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Wessex Neuro ICU
Guidelines
2015
2017
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Cordingly & Hell

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these guidelines they may not be up to date.
This version was last modified on:

10th May 2017
www.neuroicu.org.uk
Wessex Neuro ICU
Guidelines
2017
Matthew Cordingly John Hell

Consultant in Neurointensive Care Consultant in Neurointensive Care
and Neuroanaesthesia and Neuroanaesthesia
Wessex Neuro ICU Wessex Neuro ICU
Copyright 2013 Matthew Cordingly & John Hell
All rights reserved. No part of this document may be reproduced

or distributed in any form or by any means, or stored in a database
or retrieval system without the permission of the copyright holders.
Contents
Contents
1. Introduction 1
2. Patient care on Neuro ICU 3
Introduction 3
Neuro ICU daily timetable 4
3. Neuro ICU admission and discharge 5
Admission guidelines 5
Levels of care 6
Admission criteria for major trauma patients 6
Admission procedure for all patients 7
Discharge criteria 9
Transfer to patients local critical care facility 9
Discharge summary 10
4. Patient assessment 13
Patient review 13
Glasgow coma scale (GCS) 15
Assessment of pupils 17
5. Ventilation 19
Invasive ventilation 19
Non-invasive ventilation 24
Tracheostomy care 26
Management of chest drains 27
6. Cardiovascular management 29
Blood pressure targets 29
Elevating blood pressure 31
Patients admitted on anti-hypertensive medication 33
7. Fluid management 34
Electrolyte disorders 34
CNS injured patients with diabetes mellitus 39
Commencement of variable rate IV insulin infusion 41
8. Enteral feeding & bowel management 43
Establishing enteral feed 44
Insertion and management of jejunal feeding tubes 46
Enteral Feeding around Surgical / Airway Procedures 49
Bowel management 50
9. Haematology, coagulation and platelet function 54
Haemoglobin and oxygen carriage 54
Platelet function and coagulation 54
Abnormal coagulation or platelet function from disease 55
Patients on long-term anticoagulation 57
Patients on antiplatelet agents 62
Emergency neurosurgery 64
Patients born after January 1996 64
iii
10. Deep vein thrombosis prophylaxis 65
Anti-embolic stockings (AES) 65
Intermittent pneumatic compression (IPC) devices 65
Low molecular weight heparin (LMWH) 66
11. Prophylactic antibiotics, infection and sepsis 68
MRSA screening & prophylaxis 68
Diarrhoea 68
Prophylactic antibiotics 69
Infection and sepsis 70
Ventriculitis & cerebral abscess 73
12. Seizure management 75
Diagnosing seizures 75
Management of generalised seizures 76
Investigation of new onset status epilepticus 80
Management of focal seizures 81
13. Post-operative care 82
Admission process 82
Analgesia 83
Sedation & ventilation settings 84
Haemodynamic & haematological management 85
14. Traumatic brain injury 86
Introduction 86
Management of intubated and ventilated patients 87
Levels of ICP management 92
Management of self ventilating patient with head injury 101
15. Management of agitation 104
General principles 104
Richmond agitation-sedation score (RASS) 105
Management of agitation 106
RASS & Wessex modified RASS 110
16. Spinal precautions for the trauma patient 111
Transfer of patients with spinal precautions 111
Clinical assessment to exclude bony cervical injury 112
Sedated & ventilated patients 112
Use of the Occian Back of the Miami J Collar 117
17. Management of spinal cord injury 118
Patient assessment 118
Management 121
Steroid treatment in acute spinal cord injury 128
18. Spontaneous subarachnoid haemorrhage 129
Introduction 129
Complications of SAH 130
Management protocol 131
Deterioration following coiling 138
19. Lumbar puncture 139
iv
Contents
Indications 139
Contra-indications 139
Procedure 140
20. External ventricular drains 143
Introduction 143
Key points about EVDs 143
CSF sampling 144
Ventriculitis 145
EVD Sampling Guideline 147
Intrathecal (IT) Drug Administration 149
21. Thrombolysis in acute stroke 151
Initial management 151
Potential complications of thrombolysis 152
22. Decompressive craniectomy for neurological conditions 155
Who gets referred to Wessex Neurological Centre 155
Management of stroke patients prior to arrival at WNC 157
Management at Wessex Neurological Centre 160
23. Acute neuromuscular weakness 166
Introduction 166
Guillain-Barr syndrome (GBS) 166
Myasthenia gravis (MG) 169
Motor neurone disease (MND) 172
24. Therapeutic plasma exchange 174
Management 175
Complications 176
25. Pre-operative care 177
Drugs on day of surgery 177
26. Epidural blood patch for intracranial hypotension 180
Patient preparation 180
Contraindications 181
Procedure 181
Post epidural blood patch instructions 182
27. Withdrawal of therapy and end of life care 183
Withdrawal of therapy 183
Compassionate care pathway 185
Do not attempt CPR (DNACPR) 186
Do not escalate therapy 187
28. Diagnosis of brain death and brain stem testing 188
Preconditions 188
Exclusion of reversible causes of coma and apnoea 188
Clinical assessment of brain stem function 190
Performance and repetition of testing 190
Miscellaneous considerations 191
29. Organ and tissue transplantation 192
Donor identification and referral 192
v
Contraindication to organ donation 193
Consent 194
Organ donation following brainstem death 195
Non-heart beating organ donation 198
30. Unfractionated heparin IV infusion 199
Initiation of unfractionated heparin infusions 199
Bleeding whilst on IV unfractionated heparin 201
31. IV drug compatibility & infusions 204
Y-site compatibility of IV infusions 204
Common drug infusions 206
Therapeutic drug monitoring on Neuro ICU 208
32. Index 209
vi
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Introduction
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These guidelines represent the current policies and practice of The Wessex Neuro
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ICU. They have been designed to act as a framework and guidance for the manage-
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ment of commonly encountered situations in our daily work. No attempt has been
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made to reference any of the information provided, because much of it has developed
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as a consensus of management, heavily influenced by discussion and reflection at our
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monthly morbidity and mortality meetings.
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This is a practical guide which concentrates on the most basic aspects of everyday
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care of the whole patient, aiming to ensure that management is consistent from day to
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day. Where possible we have tried to provide brief explanations as to why a particular
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treatment is recommended, eg explaining why a patient with a high spinal cord injury
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will ventilate better lying flat rather than sat or tilted head up. In every situation where
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there remains doubt about the best course of management for an individual patient,
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specialist advice should be sought.
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There will be times when it is entirely appropriate to deviate from these guidelines
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to individualise management to the patient, their condition, and their circumstances.
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A guiding principle must always be to seek to return the patient to a quality of life that
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they would find acceptable. This may not have been achieved by time of discharge
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from the unit, and will require the support of their local hospital team, rehabilitation and
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community services. Where this is not deemed possible, we endeavour to ensure that
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a plan is in place for the timing and institution of palliative care. Fortunately the regular
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visits by patients who have regained their quality of life following serious brain injuries,
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act as a constant source of inspiration to the whole team.
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1
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2
2
Patient care on Neuro ICU

Introduction
Responsibilities for the Neurosciences Intensive Care Unit (Neuro ICU) team
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their time on the unit, organising diagnostic and screening tests, and communicating
with patients and relatives. A key role of the Neuro ICU team is the co-ordination of
input from neuroscience and non-neuroscience specialist teams (e.g. neurosurgery,
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4
3
Neuro ICU admission and
discharge
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6
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No anaesthetists are present on Neuro ICU out-of-hours

tae. Uptatio No
dolorem nus theatre
operating sinctemorfugit iditatiorum
recovery vit volupta
staff are present porem quatusa pedionsequis
out-of-hours
Admission procedure for all patients
rersperoAppropriate
ommo ommolor spinalposandi
management of all patients
gnimus.Laborer with a dolorehent
iaerupienis history of trauma should
lis eos doles be
volorib
assessed
usant. Quia nonat con
timenullaut
of admission
veratemoto unit. Seemodipis
tem aut spinal management chapter. aut et Wessex
cimint quia nonsequis

All patients must be reviewed by a Neuro ICU fellow on admission to the unit

none option Neuro ICUcumqui
nat quia
fer team
fellow should be availableaccus.Quis
ullest ligenihiciet to take verbal
sit, handover fromconecto
offictem quo the trans-
ditia-

volo iur?Volorent
NeuroutICU
ut que et mi, quas
admission sin cum
proforma mustquidellandel incto quassit faccatur maximi,
be fully completed

Summary of admission history, past medical conditions etc
est ad magnam Handedness
|| reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
fugit officiatis|iur,
| sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
Occupation
ad eum fugia|volorpo
|
reptur? status
Functional Et lam venda non consediam aut es dolendipsum venis rerum a
7
Wessex
solo NeuroNusda

explautem Fulleumexamination
re cor aut omnis of patient,
a vit,including
Wessexsecondary
Neuro ICUsurvey for all trauma
Guidelines consecate consect
patients. Secondary survey must include clear documentation of all abra-
emoluptae sions/contusions
veribus am rem quid eaturbeassimillat.Wessex
etc (May Neuro ICU Guidelines Tis dolupti
required by police/coroner)

autatatque Neuro ICU prescription
parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la
num et endia Transcribe
|| vendi ipsandem appropriate pre-existing
apidell endesec medication
ulloribus deribus(eg continue
di ipsam beta-block-
harit quibus, cori-
ers, anticonvulsants, antibiotics and steroids)
Busciis aceati|| omnit laut autate
All patients shouldWessex NeuroonICU
be started Guidelines
(these feature in con
theesNICU
magnam in porrovit,
Admission
Bundle on
seriatur?Pa sedioreped quosaePrescribing):
consequas acepe conest ut am, quo dis enia vitae. Perovit
odit hillorest, nusdand
Gutantibusape nonsequ assequi
protection (ranitidine 50mg IVdoluptatur?
tds initially,Qui in eum
unless on aaut aut ommolor
proton
erorerum repe conseque pump nos inhibitor already)idessum est doluptur, est min ped mod et resciunt,
et debitatia
qui doloratatas volupta seriam solorest
Gut protection is continuedvoluptatis modit
for entire explatur?
Neuro ICU stayIquiinblam
brainfaceprovit
or spinal eaqui
nosto erio. Wessex cordNeuro
injuredICU Guidelines
patients, as thisVerum
patientipidunt
group volor adit la doluptasit
is associated with a highautrisk
reiciet
pro enecta nis etofquiasim
peptic ulceration - Cushing
enimos moluptate voloulcers
qui cus explam as accae dolo bersped que
Regular
Nosam verferf erferspit
Laxatives: Senna 15mg NG/PO nocte (10ml syrup), and
que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
Docusate sodium 50mg NG/PO tds
tium entis nima
PRN Laxatives: Magnesium hydroxide 10ml NG/PO bd, and Glycerol
sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de
(glycerin) suppositories 8g PR od
re corrorporest quos Fulleum length Anti-Embolic
nobistibus Stockings
nis evento tem et(AES)
pratem. andUtIntermittent Pneumatic
rem eatenienis enimolup-
Compression (IPC) devices unless contra-indicated.

dolorumquunt
ratur, omnihit
Chest X-ray
as dit mo for corall
sapatients:
porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
|| incidus ea Wessex
Expected to stayNeuro
longerICU thanGuidelines
24hrs qui quaerov itendae volor aligenime
|| Ventilated or with abnormal gas exchange
rerspero ommo Followingposandi
|| ommolor centralgnimus.Laborer
line placement iaerupienis dolorehent lis eos doles volorib

usant. QuiaECG non con nullaut
reviewed andveratemo
signed tem aut modipis cimint quia nonsequis aut et Wessex
Venous-thromboembolism assessment must be completed for all
none option nat patients
quia cumqui admittedullest ligenihiciet
to Neuro ICU. accus.Quis
All patients must sit, offictem quo conecto ditia-
have anti-embolic
stockings (AES)
turias prepedi taecerrovita and intermittent
vit pelitatia con peraepneumatic compression
voluptae doluptia nimi, (IPC)
venisdevices
nemquame
volo iur?Volorentunlessut ut quecontra-indicated.
et mi, quas sin cum quidellandel incto quassit faccatur maximi,

comnimusam
est ad magnam
res que
Ensure
& save.
full lab
set inis coreperum
of bloods di bla
including aut U&E,
FBC, ut veria dignima gnihicimus
coagulation
reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
screen andsuntiae
group ditiis

fugit officiatis iur, sam,
Arterial blood ut quaeperrovid
gas if arterial lineulparcitaqui
present or oditappropriate.
essint aut adis as commodi ctisit ant,

Any patient
quo testis maximus that hasque
aecabore, been immobile
nonem at home or
es repereped ut in
ut adolupta
hospitalsundit,
for >24adhours
qui cullenim
should have lower limb dopplers performed as soon as possible after admis-
volor alis susdandis moluptam
sion to exclude anyeveris
DVT thatpratate
is notiliquas rem que
clinically nos endicitin est ipieneculpa sus
obvious.
8
Chapter
solo 3
est, exeriae. Nusda nonsequo temolec erovitatenis Neuro ICU admission
doles and discharge

explautem eum All patients
re cor autshould
omnisbe reviewed
a vit, Wessexby theNeuro
NeuroICU ICUGuidelines
consultant consecate
within 12 hours
consect
of admission to the unit. This must be documented clearly to ensure an
emoluptae veribus am rem
appropriate quid eaturplan
management assimillat.Wessex
is in place. Neuro ICU Guidelines Tis dolupti
Discharge criteria
BusciisAllaceati omnit
patients lautmajor
with autate Wessex
trauma andNeuro ICU Guidelines
CNS injury that no longer conneed
es magnam
specialistin neuro-
porrovit,
seriatur?Pa
surgical sedioreped quosa consequas
and neurointensive acepe conest
care are appropriate ut am, quoonce
for discharge, dis they
enia are
vitae. Perovit
stable.
Transfer to ward care if:

qui doloratatas volupta seriam
Maintained airway solorest voluptatis modit explatur? Iqui blam faceprovit eaqui

Tracheostomy acceptable once established and adequately secured
Requiring
velese ma inctota chestacest,
quidunt physiotherapy
idenihicti and suctioning
im cus a dolesto lesseatas
frequently
aut pelthan 3 hrly tibus.
is dolesci

FiO2 < 0.6 with SpO2 95% for 24 hrs

tium entis nima Haemodynamically stableeumet
sit que eostiis citam,
0.5ml/kg/hr
off inotropes / vasopressors
voluptasit with urinequam
posandu ntioreritem outputad>ma de

re corrorporest GCS quos eum> nobistibus
stable nis evento
8 and protecting cleartem et pratem. Ut rem eatenienis enimolup-
airway

dolorumquunt
Agitation controlled with oral medication and manageable with a single
as dit mo cor
appropriate sa porroprofessional
healthcare et volupti beatquo cus.Liqui dolupid molor sit vellis debis

quatem aspedit Spinally
atateminjured patient
consedia with (stable
volorerum or operatively
et omni od qui bearum stabilised) injuryrebelow
is estrunt volor C5rehent
and stable neurological deficit or no deficit

rerspero ommo Patient
rent
considered
ommolor
treatment
posandi inappropriate
gnimus.Laborer for further critical
iaerupienis care or escalation
dolorehent
of cur-
lis eos doles volorib

Neuro ICU Guidelines
Patient onlydolupta tureped
for palliative careullorepudam iunt, nulparciur?Perio. Ut de vendam,

Pain controlled with oral analgesia or patient controlled analgesia (PCA)
volo Transfer
iur?Volorent to patients
ut ut que et mi, local
quas sin critical care facility
cum quidellandel incto quassit faccatur maximi,
As soon as patients no longer require specialist neurosciences care (eg presence of
external ventricular drain / requirement for plasma exchange), explicit consideration of
the repatriation of the patient to their local hospital should occur daily.
Transfer
quo testis maximus to another
aecabore, Level
que2nonem
or Level 3 facility requires
es repereped the patient
ut ut dolupta sundit,toadhave been
qui cullenim
voloraccepted undermoluptam
alis susdandis the care everis
of an appropriate
pratate iliquas named
rem que consultant, bed est
nos endicitin available, and sus
ipieneculpa a
suitably
mi, nime trained
voluptas and qualified
simus. transfer team
dolupta tureped available
ullorepudam to transfer
iunt, the patient safely. Both
nulparciur?Perio
9
Wessex
solo NeuroNusda
Neuro ICU
explautem eumconsultant
re cor aut and specialty
omnis a vit,consultant shouldICU
Wessex Neuro be inGuidelines
agreementconsecate
that transfer is
consect
appropriate
emoluptae at that
veribus amtime.
rem Many neurosurgical
quid eatur patients require
assimillat.Wessex Neuro aICU
CT Guidelines
Brain scan Tispriordolupti
to
transfer from
ntibusande natetdefinitive
atistibus,care.
utemThis scan must
quosam be reviewed
reriberro od molendeby thenatemosame
neurosurgical team,odis
nonet
and findings
autatatque documented.
Indications for CT Brain prior to transfer
Patients
Busciis aceati omnitatlaut
riskautate
of developing
Wessex hydrocephalus (baselinecon
Neuro ICU Guidelines scan)
es magnam in porrovit,

Following insertion of a VP shunt (confirmation of appropriate position of ven-
tricular antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
catheter)

Following removal of an External Ventricular Drain (to rule out haematoma or
hydrocephalus)
Patients
pro enecta nis with midline
et quiasim enimosshift>10mm due qui
moluptate volo
has been drained. (baseline scan)
to acus
chronic
explamsubdural
as accaehaematoma that que
dolo bersped

