hemodynamic Stability and Prevention of Secondary Injury

• Blood pressure should be controlled, with acute lowering of systolic blood pressure to 140 mm Hg safe and effective for improving functional outcome in ICH patients presenting with systolic blood pressure between 150 and 220 mm Hg and without contraindication to acute blood pressure treatment 1.
• Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1.
• Glucose should be monitored, with both hyperglycemia and hypoglycemia avoided 1.

Neurological Assessment and Monitoring

• Initial monitoring and management of ICH patients should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1.
• Clinical seizures should be treated with antiseizure drugs, and patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiseizure drugs 1.
• A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk of pneumonia 1.

From the Research

Evaluating Patient in NSICU

The evaluation and management of patients in the Neurosurgical Intensive Care Unit (NSICU) require a comprehensive approach. Key aspects of this approach include:

• Monitoring of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to guide targeted therapy [(2,3)]
• Use of multimodality monitoring to assess cerebral well-being and guide individualized management 2
• Consideration of the patient's specific pathology, time, and individual characteristics when determining optimal CPP 2

Monitoring Techniques

Various monitoring techniques are available for assessing ICP and cerebral blood flow in the NSICU, including:

• Intracranial pressure monitoring using subarachnoid screws or other devices [(3,4)]
• Transcranial Doppler ultrasonography 3
• Laser Doppler and thermal diffusion flowmetry 3
• Perfusion and diffusion magnetic resonance imaging 5

Management Strategies

Management strategies for patients in the NSICU may include:

• Maintenance of CPP above 70 mmHg to ensure adequate cerebral perfusion 6
• Use of medical management to control ICP and CPP [(2,4)]
• Surgical intervention, such as exploratory burr holes or craniotomy, in cases where ICP cannot be controlled medically 4
• Individualized management based on the patient's specific needs and response to treatment [(2,6)]