Principals of Neurocritical Care in the Acute Stroke Patient

1
Principals of Neurocritical Carein the Acute
Stroke Patient
Alexander Y. Zubkov, MD, PhD, FAHA Clinical
Associate Professor of Neurology Director of
Stroke Center Fairview Southdale
Hospital Minneapolis Clinic of Neurology Kari
Olson, RN, BSN, CNRN Neuroscience Nurse Clinician
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DISCLOSURE

• Relevant Financial Relationship(s)
• None
• Off Label Usage
• None

3
Objectives

• Learning Objectives Upon completion of this
  call, participants will be able to
• Describe Neuro Critical Care management of acute
  stroke patients.
• Explain advances in neurosurgery for the stroke
  patient including decompressive hemicraniectomy
  for malignant cerebral edema
• Describe nursing care guidelines for the pre and
  post neurosurgical stroke patient

4
Pressing Issues in Acute Ischemic Stroke

• Restoring blood flow
• Monitoring for edema and swelling
• Managing risk of bleeding with tPA
• Preventing and minimizing secondary injury

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General Care Principles

• Maximize standard medical management
• B/P, fever, hyperglycemia, seizure activity
• Neuroprotection
• Improve cerebral blood flow
• Induce HTN
• Recanilization with thrombolysis
• Large vessel intra-arterial thombolectomy/lysis
• Prevention of complications

6
Airway and Mechanical Ventilation

• Management of the airway and mechanical
  ventilator is different in neurologic critically
  ill patients.
• Many patients admitted to NICU have normal
  baseline pulmonary function
• Mode of mechanical ventilation in acutely ill
  neurologic patient is often limited to
  intermittent mandatory or assist control modes
• Ventilator dependency is much less common

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Airway and Mechanical Ventilation

• Any amount of hypoxia of the injured brain will
  add a significant damage to the brain.
• Thus, intubation should be preferably performed
  in the controlled settings, and sometimes it is
  safest to perform in the anticipation of the
  respiratory problems rather than when the
  respiratory failure will occur.

8
Volume Status and Blood Pressure

• Very few patients admitted to NICU are euvolemic
  and correction of volume status is one the first
  steps in the management of critically ill
  neurological or neurosurgical patient
• Initial correction of hypovolemia should be done
  with crystalloids (normal saline). Glucose
  containing solutions may precipitate increased
  lactate production and secondary brain injury

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Volume Status

• 200 mL/hr
• .9 sodium cloride
• Correct insensible loss
• GI 250 mL
• Skin 750 mL
• Fever 500 mL/degree C
• Sweating

• Fluid balance 750-1,000 mL/ day excess
• Maintain body weight
• Hematocrit lt 55
• Osmolality lt350 mosm/L
• Serum sodium lt 150 meq/L

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The Importance of Blood Pressure

• Hypertension is a physiological response in
  stroke
• BP reduction is associated with worse outcome
• BP fluctuations are associated with worse outcome
• BP augmentation may be safe and effective at
  least in selected cases

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Management of Blood pressure

• Current recommendations include cutoff point in
  treatment of hypertension if systolic pressure is
  above 230 mm Hg, or diastolic pressure is above
  125 mm Hg, or mean pressure above 130 mm Hg.
• It is reasonable to gradually decrease blood
  pressure with rapid-acting antihypertensive
  medications if mean pressure is getting above 130
  mm Hg.

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Hypertension a physiological response to brain
hypoperfusion

• 149 pts monitored for 12 hr after IA
  thrombolysis
• SBP, DBP and MAP similar before thrombolysis
• 12 hr after thrombolysis, SBP/MAP/DBP lower
• in pts with adequate recanalization
• When recanalization failed, BP remained elevated
• longer

Mattle et al. Stroke 200536264-8
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Detrimental effect of BP reduction in first 24
hours after stroke onset

• Prospective assessment of 115 pts evaluated
  within
• 24 hr of stroke onset
• Mean NIHSS 4.5
• Most common mechanism cardioembolism (30)
• Predictors of poor outcome at 3 mo on
  multivariable
• analysis - Higher NIHSS
• (OR 1.55 per 1 point increase in score)
• - Degree of SBP reduction in first 24 hr
• (OR 1.89 per 10 SBP decrease)

Oliveira-Filho et al. Neurology 2003611047-51
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The Importance of Blood Glucose

• Hyperglycemia in acute stroke is associated with
• Worse functional outcome
• Lower rates of recanalization
• Higher rates of hemorrhagic complications
• Trials of acute intensive glycemic control
  ongoing

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Infections / Fever

• Fever develops in 25-50 of NICU patients.
• 52 percent of fevers were explained by
  infectious etiology with most predominant
  pulmonary pathology.
• Non-infectious etiologies of fever may occur and
  include reaction to blood products, deep vein
  thrombosis, drug fever, postsurgical local tissue
  injury, pulmonary embolism and central fever with
  its extreme autonomic storms (episodes of profuse
  sweating, tachycardia, tachypnea, bronchial
  hypersecretion).