Nosam verferf erferspit querequest,
Neurosurgeons voluptatius rerum
either remorutinomni
verbal ut aut res is
post-operative aut lam qui nempore
instructions.
Discharge summary
All patients
tae. Uptatio doloremmustnushave a thorough
sinctem and accurate
fugit iditatiorum discharge
vit volupta porem summary,
quatusa which has
pedionsequis
been checked
dolorumquunt bymo
as dit thecor
dutysaNeuro ICU
porro et consultant,
volupti beatquo prior to transfer
cus.Liqui out molor
dolupid of Neuro ICU. debis
sit vellis
This should include:
1 mi,
expelleces Primary neurosurgical
sam reriandic / neurological
tenecus Wessex Neuro/ stroke
ICUconsultant
Guidelines aut voloreperit proris as
2 ommo
rerspero ommolor
Primary posandi
diagnosis (eg gnimus.Laborer iaerupienis dolorehent
subarachnoid haemorrhage lis eosinjury)
/ diffuse axonal doles volorib
Neuro3 ICU Co-morbidities
Guidelines dolupta(eg diabetes
tureped mellitus, hypertension)
ullorepudam iunt, nulparciur?Perio. Ut de vendam,
4 Summary
ni consenes idendemodisof keyreevents
voluptibus.Ero cuptium consequi
during admission, including doloreh enimetu rionsed que
any complications
5 Relevant investigations (eg CT scans, LP results)
6 Insertion
volo iur?Volorent dates
ut ut queofetany
mi,invasive
quas sinlines
cum(eg arterial lines)
quidellandel / endotracheal
incto quassit faccaturtubemaximi,
7 All microbiological results and treatment
est ad8 Medication
magnam (with appropriate
reresenient stop dates
escius sequuntur eg nimodipine
sinullit assimporesse at 21 days / aspirin
veliquam, at et
omnihicit
6 weeks)
ad eum 9 fugiaGCSvolorpo reptur? Et on
and neurology lamdischarge
venda nonwith
consediam
a plan foraut es dolendipsum
investigation if anyvenis rerum a
deterio-
ration occurs
10 Plan to include:
10
Chapter
solo 3
est, exeriae. Neuro ICU
Nusda nonsequo temolec erovitatenis admission
doles and discharge
explautem eum a reDuration
cor aut of antimicrobial
omnis treatment
a vit, Wessex andICU
Neuro whether LP indicated
Guidelines as part
consecate of
consect
septic screen
ntibusande natetb Spinal management
atistibus, utem quosam plan (eg cervical
reriberro odcollar duration)
molende natemosame nonet odis
c VTE mechanical
autatatque parchilitat.Ut eosam suscias aut qui(AES
prophylaxis volorum quamwith
& IPCs), haristart
odisdate
et porersp ellaut la
for enoxa-
num et endia vendi parin if not already
ipsandem apidellcommenced
endesec ulloribus deribus di ipsam harit quibus, cori-
d Datederovit,
busaniae repreperum sitatium
for removal nosam/ sinisci
of sutures staplesliquiat eaquias iminulpa is asitatia int.
Busciis aceati omnit laut autate
e Nurse 30o / 45oWessex Neuro ICU Guidelines con es magnam in porrovit,
head up or keep flat for patients with spinal cord injury
seriatur?Pa sedioreped (reliantquosa consequas
on diaphragm acepe conest ut am, quo dis enia vitae. Perovit
excursion)
f Timing of further imaging (eg CT Scan / MRI / cerebral angiogram)
qui doloratatas g volupta
Targets (see below)
seriam solorest voluptatis modit explatur? Iqui blam faceprovit eaqui
11 Wessex
nosto erio. Contact Neuro
detailsICU Guidelines
for Neuro ICU &Verum
primary ipidunt volor adit la doluptasit aut reiciet
consultant
11
Wessex
solo NeuroNusda
Targetseum
explautem forreTBI
corpatients
aut omnis a vit, Wessex Neuro ICU Guidelines consecate consect
emoluptae
Examplesveribus ambeen
have rem given
quid eatur
below,assimillat.Wessex
these should be Neuro ICU Guidelines
individualised Tis dolupti
on a patient by
patient basis.
Current Target
MAP 95 mmHg >80 mmHg
Busciis
PaO2 aceati omnit laut autate Wessex
12.7 kPa Neuro ICU Guidelines
>12 kPa con es magnam in porrovit,
seriatur?Pa
PaCO2 sedioreped quosa consequas 5.9 kPa acepe conest 4.5 -ut6.5
am,
kPaquo dis enia vitae. Perovit
odit Serum
hillorest,Nanusdand antibusape nonsequ
142 mmol/lassequi doluptatur? Qui in eum aut aut ommolor
140-145 mmol/l
erorerum repe(140%
Nutrition conseque nos et debitatia
normal) idessum est 30
30 kCal/kg/24hrs doluptur, est min ped mod et resciunt,
kCal/kg/24hrs
qui doloratatas
Blood glucose volupta seriam solorest voluptatis modit
6.8 mmol/l explatur?
5-10 mmol/l Iqui blam faceprovit eaqui
nostoGCS E3 VT M5 Verum ipidunt
erio. Wessex Neuro ICU Guidelines If motor score
volor adit drops 2 pointsaut
la doluptasit CTreiciet
pro enecta nis et quiasim enimos moluptate volo qui cus Scanexplam as accae dolo bersped que
Targets
Nosam verferffor SAH que
erferspit patients
voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
Examples have been given below, these should be individualised on a patient by
patient basis.
re corrorporest quos eum nobistibus Current
nis evento tem etTarget
pratem. Ut rem eatenienis enimolup-
MAP 120 mmHg 100
tae. Uptatio dolorem nus sinctem fugit iditatiorum vit volupta - 140porem
mmHgquatusa pedionsequis
ie do not start antihypertensive
treatment within 6 weeks unless
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov
evidence itendae volor
of myocardial aligenime
ischaemia
quatem aspedit atatem consedia volorerum et omni odorqui MAP bearum is estrunt re volor rehent
>140mmHg
PaO2 mi, sam reriandic tenecus
expelleces 12.7 Wessex
kPa >12Guidelines
Neuro ICU kPa aut voloreperit proris as
PaCO
rerspero ommo
2 ommolor posandi5.9 kPa
gnimus.Laborer 4.5 - 6.5dolorehent
iaerupienis kPa lis eos doles volorib
Serum Na 142 mmol/l 140-145 mmol/l
NeuroNutrition 25 kCal/kg/24hrs
ICU Guidelines dolupta tureped 25 kCal/kg/24hrs
Blood glucose 6.8 mmol/l 5-10 mmol/l
GCS E3 VT M5 If motor score drops 2 points CT
Scan
12
4
Patient assessment
Patientnusdand
odit hillorest, review antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
The patient must be systematically reviewed, including:

pro enecta nis Full
etcompletion
quiasim enimos of admission
moluptate or daily
volo quireview
cus proforma
explam as accae dolo bersped que

velese ma inctota
Nosam verferf
Patientquidunt
should acest,
erferspit que
examination
have full idenihicti
voluptatius
should
examination
rerum
occur with
im cus
therem
of aalldolesto
nurse
systems.
ut omni
eatas
ut aut
present, both
aut pel is dolesci
We recommend
restoisensure
aut lam
tibus.
that this
qui nempore
complete-
ness (eg allowing the nurse to highlight any areas
num harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil of concern found duringeosan-
turning the patient) and to act as a chaperone. During the examination there
should be particular emphasis on:
re corrorporest || Neurological
quos eum nobistibus examination:
nis evento It is tem
paramount
et pratem.thatUta baseline neurological
level is determined daily, as rapid changes can occur (e.g. development
tae. Uptatio dolorem nus sinctem
of lateralizing fugit
signs iditatiorum
with vasospasm, vit volupta
altered porem
GCS with quatusa pedionsequis
hydrocephalus,
dolorumquunt as dit mo cor sa porro
neurological et volupti
deterioration beatquo
with spinal cus.Liqui
injury.) dolupid molor sit vellis debis
Any patient that is sedated for COETT tolerance (i.e. not being fully se-
quatem aspedit atatem dated consedia
for controlvolorerum et omni
of intracranial od qui siezures
pressure, bearum is estrunt
etc) shouldre have
volor this
rehent
expelleces mi, sam reriandic
sedation tenecus
reduced toWessex
a level that Neuro ICUadequate
allows Guidelines aut voloreperit
neurological proris as
assess-
rerspero ommo ommolor ment. posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non con If a nullaut
patient veratemo
is considered tem atauttoo high risk
modipis for this
cimint quiasedation
nonsequis wean,
aut this
et Wessex
must be discussed with the Neuro ICU consultant and this discussion
Neuro ICU Guidelines clearlydolupta
documented.tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
none option nat quia GCS including break down of score into Eyes (E), Voice (V),
cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
Motor(M)
volo iur?Volorent ut Pupils
ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
Examination
quunturio ium haruptatiis andem of di scalp
quidem (e.g. wound/drain
nulparchit velectesite,eos
sutures/clips,
et quid entcraniec-
vollaccuptae
comnimusam res que tomy site coreperum
lab inis fullness - a di patient
bla aut with
ut averia
tense craniectomy
dignima site requires
gnihicimus suntiae ditiis
urgent attention)
Cranial
fugit officiatis iur, sam, nerve examination
ut quaeperrovid ulparcitaquiappropriate
odit essint to aut
underlying
adis as condition
commodi ctisit ant,
ad eum fugia volorpoVisual
reptur?fieldsEt lam venda
(e.g. post non consediam
pituitary surgery, aut es or
ICH dolendipsum
CVA) venis rerum a
Eye movement
volor alis susdandis moluptam everis
to all four quadrants (e.g. may be abnormal with
pratate iliquas rem que nos endicitin est ipieneculpa sus
PCom aneurysm)
13
Wessex
solo NeuroNusda
explautem eum re Facial
cor autsymmetry
omnis a /vit, movement
Wessex (e.g.Neuroeye closure
ICU post acoustic
Guidelines consecatesurgery
consect
- many patients have a 7th nerve palsy following acoustic surgery)
ntibusande natet atistibus,
Gag / tongue utemmovement (e.g. posterior
quosam reriberro fossa conditions)
od molende natemosame nonet odis
Tone eosam
autatatque parchilitat.Ut / powersuscias
/ sensation aut /qui volorum
reflexes quam
within hariofodis
limits et porersp
patient co-opera- ellaut la
num et endia vendition. (ASIA score
ipsandem apidellinendesec
patients ulloribus
with spinal cord injury.)
deribus di ipsam harit quibus, cori-
busaniae repreperum
|| derovit, sitatium
Cardiovascular nosam sinisci liquiat eaquias iminulpa is asitatia int.
examination
Rate, rhythm, blood pressure & heart sounds
|| Respiratory
Airway:nos
erorerum repe conseque adequacy andidessum
et debitatia position est
of adjuncts
doluptur,(e.g. endotracheal
est min ped mod ettube
resciunt,
length
qui doloratatas volupta at teeth)
nosto erio. Wessex Chest
Neurosigns ICU including
Guidelines fullVerum
auscultation
ipiduntofvolor
backaditandlafront of chestaut reiciet
doluptasit
Ventilatory support parameters
|| Gastrointestinal
num harciis rest offic
Fulltem abdominal examination
aut verroviti (e.g. distended,
opta doluptam, quibus dibowelvolutsounds,
qui nonwound
reicil eosan-
sites)
Adequate
veligen diant.et quos ium, cusnutrition
cone dem including calorific Pudionsequia
nem fugiatem. intake dis suntotate laborpor
re corrorporest quos eum nobistibus
last open nis evento tem et pratem. Ut rem eatenienis enimolup-
Bowels
|| Genito-urinary
Hourly
ratur, omnihit incidus urine output
ea Wessex Neurofor ICUlastGuidelines
4 hours qui quaerov itendae volor aligenime
quatem aspedit Fluidconsedia
atatem balance volorerum et omni od qui bearum is estrunt re volor rehent
expelleces mi,
|| sam reriandic
Venous tenecus Wessex
thromboembolism riskNeuro ICU Guidelines aut voloreperit proris as
usant. Quia non
Calf examination
con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex
Presence
Neuro ICU Guidelines dolupta of tureped
anti-embolic stockingsiunt,
ullorepudam and nulparciur?Perio.
functioning intermittentUt de pneu-
vendam,
matic compression devices.
none option||nat On quia admission,
cumqui ullest completion of secondary
ligenihiciet accus.Quis survey
sit, for all trauma
offictem quo patients
conecto ditia-

turias prepedi
volo iur?Volorent
taecerrovita
Review and document
results.ut Review
ut que et
vit pelitatia
in flow
mi, quas sin
transcranial
con perae
charts thevoluptae
cum (TCD)
doppler quidellandel
doluptia
current blood
resultsincto
/ CSFnimi, venis nemquame
/ microbiology
quassit
in patients faccatur
post suba- maximi,
quunturio iumrachnoid haemorrhage
haruptatiis andem di(increased TCD velocities
quidem nulparchit velecte mayeosindicate
et quidaentpatient has
vollaccuptae
vasospasm). Check any ECGs.

est ad magnam Review reresenient
of imagingescius sequuntur
including sinullit
chest X-ray andassimporesse
CT/MRI scansveliquam, omnihicit et

Review of all prescriptions documenting any allergies and ensuring:
||
quo testis maximus All aecabore,
drugs: que nonem es repereped ut ut dolupta sundit, ad qui cullenim
volor alis susdandisare
moluptam everis
currently pratate iliquas
appropriate rem que nos
(eg withholding endicitin
of ACE est ipieneculpa
inhibitor in sus
mi, nime voluptas simus.vasospasm)
dolupta tureped ullorepudam iunt, nulparciur?Perio
14
Chapter
solo 4
est, exeriae. Nusda nonsequo temolec erovitatenis doles eatiore Patient assessment
ribusandiste molora
explautem eum re cor
have autbeen
omnis given at appropriate
a vit, Wessex Neuro timesICU Guidelines consecate consect
emoluptae veribus amareremat the appropriate
quid dosage (eg weaning
eatur assimillat.Wessex NeuroofICUsteroids)
Guidelines Tis dolupti
ntibusande natet|| atistibus,
No drugs: utem quosam reriberro od molende natemosame nonet odis
num et endia vendi ipsandem
have been omitted inappropriately (eg steroids, anticonvulsants or
apidell endesec ulloribus deribus di ipsam harit quibus, cori-
Beta-blockers.)
Busciis aceati omnit are contra-indicated (eg antiplatelet and anticoagulants in traumatic
laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit,
brain injury)
|| All patients have appropriate gut protection prescribed
erorerum repe Any patient
|| conseque nos etthat is not prescribed
debitatia idessum est LMWH mustest
doluptur, have
mina ped
planmod
documented
et resciunt,
qui doloratatas volupta in the seriam
notes with a timing
solorest for review
voluptatis modit/ commencement.
explatur? Iqui blam faceprovit eaqui
Glasgow
pro enecta comaenimos
nis et quiasim scalemoluptate
(GCS)volo qui cus explam as accae dolo bersped que
This is the standard method of assessing level of consciousness in neuroscience
patients. Assessment must be performed in a reproducible manner by all staff to ensure
consistency. This will allow important changes to be detected rapidly, triggering appro-
priate interventions in a timely manner.
Basic principles
dolorumquunt as dit mo cor ofsaassessment
porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis

ratur, omnihitPatient
incidusshould
ea Wessexbe wokenNeuro ICU
from Guidelines
sleep prior to qui quaerov itendae volor aligenime
assessment

It is not possible to assess GCS in sedated and paralysed patients, although
it is usually possible to follow a trend of responsiveness in patients that are
sedated to a posandi
minimum gnimus.Laborer
level to tolerateiaerupienis dolorehent
an endotracheal tube.lis eos doles volorib

When assessing
Neuro ICU Guidelines doluptamotor response
tureped to commands,
ullorepudam such as asking the
iunt, nulparciur?Perio. patient
Ut de to
vendam,
squeeze fingers, they must both squeeze and release the examiners fingers
ni consenes on idendemodis
command. re voluptibus.Ero
Many patients willcuptium
just gripconsequi doloreh
objects placed in enimetu rionsed
their hands as a que
none option reflex
nat quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
response.
Only place index and middle fingers in hand of patient to assess
volo iur?Volorent squeeze.
ut ut que Use et mi, of quas sin finger,
a single cum quidellandel
or 3 or moreincto quassit
fingers faccatur
may result maximi,
in per-
quunturio ium haruptatiissonal injuryandem di quidem
in very strong or nulparchit
agitated velecte
patients.eos et quid ent vollaccuptae

Response to painful stimulus should be to a standard central painful stimulus.
This should be a trapezius pinch. This involves squeezing the trapezius mus-
fugit officiatiscle
iur,atsam, ut quaeperrovid
the base of the neck,ulparcitaqui
between thumb odit essint aut adis
and fingers as commodi
firmly enough toctisit
elicitant,
ad eum fugiapain in a reptur?
volorpo normal Et individual.
lam venda non consediam aut es dolendipsum venis rerum a

The use of sternal rub, supra-orbital nerve pressure or other potentially pain-
volor alis susdandis
ful stimuli moluptam everis pratatebecause
is not recommended iliquas rem querisk
of the nosofendicitin
leaving est ipieneculpa
obvious marks sus
mi, nime voluptas
on thesimus.
patient. dolupta tureped ullorepudam iunt, nulparciur?Perio
15
Wessex
solo NeuroNusda

explautem The eum use of peripheral
re cor aut omnispainfula vit, stimuli
Wessex(eg nail bed
Neuro ICUcompression) should notconsect
Guidelines consecate be
considered a part of GCS estimation, because it may elicit spinal reflexes
emoluptae that veribus
mayam rem to
appear quid eaturincrease
falsely assimillat.Wessex
the score. Neuro ICU Guidelines Tis dolupti

autatatque On occasion, eosam
parchilitat.Ut an experienced
suscias autmember of staff quam
qui volorum may useharia odis
peripheral painful
stimulus to ensure that a patient is able to move that limb. When this is done
it should be by pressure apidell endesec
against the ulloribus deribus diNOT
side of a fingertip, ipsam harit quibus,
pressure over cori-
busaniae repreperum
the nail bed. derovit,
Pressure sitatium
to thenosam
nail bed sinisci liquiatineaquias
can result obviousiminulpa
bruising. is asitatia int.

