What are the best practices for stroke care in the Intensive Care Unit (ICU)?

Best Practices for Stroke Care in the ICU

Patients with acute stroke should be treated in a dedicated stroke unit with specialized interdisciplinary care to significantly reduce mortality, improve functional outcomes, and increase the likelihood of returning home after stroke. 1

Core Elements of Effective ICU Stroke Care

Specialized Stroke Unit Structure

• Establish a geographically defined hospital unit dedicated exclusively to stroke patients 1
• Staff with an interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1
• Admit patients to the stroke unit as soon as possible, ideally within 24 hours of hospital arrival 1

Monitoring Protocols

• Implement hourly assessments (or more frequent as needed) of:
  • Level of consciousness (using Canadian Neurological Scale Score)
  • Neurological status and symptom severity
  • Blood pressure
  • Oxygen saturation (maintain >94% only if hypoxic) 1
  • Temperature
  • Blood glucose 1

Rapid Response Systems

• Create rapid response teams with dedicated stroke training and immediate access to neurological expertise 1
• Establish clear protocols for notifying the stroke team and neurosurgeon when changes in status occur, particularly:
  • Decreased level of consciousness
  • Change in CNS score ≥1 point
  • Change in NIHSS score ≥4 points 1

Imaging and Assessment

• Perform repeat CT scans when deterioration in neurological status occurs 1
• Standardize evaluation with physical assessment and imaging 1
• Implement bedside dysphagia screening/assessment for all stroke patients 1

Management of Complications

Elevated Intracranial Pressure

• Manage according to institutional protocols, including:
  • Administration of hyperosmolar therapy
  • Head of bed elevation 1
• For patients selected for decompressive hemicraniectomy:
  • Proceed urgently before significant decline in GCS or pupillary change
  • Consider surgery within 48 hours from stroke onset 1

Airway Management

• Assess need for airway support and oxygen therapy
• Provide supplemental oxygen only to maintain oxygen saturation >94% when hypoxic 1
• Identify patients who may require more aggressive airway management:
  • Those with decreased mental status
  • Posterior circulation involvement
  • High NIHSS score
  • Major cardiopulmonary comorbidities 1

Blood Pressure Management

• Closely monitor BP in the first 48 hours after stroke onset
• Follow institutional protocols for BP management, recognizing that optimal BP targets remain uncertain 1

Quality Improvement and Systems of Care

In-Hospital Stroke Protocols

• Develop standardized stroke care order sets or pathways 1
• Establish an in-hospital stroke quality oversight program with:
  • Data-driven performance feedback
  • Targeted quality improvement efforts 1
• Implement protocols for interfacility transfer to advanced stroke treatment centers when needed 1

Staff Education and Training

• Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts 1
• Ensure staff can recognize potential complications of reperfusion therapy (e.g., hemorrhagic transformation) 1, 2

Special Considerations

In-Hospital Stroke

• Recognize that in-hospital strokes (4-17% of all strokes) have worse outcomes than community-onset strokes 1
• Be aware that cardioembolic events account for approximately 50% of in-hospital strokes 1
• Implement the same rapid response and care protocols as for patients admitted from the emergency department 1

Post-Reperfusion Therapy Care

• Monitor closely for hemorrhagic transformation after thrombolysis or thrombectomy 2
• Be vigilant for bleeding complications with patients receiving tPA, particularly those with:
  • Recent surgery or procedures
  • Thrombocytopenia
  • Other hemostatic defects
  • Severe hepatic or renal disease 3

Common Pitfalls and Caveats

• Delayed recognition and treatment of in-hospital strokes despite being in a monitored environment 1
• Failure to implement standardized protocols for stroke assessment and management 1
• Inadequate monitoring for neurological deterioration requiring repeat imaging or intervention 1
• Excessive force when managing occluded catheters in patients receiving thrombolytic therapy 3
• Overlooking the need for specialized stroke unit care for all stroke patients, regardless of stroke severity 1, 4

By implementing these evidence-based practices in ICU stroke care, healthcare facilities can significantly improve patient outcomes, reducing mortality and disability while increasing the likelihood of functional recovery and return to home after stroke.