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The Importance of Body Temperature

• Fever after acute stroke is associated with worse
  functional outcome
• Preliminary evidence suggests that aggressive
  control of hyperthermia (and perhaps induced
  hypothermia in cases of massive brain infarction)
  may be beneficial
• Rigorous, larger interventional trials needed

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Nutrition

• The main goal of nutrition should be to preserve
  muscle mass, and to provide adequate fluids,
  minerals and fats
• It is prudent to consider postpyloric feeding in
  patient with neurological catastrophies, because
  gastric atony increases the risk of aspiration.
• Enteral feeding should be preferably done by
  continuous infusion with a volumetric pump.

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Seizures

• Acute injury to the cortical structures can
  elicit seizures.
• Seizures may be focal or generalized, single or
  continuous
• Tonicclonic status epilepticus is commonly
  defined as repetitive seizures without full
  recovery between the episodes, usually with
  seizure intervals of 5 to 10 minutes

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Seizures

• Nonconvulsive status epilepticus is much
  difficult to diagnose and likely is less common.
• Clinical hallmarks are decrease in the level of
  consciousness or fluctuation in responsiveness.
• Patient may have fluttering of the eyelids or eye
  deviation as only signs of nonconvulsive status
  epilepticus.

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Seizure Assessment

• Continuous clinical assessment
• Continuous vEEG monitorin
• 20 minute EEG will demonstrate 15 of seizures
• 60 minute EEG 50
• 24 hours monitoring close to 90

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Seizure Management

• Benzodiazepins
• Ativan 4 mg IV push
• Antiepileptic medications
• Dilantin may be toxic for the acutely injured
  brain
• Depakote may cause severe platelet dysfunction
  and bleeding
• Keppra seems to avoid significant side effects
  and used widely in NICU

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Seizure Management

• Failure of lorazepam and fosphenytoin in adequate
  doses to control seizures indicates transition to
  refractory status epilepticus.
• At this point either increasing doses of
  barbiturates or midazolam should be used for
  treatment.
• Propofol is another alternative but high dosis
  are needed. Propofol infusion syndrome sudden
  cardiovascular collapse with metabolic
  acidosis-is a serious complication that limits
  the routine use of this otherwise very effective
  medication.

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Anticoagulation

• Neurological patients has a higher incidence of
  DVT due to lack of mobility in the affected
  limbs, associated with neurological injury.
• Clinically apparent DVT was reported in 1.7 to
  5 of patients with ischemic stroke
• Subclinical DVT occurred in 28 to 73, mostly in
  the paralyzed extremity
• 5 of the patient with ICH died of pulmonary
  embolism (PE) within the first 30 days.

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Anticoagulation

• Only mechanical methods (intermittent pneumatic
  compression with or without elastic stockings)
  should the standard of care.
• The use of unfractionated heparin was left on the
  discretion of the practitioner
• One study in TBI patients demonstrated no
  increase risk of hemorrhage in patients treated
  with unfractionated heparin within 72 hours

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Large Hemispheric Stroke Issues

• High risk for deterioration in first 24-72 hours
• Neurologic causes edema, hemorrhagic
  transformation, restroke
• Systemic causes fever, infection, hypotension,
  hypoxia, hypercarbia

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Malignant MCA Syndrome

• Malignant brain edema
• Mortality up to 80
• Starts days 1-3
• Peaks days 3-5
• Subsides by 2 weeks

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Who is at Risk for Developing Malignant MCA
Syndrome?

• Clinical Picture
• hemispheric syndrome with hemiparesis,
  hemianesthesia
• eye deviation
• those requiring early intubation for airway
  protection
• global asphasia
• somnolence

• Radiographic Picture
• CT findings in 1st 6 hours
• Large early hypodensity
• Loss of gray/white matter distinction
• Hyperdense MCA sign
• CT findings at 24 hours
• Mass effect

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Intracranial pressure

• Monro-Kelly doctrine
• ICP depends on the volumes of blood,
  cerebrospinal fluid and brain to be in the
  balance.

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Intracranial pressure

• CSF shift from ventricular or subarachnoid space
  into spinal compartment.
• Reduction of intracranial blood volume achieved
  by collapsing of veins and dural sinuses and by
  changes in the diameter of cerebral vessels.
• If the limits of compensatory mechanisms are
  exceeded, minimal increase in the intracranial
  volume will lead to precipitous rise of ICP.