The scale is a range from 3 to 15, where 3 is the deepest level of coma, and
15 is a fully conscious and orientated patient. The total GCS score is less
odit hillorest, nusdandthan
important antibusape nonsequ
the breakdown ofassequi doluptatur?
Eyes, Verbal Qui in
and Motor eum aut aut ommolor
Response.
A patient may be fully conscious but unable to speak because of a le-
nosto erio.
Eg WessexsionNeuro
affecting ICUBrocas
Guidelines
area.Verum
This wouldipidunt
givevolor
themadit
a GCSla doluptasit
of 11, butaut
thereiciet
pro enecta nis etinformation
quiasim enimos is more usefully volo
moluptate expressed
qui cusas E4V1M6
explam as accae dolo bersped que
numEyes
harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
4 Eyes open spontaneously
3 Eyes open to voice
tae. 2Uptatio dolorem
Eyesnus open to standard
sinctem central painful
fugit iditatiorum stimulusporem quatusa pedionsequis
vit volupta
1 as Eyes
dolorumquunt dit monotcoropen
sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
Verbal
5mi,
expelleces sam reriandic
Patient tenecus
is fully Wessex
orientated Neuro
to time, ICUand
place Guidelines
person aut voloreperit proris as
4
rerspero ommo ommolor posandi gnimus.Laborer
Patient speaking in sentences, but iaerupienis dolorehent lis eos doles volorib
not fully orientated
3
usant. Quia non con nullaut veratemo
Monosyllabic words tem aut modipis cimint quia nonsequis aut et Wessex
Neuro
2 ICU Guidelines dolupta tureped
Incomprehensible soundsullorepudam iunt, nulparciur?Perio. Ut de vendam,
1 No sound
Motor
6
quunturio haruptatiis
ium Obeying commands
andem di quidem(eg squeeze & release
nulparchit velecte examiners
eos et quid fingers, stick
ent vollaccuptae
out tongue or wiggle toes)
5 Localising to central painful stimulus. The patients upper limb must
flex to bring the hand above the nipple line.
4 Normal flexion. The patients upper limb must flex, without the wrist
pronating.
quo 3testis maximus
aecabore,
Abnormal que The
flexion. nonem es repereped
patients upper limb ut ut dolupta
flexes, withsundit, ad qui cullenim
the wrist
volor
alis susdandis moluptam
pronating. Thiseveris
may pratate iliquas
be referred to rem que nos endicitin
as decorticate posturing.est ipieneculpa sus
16
Chapter
solo 4
est, exeriae. Nusda nonsequo temolec erovitatenis doles eatiore Patient assessment
ribusandiste molora
2
explautem eum reExtension.
cor aut omnisThe patients upper limbs
a vit, Wessex Neuroextend at the elbow,
ICU Guidelines and the lower
consecate consect
limbs extend fully. This may be referred to as decerebrate posturing.
1natet
ntibusande No movement
atistibus, utem quosam reriberro od molende natemosame nonet odis
num et Normal
endia vendi
flexionipsandem apidell endesec
(M4) is sometimes ulloribus
referred deribus di ipsam
to as withdrawing. harit quibus,
However, care mustcori-
busaniae repreperum
be taken when using derovit, sitatium
this term as it nosam
implies sinisci
a movement liquiat away
eaquias
fromiminulpa is asitatia
a peripheral painfulint.
Busciis aceati Peripheral
stimulus. omnit laut painful
autate stimulation
Wessex Neuro is notICU
partGuidelines
of standard con
GCS es assessment.
magnam in porrovit,
Pitfalls in assessment of GCS:

erorerum repe
qui doloratatas
In conseque
to open
volupta
nos et debitatia
locked in syndrome
theseriam
eyelidssolorest
idessum
or patients
and lookvoluptatis
with est
for any eye
highdoluptur,
modit
est min
spinal cord
movement
ped itmod
lesions, et resciunt,
is essential

nosto erio. Wessex
pro enecta nis
Beware Neuro ICU GCS
assessing Guidelines
in deafVerum
patients ipidunt
who may volornotadit la doluptasit
respond
et quiasim enimos moluptate volo qui cus explam as accae dolo bersped que
command
to verbalaut reiciet

Dominant hemisphere lesions that affect eloquent cortex may prevent
patients from obeying commands (receptive dysphasia)
Assessment
veligen diant.et quos ium, of cus
pupils
cone dem nem fugiatem. Pudionsequia dis suntotate laborpor

tae. Uptatio The
dolorumquunt
dolorem
part
size nus
as of
ditevery
mo cor
sinctem fugit
and response
neurological
iditatiorum
of both pupils tovitlight
sa porro et assessment.
volupta
must porem quatusa
be recorded pedionsequis
accurately
volupti beatquo cus.Liqui dolupid molor sit vellis debis
as

quatem aspedit
The presence of a unilateral fixed and dilated pupil is most commonly an indi-
cationatatem consedia volorerum
of significantly et omni od
raised intracranial qui bearum
pressure from aislesion
estrunt
onrethat
volor rehent
side of
expelleces mi, thesam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
head.
The presence of a single fixed and dilated pupil may occur from uncal
usant. Quia non con nullaut (eg
herniation veratemo
temporaltemlobe
aut swelling/
modipis cimint quiafrom
pressure nonsequis
an acuteaut et Wessex
subdural
Neuro ICU Guidelines dolupta intureped
haematoma) ullorepudam
the absence of globallyiunt,raised
nulparciur?Perio.
ICP. Ut de vendam,

none option In natthequia
presence
cumquiof ullest
severeligenihiciet
trauma to accus.Quis
the face or orbit, the pupilquo
sit, offictem
and dilated as a result of local trauma to the nerve on that side, rather than
mayconecto
be fixedditia-
an indication of raised intracranial pressure.

quunturio ium Beware the patient
haruptatiis andemthat is already
di quidem blind in one
nulparchit or both
velecte eoseyes,
gone previous ocular surgery. The presence of unequal sized pupils, or lack
or has
et quid ent under-
vollaccuptae
of reaction to light, may be normal for that patient, and not indicative of any
est ad magnam new reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
intracranial pathology.
Check for and remove contact lenses at the earliest opportunity. Cos-
metic contact lenses may give the apprearance of bilaterally fixed
pupils.
17
Wessex
solo NeuroNusda

explautem The eum presence
re cor autofomnis
bilaterally
a vit,fixed and dilated
Wessex Neuropupils is most commonly
ICU Guidelines consecatean consect
indication of severely raised intracranial pressure with brainstem compres-
emoluptae sion.
veribus am rem
Unless this quid eatur
situation is assimillat.Wessex
immediately reversed, Neuro ICU Guidelines
haemorrhage Tis dolupti
or infarction
ntibusande within
natet theatistibus,
brainstemutemand quosam
brainstem reriberro od result.
death will molende It isnatemosame
associated with nonet odis
autatatque greater than 95%
parchilitat.Ut eosammortality.
suscias aut qui volorum quam hari odis et porersp ellaut la

Assessment
busaniae repreperum
with severely derovit,
swollen
apidell
of pupillary
sitatium
endesec
reaction
eyelidsnosam
may ulloribus deribus
be difficult
sinisci liquiat
(eg following
di ipsam
and painful
frontal eaquias
craniotomy),
harit quibus, cori-
in patients
iminulpa is asitatia
and may be int.
Busciis aceatiunnecessary
omnit laut ifautate
the patient
Wessex is obeying commands,
Neuro ICU Guidelines andcon
vocalising.
es magnamHowever, if
in porrovit,
seriatur?Pathe patient is quosa
sedioreped otherwise unresponsive
consequas acepeand the presence
conest ut am, quo of fixed andvitae.
dis enia dilatedPerovit
pupils is to be used to decide whether to operate or withdraw treatment, then
odit hillorest, nusdandattempts
strenuous antibusape nonsequ
must be made assequi doluptatur?
to assess Qui in eum aut aut ommolor
both pupils.

Pupilvolupta
qui doloratatas reaction and size
seriam is notvoluptatis
solorest affected by neuromuscular
modit explatur? Iqui junction blockers, eaqui
blam faceprovit
which may be used to paralyse ventilated patients.

pro enecta nisTheetpresence
and
quiasim of
loss of eye
a painful
enimos
movement,
IIIrd nerve
moluptate
should
volopalsy,
always
causing
qui cus
be
explam
assumed
pupillary
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci
as accae
to
dilation,
have
ptosis que
dolo bersped
been causedtibus.
by a PCom aneurysm until formally excluded.
18
5
Ventilation
Invasive
odit hillorest, ventilation
nusdand antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
nostoEndotracheal
erio. Wessex Neuro tubeICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
Patients requiring ventilation on admission will usually have been intubated and
ventilated at their local hospital, in the emergency department or in theatre.
num harciis rest offictotem
It is essential aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
check:

The type of endotracheal tube:
re corrorporest || quosStandard cuffed oralnis
eum nobistibus endotracheal
evento tem tube (COETT).
et pratem. Ut rem eatenienis enimolup-
tae. Uptatio | dolorem
| Flexometallic
nus sinctem (commonly referredvit
fugit iditatiorum to volupta
as reinforced
poremtube, because
quatusa of the
pedionsequis
dolorumquunt as dit presence
mo cor sa of aporro
metaletspiral
voluptiwithin the tube
beatquo wall. dolupid
cus.Liqui The metal spiral
molor reduces
sit vellis debis
the chance of the tube becoming obstructed by kinking of the tube in
theatre)
expelleces mi, sam Patients
reriandicthat are notWessex
tenecus fully anaesthetised may bite down
Neuro ICU Guidelines onto flexome-
aut voloreperit proris as
tallic tubes, completely obstructing the lumen. The lumen will not then
reopen when they release the pressure because of deformation of the
usant. Quia non con metalnullaut veratemo
spiral. tem aut
The patient will modipis cimint
not be able quia
to be nonsequis
ventilated, aut et Wessex
suctioned,
Neuro ICU Guidelines and bougie
dolupta willtureped
not usually pass through
ullorepudam iunt, the obstruction. They
nulparciur?Perio. will vendam,
Ut de
therefore require emergency re-intubation. For this
ni consenes idendemodis re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que reason patients
should not be admitted postoperatively without changing these tubes
to a standard COETT.
||
volo iur?Volorent South
ut facing
ut que RAE.
et mi, These
quas sin are
cumpreformed
quidellandelplastic
inctotubes which
quassit may look
faccatur maximi,
similar to a standard tube. They are designed to angle downwards after
leaving the mouth, rather than continuing the curvature of a standard
comnimusam res tube. que lab inisare
They coreperum di blaused
occasionally aut for
ut veria dignimaduring
anaesthesia gnihicimus suntiae
cerebral angi-ditiis
ography andescius
est ad magnam reresenient intervention.
sequuntur sinullit assimporesse veliquam, omnihicit et
19
Wessex
solo NeuroNusda
explautem eum It remay
cor be autdifficult
omnis to a suction
vit, Wessex via RAE tubes
Neuro ICU and there are consecate
Guidelines no length consect
emoluptae veribus markings
am rem to quid
indicate
eaturthat the tube is placedNeuro
assimillat.Wessex to theICU
correct depth. This
risks the tube irritating the carina if it is too long for the patient, which
ntibusande natetwill atistibus,
make weaningutem quosam reriberroimpossible
from ventilation od molende natemosame
because nonet odis
of uncontrolla-
ble coughing.eosamConsequently,
suscias aut qui volorum
patients shouldquam nothari
be odis et porersp
admitted postoper- ellaut la
num et endia vendi atively without apidell
ipsandem changing these tubes
endesec to aderibus
ulloribus standard di COETT.
ipsam harit quibus, cori-
busaniae repreperum
|| COETT derovit, sitatium nosam
with subglottic suctionsinisci liquiatnew
port. These eaquias
tubesiminulpa is asitatia int.
are increasingly
Busciis aceati omnit being laut
usedautate
by ourWessex
referring Neuro ICU Guidelines
hospitals, as they are con es magnam
reported in porrovit,
to be associ-
ated with
seriatur?Pa sedioreped less aspiration
quosa consequasonacepe ICU. Unfortunately,
conest ut am,currentlyquo dis theyenia only
vitae.have
Perovit
a single suction port above the cuff which frequently abuts the mucosa
preventing aspiration of secretions. Gentle suctioning via the access
port with nos a 10mlet debitatia
syringe may idessum
allowest doluptur,
some est min
secretions pedremoved
to be mod et resciunt,
and
qui doloratatas volupta
reduceseriamthe chancesolorest voluptatis NB
of aspiration. modit
It isexplatur?
essentialIquinot blam faceprovit eaqui
to aggressively
nosto erio. Wessex suction
Neuro sinceICUthis risks damage
Guidelines Verum to delicate
ipidunt volormucosa aditwithin the larynx
la doluptasit autorreiciet
trachea.

velese ma Length
Nosam verferf
inctota of
during
quidunt
an admission,
erferspit
acest, idenihicti
endotracheal tube, measured
and therefore
que voluptatius
im cus at
rerum rem
a dolesto
it is ut
important
omni ut to
eatas will
teeth. (Tubes aut often
autdocument
pel ismove
res is auttheir
dolesci tibus.
lam position
qui nempore
regularly, which is performed on each shift by nursing staff.)

Position
as soon
veligen diant.et
of tipeostiis
quosafterium,admission
citam, eumet
of endotracheal
cus cone as dem
tubevoluptasit
practical.
on chestposandu
nem fugiatem.
X-Ray. This
The tip Pudionsequia
ntioreritem
should be
of the tube should
quam ad ma de
assessed
be at the laborpor
dis suntotate
lower limit of the clavicular heads, 2cm above
re corrorporest quos eum nobistibus nis evento tem et pratem. Ut rem eatenienis the carina. When correctlyenimolup-
positioned on chest X-Ray, the length of the tube at the teeth should be
tae. Uptationoted.
dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis

ratur, omnihitCuff pressure
incidus must beNeuro
ea Wessex assessed ICU on admission,
Guidelines quiand is recorded
quaerov itendaebyvolor
the nurs-
aligenime
ing staff on each shift. In patients with poor lung compliance that require high
quatem aspeditlevelsatatem
of PEEP, consedia volorerum
it is essential thatettheomni cuffod qui bearum
pressure exceedsis estrunt re volor rehent
the maximum
inspiratory pressure tenecus
by 5cmH Wessex O. Neuro ICU Guidelines aut voloreperit proris as
2
|| Inadequate cuff pressure risks loss of ventilation and aspiration of
usant. Quia non potentially
con nullautinfected
veratemo tem
oral aut modipis cimint quia nonsequis aut et Wessex
secretions.
|| Excessive cuff pressure (>40cmH2O) will cause ischaemia of the tra-
ni consenes idendemodis
cheal mucosa, re voluptibus.Ero
and may leadcuptium to trachealconsequi
stenosisdoloreh enimetu rionsed que
or tracheomalacia.

turias prepediThetaecerrovita
endotracheal vittube is securely
pelitatia con perae tied into position
voluptae with a nimi,
doluptia standard
venistube tie.
nemquame
volo iur?Volorent
|| Itut
is ut
notquenecessary to tape
et mi, quas sintubes since the tie incto
cum quidellandel passes abovefaccatur
quassit any areamaximi,
where the internal jugular vein could be significantly
quunturio ium haruptatiis andem di quidem nulparchit velecte eos et quid ent vollaccuptae compressed. Tapes
are less secure and frequently result in allergic reactions on delicate
facial tissue if left for any significant length of time.
That
fugit officiatis iur,there
sam, is utaquaeperrovid
heat and moisture exchange
ulparcitaqui (HME)aut
odit essint
the patient is ventilated on a warmed humidified circuit, when it should be
filter in the
adis circuit, until
as commodi ctisit ant,
removed.
20
Chapter
solo 5
est, exeriae. Nusda nonsequo temolec erovitatenis doles eatiore ribusandiste Ventilation
molora
The standard
explautem eum re knot cor aut used on Neuro ICU
emoluptae1 veribus
Fold theam taperemin quid
half eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
2 Pass the folded end around the tube
num et 3 endiaPassvendi theipsandem
two looseapidell endesecthe
ends through ulloribus deribus
loop created anddi tighten
ipsam harit quibus,
the slip knot cori-
against the tube at the patients mouth. The knot
busaniae repreperum derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia should lie against the cranialint.
aspect of the tube (i.e. the side of the tube closest to the patients nose)
4 sedioreped
seriatur?Pa Split the twoquosa loose consequas
ends of the acepe tape and conest
wrap ut am,back
each quo around
dis eniathe vitae.
tubePerovit
and
tie in a simple knot under the tube securely
erorerum 5 repe Pass conseque
one of the nosfreeet debitatia
ends around idessum est doluptur,
the back est minneck
of the patients ped modand tieet resciunt,
securely withseriam solorest
the other end voluptatis
in a simplemodit explatur?
reef knot on the Iqui blam faceprovit eaqui
cheek.
pro enecta
Initialnis et quiasimsettings
ventilator enimos moluptate volo qui cus explam as accae dolo bersped que
NosamInitial
verferfventilator
erferspitsettings for a sedated
que voluptatius rerumand remparalysed
ut omni utpatient
aut resshould
is aut either
lam qui be:nempore

num harciis The
tium entis nima
rest settings
offic temthat
achieving
autthe
sit queappropriate
verroviti
eostiis citam,
patientoptahasdoluptam,
oxygenation
eumet voluptasit
quibus on,
been transferred
& ventilation
posandu
di volut
so long
parameters
quias
ntioreritem
non reicilare
these
(seequambelow).
eosan-
ad ma de

Or, we recommend:
|| Mode : PCV-VG: This mode targets the set tidal volume whilst minimis-
ing peak airway pressures.
|
ratur, omnihit|incidus FiOea 2
: 0.5
Wessex (unless
Neuropatient severely hypoxic)
ICU Guidelines qui quaerov itendae volor aligenime
quatem aspedit || atatemPEEP:consedia
5cmH2Ovolorerum et omni od qui bearum is estrunt re volor rehent
expelleces mi, ||
sam reriandic
Tidal Volume tenecus Wessex
: 6-8ml/kg Neuro
of ideal body ICU Guidelines
weight aut voloreperit proris as
(i.e. 300-600ml)
|| Respiratory rate: 12 breaths per minute
||
Neuro ICU Guidelines I:E ratio 1:2 tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
dolupta
ni consenes | idendemodis
| Check anrearterial voluptibus.Ero
blood gascuptium within 15 consequi
minutesdoloreh
of startingenimetu rionsed
ventilation on que
none option nat quia thesecumquisettings, change
ullest these asaccus.Quis
ligenihiciet necessary sit, to achieve
offictemtarget PaO2 andditia-
quo conecto
PaCO2. Correlate
turias prepedi taecerrovita PaOcon
vit pelitatia 2
with SpOvoluptae
perae 2
and PaCO with EtCO
doluptia
2
.
nimi, 2venis nemquame
Oxygenation

comnimusamTarget res que for lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
oxygenation
|| Acute brain injury: PaO2 13kPa (SpO297%)
|
ad eum fugia|volorpo In acute
reptur? lungEt injury,
lam vendaoncenon intracranial
consediam pressure
aut esisdolendipsum
controlled, the venisPaOrerum
2 a
target may be relaxed, but should always
quo testis maximus aecabore, que nonem es repereped ut ut dolupta sundit, ad qui cullenim be 10kPa (except in severe
lung injury - see below)
21
Wessex
solo NeuroNusda
explautem | |
eum In severe
re cor autlung omnis injury requiring
a vit, Wessex high levelsICU
Neuro of PEEP and inverse
Guidelines ratiosconsect
consecate
(I:E ratio 2:1), it may be appropriate to aim for a PaO 8kPa
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU2 Guidelines Tis dolupti

ntibusande Maintaining
autatatque |
natet atistibus,
parchilitat.Ut
oxygenation
utem quosam target reriberro od molende natemosame nonet odis
| PaO2 is eosam
related suscias
to mean aut qui pressure
airway volorum quam and FiO hari odis et porersp ellaut la
2
|| Set PEEP appropriate to lung pathology (eg collapse / consolidation on
busaniae repreperum CXR) derovit,
and body sitatium
habitus.nosam sinisci liquiat eaquias iminulpa is asitatia int.
|| In a patient with a normal CXR and normal BMI, start PEEP at 5cm
Increase
||nusdand
odit hillorest, PEEP incrementally
antibusape nonsequ assequi ensuring ICP is not
doluptatur? Quiaffected
in eumadversely to
aut aut ommolor
a maximum of 15cm H2O. (Up to 20cmH2O in extreme cases)
qui doloratatas Set FiOseriam
|| volupta 2
to achieve PaO
solorest target modit explatur? Iqui blam faceprovit eaqui
voluptatis
2
nosto erio. | Wessex

| Neuro ICU Guidelines
As oxygenation Verum reduce
improves, initially ipidunt FiO
volorsequentially
adit la doluptasit
down aut reiciet
2
pro enecta nis etto 0.28, maintaining
quiasim enimos moluptatePEEP. Only reduce
volo qui cus PEEP
explamonce FiO2 <0.3
as accae dolo with
bersped que
PaO
velese ma inctota quidunt 2
>target acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
Nosam verferf || erferspit
Consider que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
num harciis rest offic tem aut of verroviti opta doluptam, quibus dinebs
volut qui non reicil eosan-
Treatment bronchospasm with salbutamol
Fibreoptic
veligen diant.et quos
bronchoscopy if segmental or lobar collapse
ium, cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
re corrorporest quos Drainage of pneumothorax
eum nobistibus nis evento/ haemothorax
tem et pratem. Ut rem eatenienis enimolup-
Ventilation

Target PaCO2
| | Acute brain
expelleces mi, sam reriandic tenecus injury: Target
Wessex PaCONeuro
2
4.5-5.0kPa until ICP
ICU Guidelines monitored.
aut voloreperitIf proris
ICP as
<15mmHg, relax PaCO2 target gradually to 5.0-5.5kPa, so long as ICP
rerspero ommo ommolorremains posandi
<15mmHg. gnimus.Laborer iaerupienis dolorehent
Cerebral vasoconstriction caused bylishyperventila-
eos doles volorib
usant. Quia non tion con tonullaut
a lowveratemo
PaCO2 may temexcerbate
aut modipis thecimint quiainnonsequis
reduction aut etflow
cerebral blood Wessex
Neuro ICU Guidelines that occurs
doluptaimmediately following traumatic
tureped ullorepudam brain injury.
iunt, nulparciur?Perio. Ut de vendam,
ni consenes|idendemodis
| re voluptibus.Ero
If ICP consistently greater than cuptium
15mmHg, consequi doloreh
a degree enimetu rionsed que
of hyperventilation
none option nat should be reinstated
quia cumqui to target a PaCO
ullest ligenihiciet accus.Quis
2
4.5-5kPa
sit, offictem quo conecto ditia-
turias prepedi|| taecerrovita
If severe acute vit pelitatia con perae pressure
rise in intracranial voluptae causing
doluptia abnormal
nimi, venis nemquame
pupillary
volo iur?Volorentchangeut ut que (i.e.etfixation
mi, quas andsin cum quidellandel
dilation of one or both incto quassit
pupils), faccatur
it may be nec- maximi,
essary to andem
quunturio ium haruptatiis acutely di hyperventilate
quidem nulparchitto a PaCO velecte
2
4.0kPa,
eos etwhilst
quid awaiting
ent vollaccuptae
response to an osmotically active drug (e.g. Mannitol
comnimusam res que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis or hypertonic
saline). As soon as ICP is lowered to a safe level, ventilation should be
est ad magnam reduced reresenient escius
to allow PaCOsequuntur
to rise sinullit
gradually assimporesse
to 4.5-5.0kPa veliquam, omnihicit et
2
|| In acute lung injury, once intracranial pressure is controlled, the PaCO2
may be allowed to rise slowly, keeping within the normal range
22
Chapter
solo 5
molora
explautem eum ||
reIncor
severe lung injury,
aut omnis a vit,where
Wessex there is no ICU
Neuro concern over intracranial
Guidelines consecatepres- consect
sure, PaCO2 may be allowed to rise gradually to 8kPa provided that pH
emoluptae veribusremains am rem7.2. quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti

Maintaining PaCO
autatatque parchilitat.Ut eosam2 target
num et endia|vendi | PaCO is inversely
ipsandem
2
apidellrelated
endesec to minute
ulloribus ventilation
busaniae repreperum(minute derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
ventilation = tidal volume x respiratory
rate)
|| Set tidal volume appropriate to lung pathology (eg collapse / consolida-
seriatur?Pa sedioreped tion onquosa
CXR) and consequas acepe conest ut am, quo dis enia vitae. Perovit
body habitus.
erorerum repe conseque Patients with lung pathology require lower tidal volumes to prevent
nos et debitatia idessum est doluptur, est min ped mod et resciunt,
exacerbating lung injury. Aim for 6ml/kg of ideal body weight.
nosto erio. Wessex Neuro
In patients
ICU with no evidence
Guidelines Verum of ipidunt
lung injuryvoloraim forla7-8ml/kg
adit doluptasit of ideal
aut reiciet
body weight.
||
velese ma inctota Set respiratory
quidunt acest,rate to control
idenihicti PaCO
im cus . Start at
a dolesto
2
12 breaths/minute
eatas aut pel is dolesci (range tibus.
10-24 breaths per minute)

num harciis Some
tium entis nima
rest offic
is used.
patients
tem aut mayverroviti
synchronise better withquibus
opta doluptam, the ventilator
di volutif qui
the non
BiLevel reicilmode
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veligen diant.et
re corrorporest
When quos
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important
ium, cus
weaning cone
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dem nem
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nis evento
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to fugiatem.
spontaneous
temtime
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Pudionsequia
et pratem.
breathing with
(Tinsp) isUtnot
rem
dis suntotate
PCV-VG,laborpor
tooeatenienis
long (i.e.1.1s)
it is
enimolup-
rather than setting the I:E ratio at 1:2. This may be
tae. Uptatio dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis most easily achieved by
using SIMV or BiLevel, setting T and weaning the respiratory rate until the
dolorumquunt as dit mo cor sa porro et voluptiinspbeatquo cus.Liqui dolupid molor sit vellis debis
patient is instigating breaths.
quatem aspedit || Eg During
atatem consediaPCV-VG, the ventilator
volorerum et omni sets
od qui thebearum
inspiratory time for
is estrunt re all man-
volor rehent
datory breaths depending on the respiratory rate and I:E ratio. It takes
expelleces mi, sam noreriandic
accounttenecus Wessex Neuro
of any spontaneous ICU Guidelines
breaths that occur aut voloreperit
between those proris as
rerspero ommo ommolor mandatory posandi gnimus.Laborer
breaths set. Hence when iaerupienis
the setdolorehent
respiratorylis eosisdoles
rate volorib
reduced,
usant. Quia non con whilst maintaining
nullaut veratemo antem
I:E ratio of 1:2, the
aut modipis inspiratory
cimint time willaut
quia nonsequis increase
et Wessex
and the patient may fail to synchronise with
Neuro ICU Guidelines dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam, the ventilator.

ni consenes Spontaneously
none option the
idendemodis rebreathing
natCPAP/PS
quia cumqui mode.
voluptibus.Ero
patients cuptium
may beconsequi
supported doloreh
via theenimetu
ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
ventilator rionsed
using que

If PaCO2 is rising whilst patient is breathing spontaneously, ensure that they
volo iur?Volorent
are not ut receiving
ut que et excessive
mi, quas sin doses cumofquidellandel
opioids or other inctosedatives.
quassit faccatur maximi,
The presence of pneumothorax must be suspected in any patient with
elevated airway pressures on positive pressure ventilation. Beware that
est ad magnam reresenient
it is much more escius sequuntur
difficult sinullitbilateral
to diagnose assimporesse veliquam, omnihicit et
pneumothoraces.
Transfer of ventilated patients
Brain injured
volor alis susdandis moluptampatients arepratate
everis highly iliquas
susceptible
rem que to secondary
tion, perfusion and carbon dioxide control are not closely adhered to.
nos endicitin injury
est ifipieneculpa
oxygena- sus
23
Wessex
solo NeuroNusda

explautem Anyeum patient
re cor transfer
aut omnis requires
a vit, aWessex
suitablyNeuroqualified
ICUand trained doctor
Guidelines to ensure
consecate consect
the maintenance of stable intracranial haemodynamics, oxygenation and
emoluptae carbon
veribus dioxide
am remlevels.
quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti

autatatque Prior to transfer,
parchilitat.Ut eosamthe patients
suscias autbedside capnography
qui volorum quam should
hari odishave been ellaut la
et porersp
compared with a recent PaCO2 on an arterial blood gas. The transfer cap-
nography may then apidell endesec
be compared to ulloribus
the bedside deribus di ipsamas
capnography harit
thequibus,
patient cori-
busaniae repreperum
is placed ontoderovit, sitatiumventilator.
the transfer nosam sinisci liquiat eaquias
It is essential to ensure iminulpa
that theisbedside
asitatia int.
capnography
Busciis aceati omnit laut remains at the same
autate Wessex Neuro value
ICU as previously.
Guidelines This
con es ismagnam
likely to inequate
porrovit,
to a different EtCO value on the transfer capnograph, which
seriatur?Pa sedioreped quosa2 consequas acepe conest ut am, quo dis enia vitae. Perovit should be noted
and maintained.
qui Non-invasive
doloratatas voluptaventilation

Patients with increasing oxygen requirements on a face mask may benefit
velese ma from
inctota quidunt
either acest,
Optiflow idenihicti
or CPAP im cus a Positive
(Continuous dolesto eatas
Airwayaut pel is dolesci tibus.
Pressure).
|| Optiflow employs high flow, humidified oxygen enriched air delivered via
num harciis rest nasal
offic tem aut verroviti
cannulae optaoxygenation.
to improve doluptam, quibus di voluta qui
It generates modestnon amount
reicil eosan-
tium entis nima sit que eostiis
of CPAP withoutcitam, eumet
a tight fittingvoluptasit
mask. posandu ntioreritem quam ad ma de
veligen diant.et
||
quos ium, cus
For mask CPAP cone
thedem nemtypically
patient fugiatem. wearsPudionsequia dismask
a tight fitting suntotate laborpor
with the
oxygen/air nis evento
mix maintained tem et pratem.
at a pressure Ut rem
of 5-10cmH 2
O.eatenienis enimolup-
This will usu-
ally improve
tae. Uptatio dolorem oxygenation
nus sinctem and should
fugit iditatiorum vit help reduce
volupta areas
porem of atelectasis
quatusa /
pedionsequis
dolorumquunt ascollapse
dit mo corin sa
theporro
lungs.et volupti beatquo cus.Liqui dolupid molor sit vellis debis
CPAP
ratur, omnihit incidus is commonly
ea Wessex Neuroused
ICU at 5, 7.5 or 10cmH
Guidelines qui quaerov
2
O itendae volor aligenime

expelleces mi, sam tor,
It is best
reriandic
tolerated by using the separate CPAP circuit or NIV ventila-
rathertenecus Wessex
than through Neuro ICUsettings
non-invasive Guidelines autICU
of the voloreperit
ventilator proris as

Patients achieving insufficient tidal volumes (with increasing PaCO2), when
usant. Quiaselfnonventilating
con nullaut onveratemo
a face mask,tem may
aut modipis cimintBiPAP.
benefit from quia nonsequis aut et
This is similar to Wessex
Neuro ICU CPAP,Guidelines dolupta additional
but provides tureped ullorepudam
support during iunt, nulparciur?Perio. Ut de vendam,
inspiration.
|| The pressure applied during expiration is EPAP (Expiratory Positive
none option nat Airwayquia cumqui ullestand
Pressure), ligenihiciet accus.Quis
is equivalent to CPAPsit, offictem quo conecto ditia-
|| The pressure applied during inspiration is IPAP (Inspiratory Positive
volo iur?VolorentAirwayut ut que et mi, quas
Pressure), and issinsetcum quidellandel
to be greater than incto
the quassit
EPAP. faccatur maximi,
|| The difference between the EPAP and the IPAP is the additional pres-
comnimusam ressure quethelab patient
inis coreperum
receives di bla aut
during ut veria dignima
inspiration i.e. an EPAPgnihicimus suntiae
of 10cmH O, ditiis
2
est ad magnam with reresenient
IPAP of escius
15cmH2sequuntur
O, produces sinullit
5cmH assimporesse
2
O of additional veliquam,
pressureomnihicit
to aid et
fugit officiatis iur,inspiration
sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
ad eum fugia ||volorpo
BiPAP reptur? Et lam
is better vendausing
tolerated non consediam
the separate autNIV
es dolendipsum venis
ventilator, rather thanrerum a
quo testis maximus through the ICU
aecabore, queventilator
nonem es repereped ut ut dolupta sundit, ad qui cullenim
24
Chapter
solo 5
molora

explautem eum All high
re corspinal
aut cord
omnis injury (SCI)
a vit, patients,
Wessex Neuro not ICU
already on invasive
Guidelines ventilation,
consecate consect
must be considered for early nasal/facial BiPAP
ntibusande natet|| NIV shouldutem
atistibus, be started
quosam immediately
reriberro on od any patientnatemosame
molende with a high SCI, andodis
nonet
weakness affecting respiratory muscles
num et endia|vendi | Delay in starting
ipsandem NIVendesec
apidell can result in the development
ulloribus deribus di ipsam of lung atelecta-
harit quibus, cori-
sis & collapse, increasing likelihood of the patient requiring invasive
ventilation
||
seriatur?Pa sedioreped Patients with SCI
quosa must beacepe
consequas kept flat to aidutdiaphragmatic
conest am, quo dis enia movement.
vitae. Perovit
(See Chapter on Spinal Cord Injury)

erorerum repe
qui doloratatas
Patients
must
conseque with nos
have seriam
volupta
Guillain-Barr
et debitatiasyndrome
their respiratory
idessum est (GBS)
rate, vital capacity,
solorest voluptatis
& Myasthenia
doluptur, est min ped
arterial Iqui
modit explatur? blood
Gravis
mod(MG)
gases
blam
et resciunt,
(ABG) eaqui
faceprovit
and chest X-ray (CXR) monitored. NIV should be commenced early, before
nosto erio. Wessex
changesNeuro in ABG ICU Guidelines
or CXR occur, Verum
to avoidipidunt volorand
intubation aditventilation
la doluptasit aut reiciet
whilst
pro enecta nis et quiasim
awaiting effectenimos
of IVIgmoluptate
or plasmavolo qui cus explam as accae dolo bersped que
exchange.

Consider inserting NG tube in any patient receiving NIV, to allow suction-
ing of any gastric air, and prevent the subsequent development of gastric
num harciis over-distension.
rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
|| NG tubes can be used in patients who are receiving nasal BiPAP

re corrorporest Patients
quos eumwith lower cranial
nobistibus nisnerve
evento palsies
tem et
aspirated 1-2 hourly, and may not be suitable for NIV
must haveUt
pratem. anrem
NG eatenienis
tube inserted and
enimolup-

dolorumquunt Doasnot
ratur, omnihitbetter
dit attempt
incidus
mo cor sa
and ealess
porro et
to wean volupti
IPAP beatquo
or EPAP untilcus.Liqui
the patient dolupid molor sit vellis debis
is symptomatically
tired Neuro ICU Guidelines qui quaerov itendae volor aligenime
Wessex

quatem aspedit
expelleces mi,
Planatatem
NIV sam
with
consedia
the weaning
reriandic
the physio tenecus
volorerum
of SCI, GBS &etMG
teamWessex
to give best
omni
Neuro
od quifrom
patients bearum
ICU Guidelines
chance
is estrunt
invasive
of success.aut
re volor
ventilation
voloreperit
Extubate
rehent
onto
proris
early in as
rerspero ommo the ommolor
day, and posandi
at the beginning of the week.
gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non con nullaut
Patients whoveratemo
are posttem op aut modipis cimint
transphenoidal quia nonsequis
pituitary surgery MUST aut etNOT
Wessex
Neuro ICU Guidelines receive dolupta turepedventilation.
non-invasive ullorepudam Thisiunt, nulparciur?Perio.
is likely Ut de vendam,
to force gas intracranial-
ni consenes idendemodis ly thoughrethe surgical approach
voluptibus.Ero cuptiumin the nasopharynx.
consequi dolorehAny such patient
enimetu rionsed que
none option nat quia mustcumqui
be considered for early intubation
ullest ligenihiciet accus.Quis if failing to ventilate
sit, offictem quoadequately
conecto ditia-
on a face mask. (The use of the Bird respirator via a mouth piece, with
turias prepedi taecerrovita vit pelitatia may
the physiotherapists, con perae
also bevoluptae
possible.) doluptia nimi, venis nemquame
25
Wessex
solo NeuroNusda
Tracheostomy
explautem eum re cor aut careomnis a vit, Wessex Neuro ICU Guidelines consecate consect
autatatque
Insertion parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la
of tracheostomy
Tracheostomies may be inserted either percutaneously on the Neuro ICU, or sur-
gically in theatre. Patients with concerns about neck stability or potentially difficult
anatomy will need to be considered for a surgical tracheostomy.
odit hillorest,
Prior tonusdand
tracheostomy antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
insertion:

The neurosurgical / neurological consultant must be in agreement with the
qui doloratatas
Neuro volupta
ICU teamseriamthatsolorest voluptatisismodit
a tracheostomy explatur?
appropriate for Iqui blam faceprovit eaqui
the patient.

pro enecta nisTheetprocedure must have
quiasim enimos been discussed
moluptate volo qui cuswithexplam
(and documented
as accae dolo in the
bersped que
notes):
Nosam verferf the patient,
|| erferspit if they are able
que voluptatius rerum to rem
comprehend
ut omni utthe autprocedure
res is autand lamconsent
qui nempore
num harciis|rest| officpatients
the tem autfamilyverroviti opta doluptam,
(complete a consentquibus
form 4,diifvolut
patient quiunable
non reicil
to eosan-
tium entis nima sit consent)
que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de

veligen diant.et
The quos ium,feed
patients cus should
cone dem nem fugiatem.
be stopped 6 hoursPudionsequia dis suntotate laborpor
before the procedure

tae. UptatioAdolorem
group and nussave should
sinctem have
fugit been sent,
iditatiorum vitunless
voluptablood
porem transfusion
quatusa already
pedionsequis
has serum saved

ratur, omnihitSedation
incidusshould
ea Wessexbe started
Neuroprior
ICUtoGuidelines
the procedure or transfer
qui quaerov
to theatre
itendae volor aligenime
Following the tracheostomy insertion:


rerspero ommo Sedation
ommolormustposandi
be continued until any paralysing
gnimus.Laborer iaerupienisagent has worn
dolorehent off doles volorib
lis eos

usant. QuiaConsider
Neuro ICU the
non con sedating
Guidelines
nullaut veratemo
tracheostomydolupta
overnighttem
tube
aut modipis
or longer cimintpatients
in agitated quia nonsequis
that mayaut
tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
et Wessex
dislodge

Chest X-Ray must be performed and reviewed immediately following
procedure
volo iur?VolorentIfut theuttracheostomy
que et mi, quas tubesin
becomes dislodged within
cum quidellandel the first faccatur
incto quassit 10 days,maximi,
the patient should be oxygenated and ventilated by face mask. At-
tempts to re-insert a tracheostomy tube at this stage may create a false
comnimusam respassage que lab andinis fail
coreperum di bla the
to oxygenate aut patient.
ut veriaUrgent
dignima gnihicimus suntiae
re-intubation (via ditiis
est ad magnam oral route) may
reresenient be necessary,
escius sequuntur although the priority remains
sinullit assimporesse veliquam,adequate
omnihicit et
fugit officiatis iur,oxygenation and ventilation.
sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
26
Chapter
solo 5
molora
Change
explautem eumofretracheostomy
cor aut omnis a tube vit, Wessex Neuro ICU Guidelines consecate consect

emoluptae veribus
ntibusande natet
Portex am
be changed
tubes rem
atistibus,
quid be
should
at 1utem
eatur assimillat.Wessex
changed at 7 days, while Neuro ICU Guidelines
Trachoe
monthquosam reriberro od molende natemosame nonet odis
twist tubesTis dolupti
should

num et endiasuch
Any change of tracheostomy tube must be done over an appropriate guide
vendiasipsandem apidell endesec
a suction catheter, until theulloribus deribus
tract is fully di ipsam harit quibus, cori-
established.
Beware using a hard disposable bougie via a tracheostomy tube, be-
cause of the risk of causing damage to the tracheal / bronchial mucosa
Management
erorerum repe consequeof noschest drains
et debitatia idessum est doluptur, est min ped mod et resciunt,

pro enecta nis Any et patient
quiasimwith a pneumothorax,
enimos moluptate volo
considered for emergent insertion of a chest drain
particularly if beingasventilated,
qui cus explam accae dolo should
berspedbe que