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Intracranial Pressure

• Intracranial pressure monitoring is an integral
  part of NICU.
• The indications for placement of ICP monitors
  include GCS lt 8, severe traumatic brain injury,
  massive cerebral edema from infarction

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Intracranial Pressure Management

• Head position should be neutral to reduce any
  possible compression of jugular veins.
• Head elevation of 30º is considered standard
• Patients should be made comfortable, avoid pain,
  bladder distention, and agitation, because all of
  them might increase ICP.

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Intracranial Pressure Management

• Hyperventilation
• Aggressive hyperventilation might decrease
  cerebral blood flow to the levels approaching
  ischemia.
• Hyperventilation should only be used as a bridge
  measure while other means of ICP control are
  instituted

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Intracranial Pressure Management

• Osmotic diuresis mainstay of the therapy
• Mannitol is not only facilitates movement of
  extracellular water, but also might be increasing
  CSF absorption
• The effect is apparent within 15 minutes and
  failure to respond to mannitol is usually a bad
  prognostic sign
• 100 grams IV over 30 minutes
• 50 grams IV q6h with osmolality monitoring.
• Hypertonic Saline
• 3 NaCl - continuous infusion
• 7.5 NaCl - mostly used in trauma centers
• 23.4 saline

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• Sixty-eight patients met criteria for TTH and
  received 23.4 saline, and there were a total of
  76 TTH events in these patients.
• The 23.4 saline was administered as a bolus of
  30 mL in 65 events (85.5) and 60 mL in 11 events
  (14.5).

Neurology, Mar 2008 70 1023 - 1029
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Hypertonic Saline Effect

• Clinical reversal of TTH occurred in 57/76 events
  (75.0).
• Median (IQR) GCS increased from 4(3-5) at the
  time of herniation to 6(4-7) (plt0.01) 1 hour and
  7(5-9) 24 hours following TTH (plt0.001).

Neurology, Mar 2008 70 1023 - 1029
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Intracranial Pressure Management

• Hypothermia
• Need to continue the study of safety and
  effectiveness in the Neuro ICU.
• Guidelines needed for best practice temperature
  thresholds and rates of rewarming.

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Decompressive Hemicraniectomy

• Allows for the expansion of edematous tissue
  outside the cranial vault
• Decreases mortality and disability
• Issues
• Patient Selection
• Timing of surgery
• Dominant vs. non-dominant hemisphere strokes

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Outcome at 1 year by treatment group for all
three studies combined
Lancet Neurology, 8( 7) 603-604, 2009
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Subarachnoid hemorrhage

• Hydration with normal saline should be started
  immediately and patient should receive at least
  2-3L of fluids in the first 24 hours.
• Attention should be paid to possible neurogenic
  pulmonary edema and fluid management should be
  adjusted accordingly.
• Cardiac stunning might occur in the poor grade
  SAH and might contribute to pulmonary edema

42
Subarachnoid hemorrhage

• Management of hypertension depends on the stage
  of the treatment.
• In the patients with unsecured aneurysm we tend
  to keep mean arterial pressure below 100 mm Hg.
• In patients who underwent aneurysmal repair, mean
  blood pressure should be liberalized up to 130 mm
  Hg.

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Subarachnoid hemorrhage

• Nutrition usually delays to the second day.
  Nausea and vomiting are common on the first day,
  in addition to gastroparesis in more severely
  impaired patients
• Deep vein thrombosis prophylaxis should utilize
  mechanical means only.
• Gastric ulcer prophylaxis is important in all
  patients due to high incidence of stress ulcers.

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Subarachnoid hemorrhage

• Stool softeners should be used in all patients to
  prevent straining, which may lead to rerupture of
  the aneurysm.
• Indwelling catheters should be used to close
  monitoring in outputs due to potential of the
  development of SIADH.
• Headache may be relieved by acetaminophen with
  codeine or tramadol.
• Vomiting should be aggressively treated.

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Subarachnoid hemorrhage

• Deterioration in patients with SAH can be delayed
  and related to rebleeding, hydrocephalus,
  vasospasm, or enlargement of frontal or temporal
  intraparenchymal hematoma.