Nosam verferf Following
erferspitinsertion
immediately.
of a chest
que voluptatius drain,
rerum rem a chest
ut omni X-Ray
ut autmust
res be obtained
is aut lam qui nempore

tium entis nima
veligen diant.et
Anysit
Neuro
que eostiis
patient
quos ICU
with a citam, eumet
chest drain voluptasit
in-situ posandu
must have dailyntioreritem
chest x-rays
quam adonma de
while

Chest drains should not be clamped until consideration of removal.

dolorumquunt Suction
as dit mo
trar /
should
consultant.
only
cor sa be applied
porro et volupti after discussion
beatquo withdolupid
cus.Liqui the cardiothoracic regis-
molor sit vellis debis
quatem aspedit atatem Suction consedia
must not volorerum
be standard et omni wallod qui bearum
suction. There isare
estrunt re volor
dedicated tho-rehent
expelleces mi, sam racic low pressure
reriandic tenecussuction
Wessexdevices Neuro available
ICU Guidelineswhich aut
canvoloreperit
be set up by the as
proris
medical technicians. Suction must be less than
rerspero ommo ommolor posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib 5kPa at all times.

usant. Quia non Chest con
more than 24
nullaut
drains veratemo
should not betem
hourstureped
dolupta and a chest
aut modipis
removed cimint
until they
X-ray demonstrates
ullorepudam
quia
have nonsequis
stopped aut etforWessex
bubbling
no residual Ut
iunt, nulparciur?Perio. pneumo-
de vendam,
thorax. A chest drain inserted for a traumatic
ni consenes idendemodis re voluptibus.Ero cuptium consequi doloreh enimetu rionsed pneumothorax should not be que
considered for removal within 72 hours of its insertion, even if it has stopped
bubbling and swinging.
On day
volo iur?Volorent ut ofut removal,
que et mi, thequas
chest sindrain
cumshould be clamped
quidellandel
patient remains stable for 4 hours, a chest X-ray should be performed at
incto at 08:00faccatur
quassit hours. Ifmaximi,
the
midday. Provided there are no signs of pneumothorax, the drain should then
comnimusamberes que labininis
removed thecoreperum
early afternoondi blatoaut ut veria
allow patientdignima gnihicimus
assessment on thesuntiae
16:00ditiis
est ad magnam round. reresenient
If the patient escius sequuntur
should becomesinullit unstableassimporesse
whilst the drainveliquam, omnihicit
is clamped, the et
fugit officiatisclamp should
iur, sam, be removed ulparcitaqui
ut quaeperrovid immediately.odit essint aut adis as commodi ctisit ant,

ad eum fugiaWhen volorpo
quo testis maximus
possible,
reptur? the
removing
aecabore,
Et lam
they should quebe
venda
drain
nonem
fromnon
requested
consediam autventilating
a spontaneously
es repereped
to perform ut a
es dolendipsum
utvalsalva
patient,venis
dolupta sundit,
manoeuvre
where
ad qui
rerum a
cullenim
whilst
the drain
volor alis susdandis is removed
moluptam andpratate
everis the previously
iliquas rem placed
que sutures are tightened.
nos endicitin est ipieneculpa sus
27
Wessex
solo NeuroNusda

explautem Wheneum reremoving the drain
cor aut omnis fromWessex
a vit, a ventilated
Neuro patient, an inspiratory
ICU Guidelines hold should
consecate consect
be set on the ventilator whilst the drain is removed and the previously placed
emoluptae sutures
veribus aream tightened.
rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
Removaleosam
autatatque parchilitat.Ut of chest drainsaut
suscias placed by neurosurgical
qui volorum quam hari spinal
odis surgeons
Certain apidell endesec
neurosurgical ulloribus(eg
spinal surgeons deribus di ipsam
Mr Brooke) haveharit quibus, cori-
a consist-
busaniae repreperum derovit, to
ent approach sitatium nosam
chest drain sinisci liquiat eaquias iminulpa is asitatia int.
management.
They place
seriatur?Pa sedioreped quosa2 sutures:
- 1 horizontal mattress suture left as 2 long strings with knot in end
odit hillorest, nusdand antibusape
- 1 wrapped aroundnonsequ
drain assequi
no longdoluptatur?
strings Qui in eum aut aut ommolor
Removal
qui doloratatas volupta process:
nosto erio. Wessex Neuro ICU end
Cut knot off of long Verum
Guidelines strings ipidunt
& hold securely
volor adit la doluptasit aut reiciet
Cut suture wrapped around drain, which is holding it in, & remove
pro enecta nis et quiasimsutureenimos moluptate volo qui cus explam as accae dolo bersped que
velese ma inctota quidunt
On maximalacest,inspiration,
idenihicti im cus a dolesto
withdraw eatas
chest drain aut pelwhilst
smoothly is dolesci
pull- tibus.
Nosam verferf erferspit ing gently but continuously
que voluptatius rerum remon long strings
ut omni to close
ut aut res is off
autdrain sitenempore
lam qui
num harciis rest offic completely.
tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
Once drain removed, securely knot mattress suture to ensure air-
tium entis nima sit que tighteostiis
seal citam, eumet voluptasit posandu ntioreritem quam ad ma de
veligen diant.et quos ium, cussuture
Remove cone after
dem nem fugiatem. Pudionsequia dis suntotate laborpor
5 days.

Purse string sutures should not be used as they risk converting a linear clo-
sure into a circular one which may produce an unsightly scar and discomfort.

ratur, omnihitFollowing
incidus removal
ea Wessex of the drain
Neuro theGuidelines
ICU patient must quihave a chest
quaerov
2 hours if on positive pressure ventilation or at 12 hours if breathing
x-rayvolor
itendae within
aligenime
spontaneously
28
6
Cardiovascular
management
The three circulations that are essential for survival: cerebral, renal, and coronary,
are protected from fluctuations in blood pressure by autoregulation. Autoregulation
ensures a constant blood flow through these circulations over a range of blood pres-
sures. In a normotensive individual this mechanism ensures an adequate but not
excessive flow over a range of mean arterial blood pressure (MAP) of 50-150mmHg.
velese Untreated
ma inctotahypertensive
quidunt acest, idenihicti
patients im this
reset cus range
a dolesto
to a eatas
higheraut peland
level is dolesci
may needtibus.
a MAP>70 or 80mmHg que voluptatius
to maintainrerum rem ut
adequate omniflow
blood ut aut
for res is aut lam
perfusion qui nempore
through these
num circulations.
harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
Adequate cerebral circulatory flow in the awake patient may be demonstrated by
normal mentation. Unfortunately this may be impossible to assess in many of the
patients admitted with intracranial pathology to Neuro ICU. Adequate renal circulatory
flow may be demonstrated by a urine output0.5ml/kg/hr averaged over 4 hours in the
absence of any diuretics (eg mannitol) or diabetes insipidus (DI).
quatemInadequate
aspedit atatem consedia
coronary volorerum
circulation mayetbe omni od qui bearum
demonstrated is estrunt of
by evidence re ischaemia
volor rehent
expelleces
on a 12 mi,lead
samECG.
reriandic tenecus
However ECGWessex
changesNeuro
areICU Guidelines
almost universalautafter
voloreperit proris as
subarachnoid
haemorrhage, making posandi
furthergnimus.Laborer iaerupienis dolorehent lis eos doles volorib
interpretation difficult.
Beware inappropriate transducer level. If the transducer is at an
Neuro ICU Guidelines dolupta level,
inappropriate turepedeg ullorepudam
during transfer,iunt, nulparciur?Perio.
it will Ut de
give a falsely high vendam,
or low
ni consenes idendemodis re voluptibus.Ero
reading which may result incuptium consequi
inappropriate doloreh enimetu rionsed que
treatment.
volo Blood
iur?Volorentpressure
ut ut que targets
Patients on Neuro ICU may have a blood pressure target set. This generally falls
into one of three categories :
ad eum1 fugiaCerebral Perfusion
volorpo reptur? Pressure
Et lam venda(CPP) target:
non consediam aut es dolendipsum venis rerum a
quo testis maximus
|| aecabore,
CPP = MAP -que
ICPnonem es repereped ut ut dolupta sundit, ad qui cullenim
29
Wessex
solo NeuroNusda
explautem | |
eum Traumatic
re cor aut brain
omnisinjury
a vit,(TBI) patients
Wessex NeurothatICUhaveGuidelines
their ICP monitored
consecatemust consect
maintain a CPP>60mmHg, to maximise their chance of good recovery.
|
ntibusande |natet Some patients
atistibus, utemwith TBI appear
quosam to respond
reriberro better tonatemosame
od molende a higher CPPnonet tar- odis
get, and there is currently debate as to whether a dynamic target should
be set (eg guided by markers of global cerebral autoregulation such as
num et endia vendi the ipsandem apidell endesec
pressure reactivity ulloribus deribus di ipsam harit quibus, cori-
index (PRx))
|| CPP targets are not appropriate in spontaneous SAH
| There isquosa
seriatur?Pa|sedioreped no evidence
consequasfor maintenance
acepe conest of CPP
ut am, affecting
quo disoutcome in any
enia vitae. Perovit
intracranial condition except TBI.
2 repe
erorerum Mean Arterial Pressure
conseque (MAP) idessum
nos et debitatia target: est doluptur, est min ped mod et resciunt,
qui doloratatas
|| volupta
Traumatic seriam solorest
brain injuryvoluptatis modit
patients that doexplatur?
not have Iqui
theirblam faceprovit eaqui
ICP monitored
nosto erio. Wessex should maintain
Neuro a MAP>90mmHg,
ICU Guidelines to maximise
Verum ipidunt volor their
adit la chance of good
doluptasit aut reiciet
pro enecta nis etrecovery. (This allows
quiasim enimos for anvolo
moluptate ICP30mmHg)
velese ma | inctota
| quidunt acest,haemorrhage
Subarachnoid idenihicti im cus a dolesto
patients eatas aut
that present withpel is dolesci
severe hyper-tibus.
tensionque
Nosam verferf erferspit have traditionally
voluptatius had rem
rerum theirutblood
omnipressure
ut aut res reduced
is aut lamto aqui
systolic
nempore
of 160mmHg. The experience of most senior staff
num harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-in The Wessex
Neurological Centre is that this may not be beneficial in reducing the
tium entis nima sit riskque eostiis citam,
of rebleeding andeumet voluptasit
may result posandu perfusion
in inadequate ntioreritemaroundquam any ad ma de
veligen diant.et quosareasium, cus cone dem
of haematoma. ThenemICPfugiatem.
may be as Pudionsequia
high as 50mmHg dis suntotate
in theselaborpor
re corrorporest quos patients.
eum (See chapter
nobistibus nison Subarachnoid
evento haemorrhage).
tem et pratem. However hyper-
Ut rem eatenienis enimolup-
tension with a MAP>140mHg should be controlled.
dolorumquunt || asVasospasm
dit mo cor samay porrobeetthe cause
volupti of neurological
beatquo cus.Liquideterioration
dolupid moloroccurring
sit vellis debis
>72 hours after subarachnoid haemorrhage.
quatem aspedit atatem
This consedia
will usuallyvolorerum
present as et omni
focalod qui bearum
neurology is estrunt
related re volor rehent
to inadequate
expelleces mi, sam perfusion of an arterial
reriandic tenecus Wessex territory.
be performed iaerupienis dolorehenthydrocephalus,
A CT scan must to exclude significant
usant. Quia non conrebleed nullautor increased
veratemo tem oedema around
aut modipis any intracerebral
cimint quia nonsequis haematoma.
aut et Wessex
Thisdolupta tureped
may require ullorepudam iunt,
pharmacological nulparciur?Perio.
elevation Ut de vendam,
of the blood pressure to
ni consenes idendemodis maintain reperfusion through
voluptibus.Ero vasoconstricted
cuptium arteries. enimetu rionsed que
consequi doloreh
none option nat quia Thecumqui ullestshould
ligenihiciet accus.Quiselevated
sit, offictem quo conecto
any new ditia-

turias prepedi taecerrovita
MAP target
vit pelitatia con
be sequentially
perae voluptae
to reverse
doluptiawhile
nimi,actively
venis nemquame
neurological deficit, to a maximum of 140mmHg seek-
volo iur?Volorent uting ut clinical
que et or mi,ECG
quassigns of coronary
sin cum ischaemia
quidellandel incto quassit faccatur maximi,
quunturio ium || haruptatiis
Intracerebralandem di quidem nulparchit
haemorrhage patients may velecte eos et quid
be severely ent vollaccuptae
hypertensive
They mayescius
need their MAP reduced slowly to decrease the likelihood
sequuntur sinullit assimporesse veliquam, omnihicit
of further haemorrhage, whilst maintaining adequate perfusion of the et
penumbra
fugit officiatis iur, sam, around the
ut quaeperrovid haematoma.
ulparcitaqui odit essint aut adis as commodi ctisit ant,
ad eum fugia volorpo Anreptur? Et lam bevenda non consediam autleft
es ventricular
dolendipsum venis rerum a
ECG should performed, looking for
hypertrophy.
30
Chapter
solo 6
est, exeriae. Nusda nonsequo temolec erovitatenisCardiovascular doles eatiore ribusandiste management molora
If the
autECG
omnis or an echo
a vit, indicates
Wessex Neurothat ICU
hypertension
Guidelines is long standing
consecate consect
and has not previously been diagnosed or treated, then full investi-
emoluptae veribus am remofquid
gation this eatur assimillat.Wessex
is indicated, Neurocatecholamines,
including: urinary ICU Guidelines renal Tis dolupti
ntibusande natet atistibus, utem quosam
artery imaging, etc. reriberro od molende natemosame nonet odis
If the patient
potentially has a phaeochromocytoma, hypertension
apidell endesec ulloribus deribus di of
ipsam harit quibus, cori-
should be gradually controlled with an infusion phentolamine,
busaniae repreperumrather thansitatium
derovit, labetalol. nosam sinisci liquiat eaquias iminulpa is asitatia int.
Busciis aceati omnit In
lautotherautate
cases, WessexloweringNeurotheICU
blood Guidelines
pressure con mayes magnam
require in porrovit,
labetalol, by
seriatur?Pa sedioreped quosa consequas
intravenous acepe conest
bolus or infusion, prior to uttheam, quo dis enia
introduction vitae.
of oral Perovit
antihy-
odit hillorest, nusdand pertensive
antibusape agentsnonsequ assequi doluptatur? Qui in eum aut aut ommolor
erorerum repe conseque nos aim
et debitatia idessum est doluptur,
the MAP est min140mmHg
ped mod et resciunt,
An initial should be to reduce below
GradualICU
control of hypertension may be appropriate over the follow-
Guidelines Verum ipidunt volor aditagents la doluptasit aut reiciet
ing days and weeks with oral antihypertensive
3 No MAP / CPP target
Nosam verferf Awakeque
|| erferspit patients
voluptatiusshouldrerummaintain
rem autblood
omni pressure
ut aut resthat is adequate
for normal mentation and urine output. This
num harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil will normally require a eosan-
MAP50mmHg in a previously normotensive patient.
veligen diant.et|| quos Sedated
ium, cuspatients
cone should
dem nem maintain
fugiatem.a blood pressure that
Pudionsequia dis is adequate
suntotate for
laborpor
appropriate urine output in the absence of any diuretic. This will nor-
mally be on average >0.5ml/kg/hour over a 4 hour period, but in a small
tae. Uptatio dolorem nuspatient
elderly sinctem withfugit iditatiorum
normal vit volupta
renal function porem
it may quatusa pedionsequis
be appropriate to accept
dolorumquunt as dit less.
moThis willporro
cor sa usually requirebeatquo
et volupti a MAP50mmHg in a previously
cus.Liqui dolupid molor sitnormo-
vellis debis
tensive patient.
quatem aspedit atatem consedia
Brain injured volorerum
patients may et omni od
develop qui bearum
significant is estrunt re
hypertension. volor
This may rehent
expelleces mi, sam bereriandic
appropriate
tenecus to maintain
Wessexperfusion
Neuro ICU of ischaemic
Guidelinesbrain in the faceproris
aut voloreperit of as
rerspero ommo ommolor raised intracranial pressure, hydrocephalus,
posandi gnimus.Laborer or vasospasm.
iaerupienis dolorehent lis eos However
doles volorib
there are risks associated with severe hypertension, eg expansion of
ICH, cardiac ischaemia. Hypertension with a MAP>140mmHg is an
Neuro ICU Guidelines indicationdolupta turepedcontrol
for gradual ullorepudam iunt, nulparciur?Perio.
of the blood pressure. Ut de vendam,
Elevating blood pressure
quunturio1 iumEnsure
haruptatiis
adequate andem volume di quidem
expansionnulparchit
using velecte
boluses eosof 0.9%et quidsaline.ent Suspect
vollaccuptae
comnimusamhypovolaemia
res que lab inis in all trauma patients
coreperum di bla autandutthose
veria with significant
dignima gnihicimus aspiration
suntiae ditiis
pneumonitis.
2 1st
fugit officiatis iur,line
sam, ut quaeperrovid
vasopressor ulparcitaqui
: phenylephrine odit essint
infusion (canautbe adis
givenasvia commodi ctisit ant,
peripheral
ad eum fugialine)volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a
quo testis maximus
|| aecabore, que
phenylephrine 10mgnonem es repereped
in 500ml 0.9% Saline ut utatdolupta sundit, ad qui cullenim
rate 0-180ml/hr
3 2nd line vasopressor : noradrenaline infusion (via central line only)
31
Wessex
solo NeuroNusda
explautem eum The re cor subclavian
aut omnis linea is
vit,the preferred
Wessex site for
Neuro ICUcentral venous
Guidelines cathetersconsect
consecate
emoluptae veribus on amNeuro remICU,quidin eatur
view of use of hard collars.
assimillat.Wessex NeuroHowever if a subclavian
ICU Guidelines Tis dolupti
line cannot be easily inserted, or there is abnormal clotting or platelets,
ntibusande natetthen atistibus,
internalutemjugular quosam
or femoralreriberro
access odshould
molende natemosame
be used. Ultrasound nonet odis
should alwayseosambe suscias
used to aut qui volorum
confirm quamofhari
the position theodis
vein,etbutporersp
need notellaut la
num et endia vendi be used for insertion.
ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-
busaniae repreperum If therederovit,
has been sitatium nosam sinisci
an unsuccessful liquiattoeaquias
attempt insert a iminulpa
subclavian is line
asitatia int.
Busciis aceati omnit into alautpatient
autate never
Wessex attemptNeuroa subclavian
ICU Guidelines line oncon the es
opposite
magnam sidein porrovit,
within 24 hours. The patient will require a chest X-Ray to look for
pneumothorax. Bilateral subclavian attempts risks bilateral pneumo-
thoraces,antibusape nonsequ
with potentially assequi doluptatur?
catastrophic consequences. Qui in Central
eum autvenous
aut ommolor
access may nosbe et safely
debitatia idessum
achieved byestthedoluptur, est minor
internal jugular ped mod et
femoral resciunt,
route.
|| noradrenaline 20mg in 250ml 5% glucose at 0-40ml/hr
|| Ensure baseline 12 lead ECG has been performed prior to starting
noradrenaline, and repeat 6 hourly until MAP / CPP target has been
velese ma inctota quidunt All
achieved. acest,
ECGs idenihicti
must beimreviewed
cus a dolesto
and signed eatasbyaut pel is within
a doctor dolesci1 tibus.
hour. que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
|| Once noradrenaline infusion >10ml/hr
Start
hydrocortisone 100mg IV tds
re corrorporest quos Consider fludrocortisone
eum nobistibus nis evento 100mcg
tem et PO /NG tdsUt rem eatenienis enimolup-
pratem.
tae. Uptatio dolorem nus sinctem fugit
to iditatiorum vit volupta
inhibitorporem(PPI), quatusa pedionsequis
Convert ranitidine a proton pump if not already on
dolorumquunt as ditPPI mo (Increased
cor sa porrorisk of GI haemorrhage
et volupti beatquo cus.Liqui in patient withmolor
dolupid vasoconstrictor
sit vellis debis
and steroids)
quatem aspedit atatemChoosing consedia
the right volorerum
proton pump et omni od qui
inhibitor onbearum
Neuro ICU is estrunt re volor rehent
Oral /NG route: lansoprazole 30mg NG od
rerspero ommo ommolorIVposandi route: gnimus.Laborer
pantoprazole 40mg iaerupienis
IV od dolorehent lis eos doles volorib
Neuro ICU Guidelines Set up LiDCO
dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
EnsurereSTvoluptibus.Ero
ni consenes idendemodis segment monitoring cuptium is consequi
operational on monitor
doloreh enimetu rionsed que
none option nat quia
Daily12cumqui leadullest
ECGs, ligenihiciet
checkingaccus.Quis
for ischaemic sit,changes
offictem quo conecto ditia-
Any patient with sudden onset hypotension must have the presence of
volo iur?Volorentpneumothorax
ut ut que et mi, quas sinNB
excluded. cumthisquidellandel
is more likelyincto withquassit
positivefaccatur
pressuremaximi,
quunturio ium haruptatiis
ventilation. andem di quidem nulparchit velecte eos et quid ent vollaccuptae
32
Chapter
solo 6
est, exeriae. Nusda nonsequo temolec erovitatenisCardiovascular management
doles eatiore ribusandiste molora
Patients
explautem eum re admitted
cor aut omnis on aanti-hypertensive
vit, Wessex Neuro ICU medication

Most patients should have their anti-hypertensive medications withheld
initially. eosam suscias aut qui volorum quam hari odis et porersp ellaut la

The exception to this rule, is that all beta-blockers must be continued to avoid
precipitating myocardial ischaemia.
Most patients
seriatur?Pa sedioreped that are
quosa established
consequas acepeon aconest
beta-blocker
ut am, have
ischaemic heart disease rather than control of hypertension.
hadenia
quo dis it started
vitae. for
Perovit

erorerum repe
qui doloratatas
conseque nos
Beta-blockade
beta-blockers
volupta seriam
willetlead
acutely
debitatia idessum estofdoluptur,
to up-regulation
in thevoluptatis
solorest presencemoditof raised
est min Stopping
beta-receptors.
catecholamines
explatur?
ped mod et resciunt,
associ- eaqui
Iqui blam faceprovit
ated with intracranial hypertension, may lead to myocardial ischaemia or
infarction.
Beta-blockers
velese ma inctota
infused
quidunt should
to achieve a
be continued
acest, idenihicti
high MAP / CPP
even
im cus a when
target.
vasopressors
dolesto eatas aut pel
areisbeing
dolesci tibus.

num harciis Calcium
rest officchannel
scribed
tem autblocker
for their
verrovitidrugs
anti-arrhythmic
opta (eg
doluptam,
Verapamil,
effect rather
quibus di volutmay
diltiazem)
than as
qui have
non reicil
anti-hypertensives
been eosan-
and
pre-
veligen diant.etshould
quostherefore
ium, cusbe continued.
33
7
Fluid management
oditEnteral
hillorest, feeding
Aim to start enteral feeding as soon as possible to provide appropriate caloric and
uid intake. Enteral feeding also promotes the integrity of the gastrointesinal mucosa.
The enteral feeding guidelines are described in the following chapter.
Intravenous fluid therapy

re corrorporestCheck to ensure
quos that renalnis
eum nobistibus function
eventoistem
normal

tae. UptatioIfdolorem
dolorumquunt mmol)
nus sinctem
renal function
as ditatmo
100-125ml/hr
fugit
is normal,
cor sa porrobased
iditatiorum
prescribe 0.9%
on body
et volupti
vitsaline
volupta
weight,
beatquo
porem
1000
age and
cus.Liqui
quatusa
ml with
habitus
dolupid
KCl 3pedionsequis
g (40

ratur, omnihit
quatem aspedit
In incidus
serum atatem
ea Wessex
any patient Neuro
with renal
consedia
potassium
ICU Guidelines
impairment, potassiumquishould
quaerovbeitendae volor aligenime
reduced/withheld
volorerum et omni od qui bearum is estrunt re volor rehent
elevated
if

Liaise with nursing staff to slow rate of IV uids as enteral feeding becomes
established
Electrolyte
ni consenes disorders
idendemodis re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
voloHypernatraemia
iur?Volorent ut ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
The commonest causes of hypernatraemia on Neuro ICU are cranial diabetes insip-
idus, water dehydration from inadequate intake in patients with impaired GCS, and
following administration of mannitol or hypertonic saline for the treatment of cerebral
oedema / raised ICP.
Acute
quo testis hypernatraemia
maximus aecabore,(eg occurring
que nonem es over a time period
repereped shortersundit,
ut ut dolupta than 6hrs) can
ad qui be
cullenim
corrected
volor acutely.moluptam
alis susdandis In chroniceveris
hypernatraemia, correction
pratate iliquas rem queofnosplasma sodium
endicitin should pro-sus
est ipieneculpa
mi, ceed
nime more cautiously;
voluptas brain cells
simus. dolupta form ullorepudam
tureped ideogenic osmoles that act as a strong osmotic
iunt, nulparciur?Perio
34
Chapter
solo 7
est, exeriae. Nusda nonsequo temolec erovitatenis doles eatiore Fluid management
ribusandiste molora
force when
explautem eum exposed
re cor auttoomnis more hypotonic
a vit, Wessex plasma
Neurouid.ICURapid correction
Guidelines leads to consect
consecate brain
oedema.
emoluptae Use ofam
veribus dextrose-
rem quid containing IV uids must beNeuro
eatur assimillat.Wessex avoided ICUforGuidelines
this reason. Tis dolupti
ntibusande natet hypernatraemia
Moderate atistibus, utem isquosam acceptablereriberro od molende
in patients with raised natemosame
ICP (serumnonet sodiumodis
<154mmol/l or serumeosam suscias
osmolality aut qui volorum quam hari odis et porersp ellaut la
<320mosmol/kg)
Rate of change of serum sodium, whether increase or decrease,
Busciis aceati omnit laut NOT
should autate Wessex
exceed Neuro ICU
0.5mmol/l Guidelines
per hour, i.e. nocon es than
more magnam in porrovit,
12mmol/l in
seriatur?Pa sedioreped 24hrs. quosa consequas acepe conest ut am, quo dis enia vitae. Perovit
Cranial diabetes
qui doloratatas voluptainsipidus

Excess loss of enimos moluptate
free water secondaryvolo qui cus explamsecretion
to inadequate as accaeofdolo ADH. bersped que

Common in craniopharyngioma, less common in other pituitary surgery, but
may be seen with any intracranial condition, particularly if associated with
num harciis raised
rest offic tem aut verroviti
intracranial pressure.opta doluptam, quibus di volut qui non reicil eosan-

Diagnosis is suggested by a urine output > 200 ml/hr for 2 hrs (with urine
specic gravity < 1.01) and a rapidly rising serum sodium.

tae. Uptatio Conrmation
dolorem nus of diagnosis
sinctem fugitbyiditatiorum
markedly vit negative
voluptauid balance
porem
high serum osmolality (> 300 mosmol), low urine osmolality and low urinary
over pedionsequis
quatusa 4 hrs with
electrolyte concentrations, is not usually necessary

quatem aspedit Treatment
may
atatem should
be
consedia
withheld in
only be considered
volorerum
patients with
et omni
raised
when serum
od qui
ICP until
bearumsodium
serum
> 145 re
is estrunt
sodium
mmol/l,
volor but
>150mmol/l
rehent
(DDAVP will prevent free water loss, which may worsen cerebral oedema.)
usant. Quia non || con Treatment: DDAVP 0.5
nullaut veratemo temgautIV modipis
PRN (Max 1hrly)
cimint quia nonsequis aut et Wessex

Any patientdolupta
ni consenes performed
idendemodis
with urine
immediately
tureped
outputullorepudam
> 200 ml/hr iunt,
to checkcuptium
re voluptibus.Ero
for 2
serum sodium.
nulparciur?Perio.
hrs should have Ut de vendam,
blood
consequi doloreh enimetu rionsed que
gases

turias prepedi
Replace volume with 0.9% saline ( KCl). Recheck sodium regularly to check
it istaecerrovita
returning tovit pelitatia
normal con perae
(at least voluptae doluptia nimi, venis nemquame
6 hourly).

If diagnosis is delayed and serum sodium > 150 mmol/l,
comnimusam|res | Addition
que lab inis of water to enteral
coreperum feed
di bla autmay allowdignima
ut veria gradualgnihicimus
correction suntiae
of serumditiis
est ad magnam reresenientsodium escius sequuntur sinullit assimporesse veliquam, omnihicit et
| sam,IV titration of hypotonic
ut quaeperrovid saline (0.45%)
ulparcitaqui should
odit essint only
aut beasused
adis to slowly
commodi ctisit ant,
correct serum sodium (by < 0.5 mmol/hr), if enteral
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a water is not
tolerated
35
Wessex
solo NeuroNusda
explautem eum Never re cor give DDAVPa and
aut omnis vit, hypotonic
Wessex Neuro IV fluids
ICUconcurrently.

Occasionally,
busaniae repreperum
patients
there is an derovit,
apidell
may endesec
isolated sitatium
have partial
increasenosam
in plasma
ulloribus
sinisci
deribus
diabetes
liquiat
sodium
di ipsam
insipidus.
eaquias
without
haritcases,
In these
iminulpa
a high
quibus, cori-
is asitatia int.
urine output.
Busciis aceatiTreatment
omnit laut should
autatebe Wessex
discussed with the
Neuro ICUduty consultant
Guidelines conbut
es the condition
magnam in porrovit,
responds to low doses of DDAVP.
Hyponatraemia
veleseHyponatraemia
ma inctota quidunt in Neuro ICUidenihicti
acest, may be caused
im cus by increased
a dolesto retention
eatas aut pelof is
water by the
dolesci tibus.
kidneys due to SIADH, or excess loss of sodium (cerebral salt
Nosam verferf erferspit que voluptatius rerum rem ut omni ut aut res is aut lam qui nemporewasting, diuretic use
numorharciis
adrenocortical
rest officfailure).
tem aut It can also
verroviti result
opta from long-term
doluptam, quibus di anticonvulsant use (e.g
carbamazepine). Symptoms are rare until plasma sodium falls below
tium entis nima sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de 125 mmol/l, and
consist
veligen of: headache,
diant.et quos ium,nausea,
cus cone confusion,
dem nemdisorientation, coma and seizures.
fugiatem. Pudionsequia dis suntotate laborpor
re corrorporest quos the
Differentiating eumunderlying
nobistibuscausenis evento tem et pratem.
of hyponatramia on Ut rem eatenienis
Neuro enimolup-
ICU is practically
tae.impossible
Uptatio dolorem
in mostnus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis
cases.
SIADH

Persistent secretion tenecus
of ADH Wessex
withoutNeuro ICU Guidelines
an osmotic trigger. aut voloreperit proris as

May result from CNS disease (trauma, infection, tumours, SAH), other malig-
nancies, pulmonary disease, drugs, hypothyroidism, Addisons disease,
Neuro ICU porphyria.
Guidelines dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,

Diagnosis may be suggested by hyponatraemia, oliguria in context of euvola-
emia and a normal to low urea and creatinine.
Diagnosis
volo iur?Volorent ut utdepends
que et mi, on: quas sin cum quidellandel incto quassit faccatur maximi,
quunturio ium || haruptatiis andem >diserum
urine osmolality quidem nulparchit velecte eos et quid ent vollaccuptae
osmolality.
|| urinary Na+ > 20 mmol/l.
iur,serum
sam, utNa < 130 mmol/l.
+
||
fugit officiatis quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
ad eum fugia normal
||volorpo renal,Ethepatic,
reptur? lam vendacardiac, pituitary, adrenal
non consediam aut es and thyroid function.
quo testis maximus
|| aecabore,
absence que nonem es
of hypovolaemia, repereped ut
hypotension, ut dolupta
oedema, sundit,
drugs ad qui
affecting cullenim
ADH
secretion.
36
Chapter
solo 7
ribusandiste molora

explautem eum Although
re cormedical
aut omnismanagement
a vit, Wessex of SIADH
Neuro commonly involvesconsecate
ICU Guidelines fluid restric-
consect
tion, this is not usually indicated for patients on Neuro ICU due to the risk of
intravascular quid eatur
depletion assimillat.Wessex
causing inadequate cerebral Neuro perfusion.
ICU GuidelinesThis isTis
com-dolupti
ntibusande natetpounded atistibus,
by the utem
potentialquosam reriberro
for cerebral saltod molende
wasting natemosame
to exist concurrently. nonet odis
num Ceterebral
endia vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-
salt wasting

busaniae repreperum
Busciis aceati
Syndromederovit,
areomnit
associated
laut autate
released
sitatium
with nosam
by the Wessex
atria of the Neuro
siniscidisease
neurological
heartICU
liquiat eaquias
andGuidelines
iminulpa compounds
where natriuretic
con es magnam
possibly periventricular
is asitatia int.
areasin of
porrovit,
the
brain, and induce
seriatur?Pa sedioreped quosarenal sodiumacepe
consequas loss. conest ut am, quo dis enia vitae. Perovit

erorerum repe
Hyponatraemia may be potentiated by appropriate ADH secretion to compen-
sateconseque nos et debitatia idessum est doluptur, est min ped mod et resciunt,
for hypovolaemia.

Diagnosis is suggested by hyponatraemia with normal to high urine output,
normal to high urea and creatinine, negative fluid balance.
Confirmation
velese ma inctota quiduntofacest,
diagnosis requires
idenihicti demonstrating
im cus a dolesto eatas
ence of hypovolaema. This is a situation that can never be tolerated in
a natriuesis
aut pelinisthe pres- tibus.
dolesci
acutely unwell neurosurgical patients because of the risk of impairing cere-
num harciis bralrest perfusion.
offic tem aut Henceverroviti
making optathedoluptam,
diagnosisquibus di volutimpossible.
is practically qui non reicil eosan-

Diagnosis also requires the absence of aldosterone deciency, diuretics,
renal tubular damage or Bartters syndrome.
Management
dolorumquunt as dit
ofmo cor sa porro et
hyponatraemia (Na<135 mmol/l) cus.Liqui dolupid molor sit vellis debis
volupti beatquo
1 Ensure
adequate sodium and potassium intake by prescribing oral/enteral
sodium andconsedia
potassium volorerum et omni od
supplementation qui bearum
(Slow sodium 4istablets
estruntqds,
re volor
Slow/rehent
expelleces mi, sam K
Sando reriandic
4 tablets tenecus
qds) Wessex Neuro ICU Guidelines aut voloreperit proris as
2 Minimize
usant. Quia non
enteral free water, by flushing enteral drugs with either a minimum
amount of water,veratemo
con nullaut or with 0.9%tem autsodiummodipis cimint
chloride quia nonsequis
solution. Discourage autpatients
et Wessex
from drinking dolupta
water,tureped
although ullorepudam
tea, coffee and iunt,juices
nulparciur?Perio.
are allowed. Ut de vendam,
Removing the patients water jug and glass from their bedside will help
none option nat quia preventcumqui
excess ullest ligenihiciet
water consumption. accus.Quis
To ensure sit, patient
offictemcomfort
quo conecto
they ditia-
should bevit pelitatiatocon
permitted perae
drink voluptae
tea, coffee, doluptia
milk nimi,
and fruit venis
juices. Teanemquame
and
coffee are both diuretics and will only be supplied
volo iur?Volorent ut ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi, on request, limiting
the volume
quunturio ium haruptatiis andemingested. They nulparchit
di quidem will also usually
velectebeeosmade with milk,
et quid which
ent vollaccuptae
contains electrolytes. Fruit juices may also be consumed in moderation
comnimusam res since que lab inis also
these coreperum
containdielectrolytes.
bla aut ut veria dignima gnihicimus suntiae ditiis
3 Target
fugit officiatis a maintenance
iur, sam, ut quaeperrovid totalulparcitaqui
fluid intake oditof 1ml/kg/hr
essint aut foradis
patients>60
as commodi years.
ctisit ant,
Include dietary fluid in balance.
4 maximus
quo testis Chronicaecabore,
low sodium que nonem es should
<125mmol/l repereped ut ut dolupta
be corrected sundit,with
gradually ad qui
0.9% cullenim
saline, with
volor alis susdandis 3 grams
moluptam KCl pratate
everis per litre.iliquas rem que nos endicitin est ipieneculpa sus
37
Wessex
solo NeuroNusda
5 Moderate
explautem eum re cor hyponatraemia
aut omnis a vit, mayWessex
be corrected
NeurowithICU1.8% saline 50ml/hr,
Guidelines consecate which consect
may be administered by a peripheral IV cannula. If serum sodium does not
emoluptae gradually
veribus am rem quid
increase, eatur
then assimillat.Wessex
consider Neuro ICU
5% saline 20-50ml/hr via Guidelines
a central line.Tis dolupti
Rate of change of serum sodium, whether increase or decrease,
should NOT exceedapidell0.5mmol/l
endesec perulloribus
hour, deribus di ipsam
i.e. no more than harit quibus,
12mmol/l in cori-
busaniae repreperum 24hrs.derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
Busciis aceati omnit Rapid laut autate Wessex
correction Neuropontine
risks central ICU Guidelines
myelinolysis,conwhich
may result in
permanent quosa consequas
neurological acepe conest
impairment; ut am,
ranging fromquo dis eniatovitae.
weakness locked Perovit
in syndrome.
pro enecta1400nis et quiasim enimos moluptate volo qui cus explam as accae dolo bersped que
Nosam verferf
1200erferspit que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
SIADH
or
Cerebral Salt
tium entis 1000
nima sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de
Wasting
Urine Osmolality
Normal
800 quos eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
re corrorporest
dolorumquunt 600as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid
Solute Diuresis or molor sit vellis debis
Incomplete Diabetes Insipidus
quatem aspedit400 atatem consedia volorerum et omni od qui bearum is estrunt re volor rehent
y
Pasma Osmolality = Urine Osmolalit
Diabetes
rerspero ommo 200 ommolor posandi gnimus.Laborer iaerupienis
Diabetesdolorehent
Insipidus lis eos doles volorib
Insipidus
or
Overhydration
0
276 280 284 288 292 296 300 304 308 312 316
Plasma Osmolality
volo Figure 1: Nomogram
iur?Volorent ut ut querelating
et mi, quas plasma and urine
sin cum osmolality
Modified from Moses AM, Blumenthal SA, Streeten
quunturio ium haruptatiis andem di quidem nulparchit velecte eos et quidDH. Acid-base and ent
electro-
vollaccuptae
lyte disorders associated with endocrine disease: Pituitary and thyroid: In: Arief AI,
comnimusam
Defronzo RA res (eds):
que lab inis Electrolyte
Fluid coreperumand di bla aut ut veria
Acid-Base dignimaNew
Disorders. gnihicimus suntiae ditiis
York, Churchill
est ad magnam 1985,
Livingstone reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
pp 851-892.
ad eum 6 fugiaStart
volorpo reptur? Et lam
fludrocortisone venda
100mcg non consediam
PO/NG tds in any aut es dolendipsum
patient that may have venis
pitui-rerum a
quo testis maximus aecabore,orque
tary insufficiency, is atnonem
risk ofes repereped
cerebral ut ut dolupta sundit, ad qui cullenim
salt wasting.
38
Chapter
solo 7
ribusandiste molora
explautemNon-neurosurgical
eum re cor autpatientsomnis athat vit, are likely Neuro
Wessex to have ICUSIADH may be
Guidelines considered
consecate for
consect
fluid restriction
emoluptae veribus am (1500ml/day),
rem quid eatur or inassimillat.Wessex
severe cases demeclocycline
Neuro ICU Guidelines(impairs action of
Tis dolupti
ADH onnatet
ntibusande the kidney) canutem
atistibus, be used.quosam reriberro od molende natemosame nonet odis
Tolvaptaneosam
shouldsuscias
NOT aut qui volorum
be used on Neuro quam
ICU hari
(riskodis et porersprapid
of excessively ellaut la
num et endia vendi riseipsandem
in serum apidell
sodium)endesec ulloribus deribus di ipsam harit quibus, cori-
CNS injured
seriatur?Pa sediorepedpatients with diabetes
quosa consequas acepe conest mellitus
ut am, quo dis enia vitae. Perovit

erorerum repe
qui doloratatas
conseque
Patients
volupta
insulin
with nos
Typeet1debitatia
seriam
at the time of
diabetesidessum
solorest
mellitus est
voluptatis
diagnosis.
will doluptur,
This ismodit
est min
usually have
explatur? Iqui
an autoimmune
been ped mod et resciunt,
commenced
blam faceprovit
condition with destruc-
on
eaqui
tion of insulin
nosto erio. Wessex Neuroproducing cells. These
ICU Guidelines Verumpatients
ipidunt have
volor an absolute
adit requirement
for insulin, whish should be supplied as a variable rate intravenous insulin
infusion whilst on Neuro ICU.