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Intracerebral hemorrhage

• Hemorrhages have a potential of enlargement in
  about a third of the patients and management
  should be directed towards supportive measures.
• Very aggressive decrease of blood pressure may
  precipitate ischemia
• Comatose patients could benefit from the
  monitoring in intracranial pressure.
• Intracranial pressure should remain below 20 mm
  Hg and cerebral perfusion pressure must remain
  in the range of 60 to 80 mm Hg to provide
  adequate cerebral blood flow

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AAICH

• Anticoagulation-associated intracerebral
  hemorrhages should be immediately reversed with
  fresh frozen plasma and vitamin K.
• Factor VIIa - works within 10 minutes
• It is short lived factor.
• Treatment should be followed by administration of
  FFP and Vitamin K
• INR should be monitored for at least 72 hours

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Time is Brain

• For every minutes delay, the brain loses
• 1.9 million neurons
• 14 billion synapses
• 7.5 miles of myelinated fibers.
• If a stroke runs its full course an estimated
  10 hours on average the brain loses
• 1.2 billion neurons
• 8.3 trillion synapses
• 4,470 miles of myelinated fibers.

Stroke 200637263-266
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Nursing management of Acute Stroke

• Airway management/ventilator management
• Assessment and evaluation of neurologic status to
  detect patient deterioration
• Blood pressure management
• General supportive care and prevention of
  complications associated with
• Dysphagia, HTN, hyperglycemia, dehydration,
  malnourishment, fever, cerebral edema, infection,
  and DVT, immobility, falls, skin care, bowel and
  bladder dysfunction.

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Nursing Management of Acute Stroke

• Coordination of interdisciplinary team and plan
  of care
• Support and counsel for patient family

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Intensive Nursing Management

• Monitor for bleeding complications after tPA
• ICH-Hemorrhagic transformation
• retroperitoneal bleed, genitourinary and
  gastrointestinal hemorrhages
• Patients over age of 80 with higher NIHSS score
  at greater risk of ICH

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Intensive Nursing Management

• Management of suspected ICH after tPA
• Notify physician, possible neurosurgery consult
• Stop tPA infusion
• Prepare for stat brain imaging, lab, type and
  cross
• Prepare to administer platelets, cryoprecipitate,
  FFP
• Increase frequency of nursing assessment

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Intensive Nursing ManagementCerebral Edema after
stroke

• Usually peaks 3-5 days after stroke
• Can be an issue in first 24 hours in cerebellar
  infarct and younger stroke patients
• If not detected and treated can lead to increased
  intracranial pressure, brain herniation and death

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Recognizing Increased ICP

• Early signs
• Decreased LOC
• Deterioration in motor function
• Headache
• Changes in vital signs

• Late signs
• Pupillary abnormalities
• Changes in respiratory pattern
• Changes in ABGs

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Nursing Care of the Decompressive Hemicraniectomy
Patient

• Airway management adequate O2 saturation
• Preventing increased ICP and providing supportive
  care.
• Hourly vitals/neuros including ICP, CPP, CVP.
• Maintaining BP to ensure adequate CPP
• Seizure precautions
• Antibiotic prophylaxis

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Nursing Care of the Decompressive Hemicraniectomy
Patient

• Place a sign on bed to alerting care providers
  which side of the skull is missing the bone flap
• Do not turn patients onto side of missing flap
• Monitor hemicraniectomy site for changes in
  appearance- bulging, inflammation, CSF leakage
• Fit with head gear to protect surgical site when
  up

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Decompressive Hemicraniectomy

• Bone flap stored in a Bone Bank or sewn into a
  pouch in patients abdomen.
• Bone replaced at around 3 months from the time of
  the infarction.

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Team Work

• Key to the care of the NICU patient
• Stabilization
• Prevention of complications
• Monitoring neuro status
• Family support and education

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Resources

• Adams, H. et al (2007). Guidelines for the Early
  Management of Adults with Acute Ischemic Stroke.
  Stroke 38, 1655-1711.
• Ropper, A.H., Gress, D.R., Diringer, M.N., Green,
  D.M. , Mayer, S.A. , Bleck, T.P. Neurological and
  Neurosurgical Intensive Care. Fourth edition.
  Lippincott Williams Wilkins.2004. Philadelphia,
  PA
• Summers, et al. (2009) Comprehensive Overview of
  Nursing and Interdisciplinary Care of the Acute
  Ischemic Stroke Patient. Stroke 40, 2911-2944.
• Tazbir, J., Marthaler, M.T., Moredich, C.,
  Keresztes, P. Decompressive Hemicraniectomy with
  Duraplasty A treatment for Large-Volume
  Ischemic Stroke. Journal of Neuroscience
  Nursing. August 2005. 37(4).
• Wojner Alexandrof, A. W., Hyperacute Ischemic
  Stroke ManagementReperfusion and Evolving
  Therapies. Critical Care Nurse Clinician North
  America. 21(2009) 451-470.