Nosam verferf Patients
erferspitwith Type
que 2 diabetes
voluptatius mellitus
rerum rem utwillomni
usually produce
ut aut res is some
aut lam
may require modification of diet, tablets or insulin to control their blood sugar.
insulin. They
qui nempore
tium entis nima sitofque
Principles eostiis the
managing citam, eumet
diabetic voluptasit posandu ntioreritem quam ad ma de
patient:

Blood sugar should be maintained 5-10 mmol/l. This is most safely and reli-
ably achieved with a variable rate intravenous insulin infusion whilst on Neuro
tae. Uptatio ICU.

Type 1 diabetics should receive insulin continuously, even if their blood sugar
is within the normal range. This is to prevent the development of diabetic
ketoacidosis. volorerum
These patients mayet require
omni odIVqui bearum
glucose is estrunt
if they re volor
are being rehent
fasted.
Type 1 diabetic patients require continuous insulin administration. In
the absence of insulin, they will develop diabetic ketoacidosis (DKA).
usant. Quia non con Thisnullaut veratemo
can occur with atem aut modipis
normal cimint quia nonsequis aut et Wessex
blood glucose.
ni consenes idendemodis These patients should recieve
re voluptibus.Ero a continuous
cuptium consequiinfusion
dolorehofenimetu
insulin even
rionsed que
when their blood glucose is in the target range of 4-10 mmol/l. To
maintain an adequate blood glucose level, carbohydrate must also be
supplied as viteither
pelitatia
food,con peraefeed
enteral voluptae doluptia nimi,
or intravenous venis
glucose nemquame
in the form
volo iur?Volorent of ut 500ml
ut quebags
et mi,ofquas
fluid containing: 5% glucose
sin cum quidellandel withquassit
incto 0.9% saline
faccatur& 0.3%
maximi,
KCl.

comnimusamIntravenous
est ad magnam
res que labglucose
or 10% reresenient
inis coreperum
glucose) escius
must notdibe
sequuntur
in patients
bla
with CNS
aut ut
given in veria
sinullit
the form
injury.
dignima
assimporesse
gnihicimus
of hypotonic suntiae
fluids (eg 5%
veliquam, omnihicit
Therefore, if intravenous
ditiis
glucose et
fugit officiatisisiur,
required,
sam, utitquaeperrovid
should be given as 500mlodit
ulparcitaqui bags of fluid
essint aut containing:
adis as commodi 5% glucose
ctisit ant,
with 0.9% saline & 0.3% KCl at an appropriate maintenance
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a rate (eg 100ml/
hr).
39
Wessex
solo NeuroNusda
explautem eum The re cor useaut
of omnis
hypotonic solutions
a vit, Wessexcontaining
Neuro ICU glucose (eg 5%
Guidelines glucose,10%
consecate consect
glucose, 0.18% saline/4% glucose) as a part of diabetic
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti management
with an insulin infusion has been associated with worsening of cerebral
ntibusande natetoedema.atistibus, utem quosam reriberro od molende natemosame nonet odis

num et endia Patients
vendi should
ipsandem not apidell
receiveendesec
any preparation
ulloribusofderibus
subcutaneous
di ipsaminsulin
ing the initial phase of their admission to Neuro ICU. These patients will be
dur-
harit quibus, cori-
either: perioperative, septic, or recieving vasopressors. All of these factors
Busciis aceati omnitthe
prevent laut autateperfusion
normal Wessex of Neuro ICU Guidelines
subcutaneous fat andcon es magnam
reduce in porrovit,
the absorption
seriatur?Paofsedioreped
any insulinquosathat has been delivered
consequas acepethere.
conest ut am, quo dis enia vitae. Perovit

erorerum repe
Inadequate perfusion of subcutaneous tissue will prevent reliable absorption
of allconseque
forms of nos et debitatia
insulin. idessum est doluptur, est min ped mod et resciunt,
This risks:
|| Acute lack of insulin around the time of subcutaneous insulin adminis-
tration, whichICUisGuidelines Verum
likely to cause ipidunt
diabetic volor adit la doluptasit aut reiciet
keto-acidosis.
|| Insulin being left as a depot in inadequately perfused subcutaneous
tissue, which will result in an excessive effect once this tissue is rep-
erfused.queThis voluptatius
risks causingrerum rem ut
severe omni ut aut
persistent res is aut lam
hypoglycaemia asqui
thenempore
num harciis rest patient
offic temrecovers.
aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
tium entis nima
|| sit que eostiis
Delaying citam, resumption
the normal eumet voluptasit posandu
of glucose ntioreritem
control quam ad of
by administration ma de
veligen diant.et quos ium, cus cone
subcutaneous dem
insulin, nem fugiatem.
because Pudionsequia
of the variability dis suntotate
of insulin laborpor
delivery from
re corrorporest quos subcutaneous
eum nobistibusdepotsnis asevento
the tissue
tem isetreperfused.

tae. UptatioPatients
dolorumquunt
doloremadmitted
andaswill
nus sinctem
ditrequire
mo corfluid
sa porro
fugit iditatiorum
with diabetic
et voluptiwith
resuscitation beatquo
vit volupta
ketoacidosis
normal cus.Liqui
porem quatusa
will be profoundly
dolupid molor
saline (+/-KCl)
pedionsequis
dehydrated
sit vellis
in addition to debis
anincidus
ratur, omnihit insulin infusion
ea Wessex andNeuro
500mlICU bags of fluid containing:
Guidelines qui quaerov 5%itendae
glucosevolor
with aligenime
0.9%
saline & 0.3% KCl at an appropriate maintenance rate (eg
quatem aspedit atatem consedia volorerum et omni od qui bearum is estrunt re volor rehent 100ml/hr).

expelleces mi,
rerspero ommo
sam rapid
Beware reriandic
fast reduction
tenecus
reduction
ommolor posandi
in Wessex Neuro ICU
serum glucose.
in serumgnimus.Laborer
osmolality, provoking
ThisGuidelines
may causeaut
CNS dolorehent
iaerupienis
anvoloreperit
oedema. Serum
excessively proris as
lis eosglucose
doles volorib
should be reduced at a controlled rate. Consideration
usant. Quia non con nullaut veratemo tem aut modipis cimint quia nonsequis aut et should be given to Wessex
increasing the serum sodium to offset the reduction in serum osmolality.
Neuro ICU (Consider
Guidelinesallowing
doluptasodium
turepedtoullorepudam
rise by 1mmol/l iunt,fornulparciur?Perio.
every reduction inUtglucose
de vendam,
ni consenesofidendemodis
2mmol/l) re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
turias prepedi
Level 0 &taecerrovita
1 Patientsvit pelitatia con perae voluptae doluptia nimi, venis nemquame

quunturio ium When a patientandem
haruptatiis enters di
thequidem
rehabilitation phase
nulparchit of their
velecte eosillness i.e.ent
et quid is no longer
vollaccuptae
perioperative (able to absorb feed or eat and drink without nausea), has no
comnimusam res queoflab
evidence inis coreperum
sepsis, and is not di bla aut vasopressor
receiving ut veria dignima gnihicimus
or sedative suntiae ditiis
medication;
est ad magnam they mayreresenient
be restartedescius
on sequuntur
subcutaneous sinullit assimporesse
insulin. This may onlyveliquam, omnihicit
be started on et
theiur,
fugit officiatis documented instruction ulparcitaqui
sam, ut quaeperrovid of a Neuro ICU oditconsultant.

Peri-operative level 0 & 1 patients normally controlled with a long acting
quo testis maximus
insulin (egaecabore,
insulatard)quemay
nonemhavees repereped
this restartedutonce ut dolupta
they aresundit,
eatingadandqui cullenim
drinking without
volor alis susdandis moluptam nausea.
everisAlternatively,
pratate iliquas the
remlongque acting insulin may
nos endicitin be contin- sus
est ipieneculpa
ued at simus.
mi, nime voluptas 80% of dolupta
the normal doseullorepudam
tureped if the patientiunt,
is first on the operating list for
nulparciur?Perio
40
Chapter
solo 7
ribusandiste molora
explautem eum a relatively
re cor autshort operation
omnis a vit,(ie less than
Wessex 4 hours)
Neuro ICU and is expected
Guidelines to eat and
consecate consect
drink without nausea immediately postoperatively. In both cases a Variable
emoluptae veribus am rem quid
Rate Intravenous eaturInfusion
Insulin assimillat.Wessex
may be continued Neuro alongside
ICU Guidelines the long Tisacting
dolupti
ntibusande natetinsulin. atistibus, utem quosam reriberro od molende natemosame nonet odis

Level 0 & 1 patients may have their short acting isulin restarted subcuta-
num et endianeouslyvendi ipsandem
when theyapidell endesec
are eating ulloribusnormally
and drinking deribus without
di ipsam harit quibus,
nausea. The cori-
busaniae repreperum
Variable Rate derovit, sitatium Insulin
Intravenous nosam Infusion
sinisci liquiat
must be eaquias
continued iminulpa
for a is asitatia
further 60 int.
Busciis aceati minutes to ensure
omnit laut autatethat the subcutaneous
Wessex short acting
Neuro ICU Guidelines coninsulin is effective
es magnam and
in porrovit,
maintaining quosa
seriatur?Pa sedioreped a bloodconsequas
glucose between 5-10 mmol/l,
acepe conest ut am,before
quo dis its discontinuation.
enia vitae. Perovit
Commencement
erorerum repe conseque nosof variable
et debitatia rate est
idessum IV doluptur,
insulinestinfusion min ped mod et resciunt,
Indications
pro enecta nis etfor quiasim enimos moluptate
commencement of variablevolo rate
qui cus explam asinsulin
intravenous accae dolo infusion :
bersped que

All diabetic patients that are normally controlled with insulin

num harciis Any rest patient
offic tem that
authas:
verroviti opta doluptam, quibus di volut qui non reicil eosan-
tium entis nima || sita que
blood eostiis citam, eumet voluptasit
glucose>10mmol/l posandugreater
on two occasions ntioreritemthan quam
one hour ad ma de
veligen diant.et quos apartium, cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
re corrorporest || quos eum nobistibus
a single nis evento temthat
blood glucose>15mmol/l et pratem.
has been Ut repeated
rem eatenienisto confirmenimolup-
the
tae. Uptatio dolorem reading.
nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis
ratur,Comnihit
ommencing patient
incidus on variable
ea Wessex Neuro rate
ICUintravenous
Guidelines qui insulin infusion
quaerov :
quatem1 aspedit
Theatatem
insulin consedia
prescription volorerum
(50 unitsetactrapid
omni odinqui bearum
50ml 0.9% isSaline)
estruntisre partvolor rehent
of the
expelleces mi, NICUsamAdmission drug protocol
reriandic tenecus Wessex on Neuro
JAC. ThisICU includes
Guidelines a standard note defin-
rerspero ommo ing ommolor
rate of insulin
posandiinfusion for differingiaerupienis
gnimus.Laborer glucose levels. dolorehent lis eos doles volorib
2 non
usant. Quia Targetconblood
nullaut veratemo
glucose 5-10tem aut modipis cimint quia nonsequis aut et Wessex
mmol/l
3 Blood
ni consenes
glucose level must be monitored:
none option |nat Hourly
| quia until the
cumqui blood
ullest glucose is
ligenihiciet maintainedsit,
accus.Quis in the targetquo
offictem range for twoditia-
conecto
consecutive hourly readings with the feeding or
turias prepedi taecerrovita vit pelitatia con perae voluptae doluptia nimi, venis nemquame diabetic fluid (5% glu-
cose with 0.9% saline & 0.3% KCl) infusion rate remaining unchanged.
quunturio ium Thereafter,
||haruptatiis it may
andem di be monitored
quidem 2-4 hourly
nulparchit velecte depending
eos et quid on theentstability of
vollaccuptae
the patient.
est ad 4 magnam reresenient
If a patient escius
is fasted sequuntur
or stops absorbingsinullit assimporesse
enteral feed, the blood veliquam,
glucose omnihicit
level et
fugit officiatisshould be ut
iur, sam, measured
quaeperrovidand the rate of insulin
ulparcitaqui infusion
odit essint autstopped
adis as (if not typectisit
commodi 1 ant,
diabetic), reduced or diabetic fluid commenced. Blood glucose level must be
monitored hourly until blood glucose level is stable in the target range.
5 susdandis
volor alis A variable rate intravenous
moluptam insulin
everis pratate infusion
iliquas remmay onlyendicitin
que nos be run without feed/dia-sus
est ipieneculpa
betic fluid if the blood glucose level>15mmol/l.
41
Wessex
solo NeuroNusda
explautem eum The re cor
useaut
of omnis a vit,
a variable Wessex
rate Neuroinsulin
intravenous ICU Guidelines consecate
infusion without either consect
emoluptae veribus feedamorrem
diabetic
quidfluid
eaturrisks severe hypoglycaemia,
assimillat.Wessex Neuro ICUparticularly in pa-
tients that are not normally diabetic.
Diabetic eosam
autatatque parchilitat.Ut fluid (5% glucose
suscias autwith
qui 0.9% saline
volorum & 0.3%
quam hari KCl) is available
odis et porersp ellaut la
without KCl for use in patients with significant renal impairment, inad-
dequate urine output (<0.5ml/kg/hr averaged over 4 hours) or hyperkal-
busaniae repreperum aemiaderovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
(K>5.0mmol/l).
42
8
Enteral feeding & bowel

management

ICU patients should normally receive 25kCal per kilogram per 24hrs.
erorerum repe A recentnos
|| conseque study has shown
et debitatia that best
idessum estoutcomes
doluptur, est aremin
observed
ped mod whenet resciunt,
patients receive a minimum of 25kcal/kg/24hrs.
qui doloratatas volupta seriam solorest voluptatis modit explatur? Iqui blam faceprovit (10kcal/kg/24hr less eaqui
was associated with 30-40% increase in mortality)
pro enecta nis Government
|| et quiasim enimos recommendations
moluptate volo qui arecus
thatexplam
femalesasreceive
accae 2000kCal
dolo bersped per que
24hrs, and males 2500kCal per 24hrs.
Nosam verferf erferspit Standardqueand multifibre
voluptatius feedsrem
rerum contain
ut omni 1kCal/ml
ut aut and
res is0.4g
aut protein/ml
lam qui nempore
All energy feeds contain 1.5kCal/ml and 0.6g protein/ml
veligen diant.et quos ium,plus
Protein cus feed
conecontains
dem nem1.25 fugiatem.
kCal/mlPudionsequia dis suntotate laborpor
and 0.63g protein/ml

tae. Uptatio All nutrison
dolorem nusfeeds are gluten
sinctem free, lactose
fugit iditatiorum
of vitamins, iron and trace elements.
vit free,
voluptaandporem
containquatusa
a full complement
pedionsequis

ratur, omnihitPatients
quatem aspedit
incidus should
mucosa
atatem
ea Wessex
andconsedia
be fed
allow more
continuously
stable blood
volorerum et omni
over 24qui
glucose
hoursquaerov
to help
od quiconcentrations
itendae
protectvolor
bearum is estrunt when
aligenime
gastric
re insulin is
volor rehent
expelleces mi, being
samadministered.
reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as

rerspero ommo
usant. Quia non
ommolor
Patients
Hence conuse
withposandi
traumatic
of energy
nullaut
gnimus.Laborer
brain injury increase
feedtem
veratemo rather
autthan
iaerupienis
standard
modipis
their dolorehent
metabolic rate
cimintinquia
this group.
nonsequis
lis eos
by doles
40%. volorib
Prescribe
aut et feed
Wessex
at the same rate, but energy feed rather than standard
Neuro ICU Guidelines dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam, feed.

ni consenes Early
none option ated
idendemodis
with reduced
nat quia
re voluptibus.Ero
establishment of adequatecuptium
intercurrent
cumqui ullest
nutritionconsequi
infections
ligenihiciet and improved
accus.Quis
dolorehpatients
in head injured enimetu
survival.
sit, offictem
is rionsed
associ- que
quo conecto ditia-

Enteral feeding has many advantages over parenteral feeding and should be
volo iur?Volorent ut ut que
established et mi,asquas
as early sin cum
possible. quidellandel
Intragastric inctomay
feeding quassit
fail tofaccatur maximi,
be absorbed
quunturio ium due to gastricandem
haruptatiis stasis and pyloric nulparchit
di quidem closure secondary
velecte eos to high doseent
et quid opioids.
vollaccuptae

est ad magnam
Jejunal feeding should be considered in patients at high risk of intolerance
reresenient
to gastric feedingescius sequuntur
(i.e. patients sinullit assimporesse
on continuous veliquam, omnihicit et
infusion of sedation/paralysing
fugit officiatisagents andutpatients
iur, sam, with high
quaeperrovid gastric aspirates
ulparcitaqui odit essint >250ml
aut adisdespite prokinetics.)

ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum
Traumatic brain injury patients under 40 years of age with a BMI25kg/m2
quo testis maximus
requiring aecabore, que nonem
ICP monitoring es repereped
and high dose morphine ut ut dolupta sundit, ad
and midazolam qui cullenim
should
a
43
Wessex
solo NeuroNusda
explautem always
eum re be corconsidered
aut omnisfor early
a vit, placement
Wessex Neuroof aICU
jejunal feeding consecate
Guidelines tube. Theseconsect
tubes are easier to place before any signs of delayed gastric emptying.
Establishing enteral feed
1 Asedioreped
seriatur?Pa Malnutition quosa
Universal Screening
consequas Tool conest
acepe (MUST)utmust am, bequocompleted
dis enia by the Perovit
vitae.
nursing
odit hillorest, nusdand staffantibusape
on admission and re-screened
nonsequ weekly. This
assequi doluptatur? Qui must
in eum include
aut aut anommolor
accurate height and weight, either reported by relatives, or measured.
2 If notvolupta
qui doloratatas alreadyseriam
present, insert voluptatis
solorest a wide bore (14-16G)
modit feeding
explatur? Iqui tube
blameither nasally
faceprovit eaqui
or, if anterior base of skull fracture present or previous
nosto erio. Wessex Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciettransphenoidal
surgery, orally. In intubated and ventilated patients, the patient must be ade-
quately sedated to prevent any coughing or straining during the placement of
velese ma a inctota
gastricquidunt
tube. acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
NG tubes and base of skull fractures?
A feeding tube may be placed via the nose provided the base of skull
tium entis nima sit que eostiis
fracture does notcitam, eumet
involve voluptasit
sphenoid posandu
sinus, there isntioreritem quamand
no rhinorrhea, ad ma de
veligen diant.et quosany facial fractures
ium, cus cone dem do not involve
nem nose Pudionsequia
fugiatem. or nasopharynx. disThis is not laborpor
suntotate
re corrorporest quos usuallyeum performed
nobistibus until
nisshortly
eventobefore
tem etextubation.
In these circumstances the feeding tube should be placed by the Neuro
ICU consultant and may require use of a fibrescope to visualise correct
dolorumquunt aspassage dit mo cor of sa
theporro
tube et voluptithe
through beatquo cus.Liqui dolupid molor sit vellis debis
nasopharynx.
Feeding tube placement must be confirmed by a chest x-ray demon-
stating tenecus
that the tip of Wessex
the tube Neuro ICU Guidelines
is positioned below theaut voloreperit proris as
hemidiaphragm
rerspero ommo ommolor posandienteral
prior to starting gnimus.Laborer
feed. iaerupienis dolorehent lis eos doles volorib
Neuro ICU Tube
3 Guidelines length dolupta
must betureped
recordedullorepudam iunt, nulparciur?Perio.
at time of insertion, and checked with Ut each
de vendam,
ni consenesnursing
idendemodis re voluptibus.Ero
shift (recorded on main obs cuptium
chart.)consequi doloreh
If the patient enimetu
vomits rionsed que
or a change
none optionofnat length
quiais cumqui
noted, tubeullestposition must accus.Quis
ligenihiciet be reconfirmed sit, as above.quo conecto ditia-
offictem
4 Aim to start enteral feeding as soon as patient is haemodynamically stable,
(inadequate et mi, quas
gut perfusion sintocum
prior this quidellandel incto quassit
limits its usefulness) faccatur
to provide maximi,
appro-
quunturio iumpriate caloric, protein
haruptatiis andemand uid intake.
di quidem Enteral
nulparchit feeding
velecte eosalso
et promotes the
quid ent vollaccuptae
comnimusam integrity
res que of lab
the inis
GI mucosa.
coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
est ad5 magnam reresenient
Start enteral feed atescius sequuntur
50ml/hr nutrisonsinullit assimporesse
standard (energy feedveliquam, omnihicit et
in TBI patients).
Increase
fugit officiatis iur, sam,to ut
fullquaeperrovid
feeding rate ulparcitaqui
of 1ml/kg/hr odit
(max 100ml/hr)
essint as as
aut adis guided by enteral
commodi ctisit ant,
feeding algorithm.
6 maximus
quo testis aecabore,
Ensure patient que nonem
receives at leastes repereped
500ml ut ut feed
multifibre dolupta
per sundit,
24hours. ad qui cullenim
Prescribemoluptam everis pratate
1 bag of nutrison iliquas
multifibre rem que
(energy nos endicitin
multifibre for TBIest ipieneculpa
patient). NB sus
44
Chapter
solo 8
est, exeriae. Nusda nonsequo temolec Enteral erovitatenis feeding & bowel
doles eatiore management
ribusandiste molora
explautem eum consider
re coravoiding
aut omnis multifibre
a vit, feeds
Wessex in patients
Neuro ICU withGuidelines
high gastricconsecate
aspirates as consect
the fibre content can slow gastric transit.
7 natet
ntibusande If gastric aspirates
atistibus, utemarequosam
>250ml per 4 hours,
reriberro od molende natemosame nonet odis
autatatque parchilitat.Ut eosam suscias
a start prokinetic drugs aut qui volorum quam hari odis et porersp ellaut la
busaniae repreperum metoclopramide 10mg IV tds
derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
Busciis aceati omnit erythromycin
laut autate Wessex 250mg NeuroNG qds, ICUreview after 72con
Guidelines hourses magnam in porrovit,
b Consider
seriatur?Pa sedioreped quosa NJ tube insertion
consequas usingconest
acepe Cortrakutoram, Tigerquo 2 tube.
dis enia vitae. Perovit
odit hillorest,c nusdand antibusape
If unable nonsequ
to establish adequateassequi doluptatur?
enteral nutritionQui in eum
in first aut aut
3 days, ommolor
consider
erorerum repe conseque starting nosTPNetbut debitatia
aim to idessum
wean it as est doluptur,
soon est min
as enteral ped mod
feeding et resciunt,
established
qui doloratatas volupta seriam solorest voluptatis modit explatur? +Iqui blam faceprovit eaqui
8 Patients may require separate supplementation of Na and K+.
9 nisStop
pro enecta enteral feed
et quiasim enimos for 2 hours before
moluptate volo and afterexplam
qui cus administration
as accaeofdolo enteral phe- que
bersped
nytoin. Where feed is stopped for phenytoin administration,
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus. or any procedure,
the rate over the remainder of the 24 hour period should be augmented to
ensure que voluptatius
full feeding. Phenytoin rerum rem only
should ut omni ut aut res is aut
be administered lam qui
enterally nempore
when
num harciis patient
rest offichas tem aut verroviti
excellent opta doluptam,
absorption (eg NG aspiratesquibus <100ml
di volut per qui 4non reicil
hours eosan-
with no
tium entis nima discards
sit que foreostiis
24 hours) citam,andeumet
can tolerate
voluptasit the posandu
increasedntioreritem
rate of feeding quamneces-
ad ma de
sary to allow for the period of fasting.
Phenytoin is the only nis evento
drug given tem et pratem. for
enterally Ut rem
which eatenienis
feed should enimolup-
tae. Uptatio dolorem be stopped
nus sinctem around fugitthe time of administratioin
iditatiorum vit volupta porem quatusa pedionsequis
dolorumquunt as dit If ciprofloxacin
mo cor sa porro is given NG inbeatquo
et volupti a patient receiving
cus.Liqui enteral
dolupid feed,sitthe
molor dose
vellis debis
should be increased from 500mg to 750mg NG bd without stopping
ratur, omnihit incidus ea Wessex
enteral feed. (The Neuro ICU Guidelines
proportion qui quaerov
of drug absorbed itendaeby
is reduced volor aligenime
binding
to divalent cations volorerum
in enteral et feed.
omni od qui giving
Avoid bearum is estrunt
ferrous re volor
fumarate near rehent
expelleces mi, sam time of ciprofloxacin
reriandic tenecus Wessexadministration.)
10 Any patient suspected of suffering from alcohol abuse, needs vitamin B sup-
usant. Quia non con nullautstarting
plementation; veratemo withtem aut modipis
Pabrinex cimint (Pabrinex
parenterally quia nonsequis 1 pair aut
IV bdet for
Wessex
3
days). Vitamin dolupta tureped ullorepudam
B supplementation may beiunt, nulparciur?Perio.
continued Ut de vendam,
when fully enterally fed
ni consenes &idendemodis
able to absorb as vitamin B compound,
re voluptibus.Ero strong and
cuptium consequi thiamine.
11 Ifnat
none option quiaosmolality
serum cumqui ullest ligenihiciet
excessive accus.Quisenteral
(>320mosm/kg), sit, offictem
feed may quobe conecto
supple-ditia-
mented with water vit pelitatia con perae
via the feeding tubevoluptae
on Neurodoluptia nimi, venis
ICU consultant nemquame
advice at
20-50ml/hr, without reducing the rate of enteral feed.
12 If feed
stopped andem
for any di reason
quidemand nulparchit
patient on velecte
insulin eos et quidcheck
infusion, ent vollaccuptae
blood
comnimusamglucose res que1 lab inis until
hourly coreperum
glucosedistablebla aut ut feed
and veriarestarted,
dignima gnihicimus suntiae ditiis
adjusting insulin
est ad magnam dosereresenient
appropriately, according
escius sequuntur to variable
sinullitrate intravenousveliquam,
assimporesse insulin infusion
omnihicit et
(see note on ePrescribing)
ad eum13 fugiaDrugs
volorpo may reptur?
be givenEt lam viavenda non consediam
the gastric aut esare
tube if aspirates dolendipsum
low, otherwise venisgive
rerum a
all drugsaecabore,
quo testis maximus parenterally que nonem es repereped ut ut dolupta sundit, ad qui cullenim
45
Wessex
solo NeuroNusda
14 All
explautem eum patients
re cor should
aut omnishaveablood taken for
vit, Wessex serumICU
Neuro magnesium
Guidelines & phosphate
consecate lev-consect
els, once they have been resuscitated and stable>24hrs
15 Any
ntibusande patient
natet with low
atistibus, utem serum
quosam phosphate thatod
reriberro is suspected to be at risk from
refeeding syndrome (eg anorexia nervosa or cachexia),
autatatque parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la must receive enteral
phosphate and potassium, and IV magnesium supplementation with a grad-
num et endia ualvendi
increaseipsandem
in rate apidell
of feeding endesec ulloribusofderibus
from 30ml/hr standard difeed,
ipsamwhilst
haritserum
quibus, cori-
busaniae repreperum
phosphate derovit, sitatium
levels remain low.nosam sinisci liquiat eaquias iminulpa is asitatia int.
Insertion and management of jejunal feeding tubes
1 A wide
qui doloratatas bore seriam
volupta gastric solorest
feeding tube shouldmodit
voluptatis already have been
explatur? inserted,
Iqui blam and eaqui
faceprovit
its position checked. This should be maintained to assess
nosto erio. Wessex Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet gastric aspi-
rates every 4 hours and to allow the administration of enteral drugs when
appropriate.
Nosam 2 verferf
Instructions
erferspit for
queinsertion
voluptatiusof Cortrak
rerum rem and ut
Tiger
omni2 feeding
ut aut res tubes arelam
is aut included
qui nempore
with the tubes and are easy to follow. In general, insert the jejunal tube to the
70cm mark and fix the tube to the side of the face with tape at 80cm. This will
tium entis nima
leavesita que
loop eostiis
of 10cm citam,
of tubeeumet voluptasit
to allow posandu
spontaneous ntioreritem quam ad ma de
migration.
3 Givequos
re corrorporest
metoclopramide 10mg IV prior to attempting insertion and start erythro-
mycin 500mg IV infusion to aid tube migration.
4 Theastube
dolorumquunt dit moshould beporro
cor sa examined afterbeatquo
et volupti one hourcus.Liqui
to determine
dolupid whether migration
has occured. If the tube has migrated, a further 10cm loop should be formed
and the tube reattached to the side of the face with tape at 90cm.
5 mi,
expelleces Leaving time for tube
sam reriandic migration
tenecus Wessex is usually
Neuro ICUbetter than repeated
Guidelines manipulation,
once end of tube is at the pylorus.
usant.6 QuiaCheck
non conthenullaut
positionveratemo
of the tubetemon autanmodipis cimint quiaX-ray
upper abdominal nonsequis
prior toaut
useet Wessex
7 Flush jejunal tubes with 20ml water or saline at each feeding bag change
none 8 optionNever use acumqui
nat quia jejunal ullest
tube to give drugsaccus.Quis
ligenihiciet it is only for
sit, continuous
offictem quo feeding
conecto ditia-
9 Do not stop jejunal feed for physiotherapy or turns, just aspirate gastric tube
volo iur?Volorent
to ensureut utthat
que et mi, quas
stomach is emptysin cum quidellandel incto quassit faccatur maximi,
10 Should
comnimusam
insertion of a jejunal tube prove impossible, refer patient for endo-
res que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
scopic tube insertion urgently, unless absorbing well via gastric tube
46
Chapter
solo est, exeriae.8 Nusda nonsequo temolec Enteral erovitatenis feeding & bowel
ribusandiste molora
explautem Wessexeum re cor aut omnis a
Neurosciences vit, Wessex
Intensive Care Neuro
Unit ICU Enteral Guidelines
Feeding consecate
Algorithm consect
! Check position of NG/OG enteral feeding tube as per Adult Enteral Feeding Guidelines
ntibusande ! Aimnatetto startatistibus,
enteral nutrition utem as soonquosam
as patientreriberro od molende
is haemodynamically stable natemosame nonet odis
! Start feeding Nutrison Standard (Energy in Traumatic Brain Injury patients) at 50ml/hr
! Aspirate gastric feeding eosam tube 4suscias aut qui
hourly & monitor volorum
gastric residualquam volumeshari odis et porersp ellaut la
! Follow NICU Enhanced Feeding Protocol
num et !endia CommencevendiNICU ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-
bowel management
Aspirate gastric
busaniae repreperum derovit, sitatium
! feeding tube prior to chest physiotherapy
nosam sinisciand turning
liquiat eaquias iminulpa is asitatia int.
Busciis aceati
Consider earlyomnit lautofautate
placement NJ or OJWessex Neuro ICU Guidelines con es magnam in porrovit,
tube, especially if all of the following apply
seriatur?Pa
to patient:
sedioreped quosa consequas acepe conest Isutgastric am, aspirate
quo dis> 250ml? enia vitae. Perovit
odit hillorest,
Requires nusdand antibusape nonsequ Yes
ICP monitoring assequi(Replace doluptatur? Qui and
up to 250ml in eumdiscardaut aut ommolor
remainder)
Aged <40 years
erorerum
BMI repe
<25kg/mconseque
2 nos et debitatia idessum est doluptur, est min ped mod et resciunt,
Sedated with morphine & midazolam
No
Feed at 50ml/hr for further 4hrs.
pro enecta nis Is et quiasim
aspirate > 250ml?enimos moluptateNo volo qui cus Continue explamfeeding as accae dolo bersped que
at 50ml/h until 0000
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas
then follow NICU autEnhanced
pel is dolesci
Feeding tibus.
Yes Protocol and adjust feed rate as needed.
Nosam verferf erferspit que voluptatius rerum No rem ut omni utAlternate aut reswith is multifibre
aut lamfeed. qui nempore
num harciis rest offic tem
Add Metoclopramide 10mgauttdsverroviti
IV opta doluptam, quibus di volut qui
Is aspirate non reicil eosan-
> 250ml?
Continue at same rate for further 4hrs.
No - Continue
Is aspirate eostiis citam, eumetYes
> 250ml? voluptasit posandu ntioreritem quam ad ma de
veligen diant.et quos ium, Yes
cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
Continue Metoclopramide 10mg tds IV
tae. Uptatio dolorem 250mg
Add Erythromycin nus sinctem
qds NG/OGfugit iditatiorum vit volupta porem quatusa pedionsequis
No
No
dolorumquuntContinue dit feed
asAspirate for 4hrs.
mo4hrlycor sa porro et volupti beatquo cus.Liqui dolupid to
Consider switching molor
peptidesitfeed
vellis debis
(Nutrison Peptisorb 1kcal/ml).
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines Continue qui quaerov itendae volor aligenime
feeding at 50ml/hr for 24hrs.
Is aspirate > 250ml?
quatem aspedit atatem consedia volorerum et omni od qui bearum Reviewisafter estrunt
24hrs. re volor rehent
expelleces mi, sam reriandic Yes tenecus Wessex No Neuro ICU Guidelines Is aspirate aut voloreperit proris as
> 250ml?
No - Continue
Is abdomen distended with absent
usant. Quia nonbowel consounds?
nullaut veratemo tem aut modipis cimintIsquia Yes
nonsequis aut et Wessex
aspirate >250ml/4hrs
Place OJ/NJ tube and confirm position.
ni consenes idendemodis Yes re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
none optionConsider nat quia cumqui
abdominal X-rayullest ligenihiciet accus.Quis Feed continuously
sit, offictemasquo per Enhanced
conecto ditia-
Put NG/OG on free drainage for 24hrs Feeding Protocol via jejunal tube without
turias prepedi Aspiratestaecerrovita
and drainage vitstill
pelitatia con perae voluptae doluptia
aspirating nimi,
for turns venis nemquame
or physiotherapy.
> 250ml (every 4hrs)?
Yes No
If bowel sounds are present start feeding at
Consider Parenteral Nutrition with NICU
fugit officiatis iur, sam, ut quaeperrovid ulparcitaqui odit essint
consultant/pharmacist/dietitian/nutrition autand
50ml/hr adis astocommodi
return ctisit ant,
start of algorithm.
support team
ad eum fugia Needsvolorpo
to be orderedreptur? Et lam venda non consediam aut es dolendipsum venis rerum a
by 11.00am
Bleep 1582
volorMacintosh
alis susdandis moluptam
HD:Users:Family:Dropbox:Mat:NICU everisbook
Fresh start:Fresh pratate iliquas
red:Wessex NICU rem
Enhanced Enteral que
Feeding nos endicitin
Algorithm 2014.doc est ipieneculpa sus
P.T.O
Wessex NICU Enhanced Feeding Algorithm 2014
47
Wessex
solo NeuroNusda
! Complete MUST score on admission and review weekly
Record height eosamand weight susciasof autpatient
qui volorum (measure quamif hari odis et porersp ellaut la
necessary)
busaniae Aim to givederovit,
repreperum at least 500ml nosam
sitatium multifibre sinisci feed/day
Busciis !aceati Flush omnit laut autate
gastric tube with Wessex minimal Neuro ICU Guidelines
amount of water con es magnam
or saline beforein porrovit,
seriatur?Paand sedioreped
after drugs quosa consequas
(especially acepe conest
Nimodipine) and utafter
am, quo dis eniatovitae. Perovit
stoppages
odit hillorest, prevent
nusdand blocking.
! If feed stopped for a procedure, adjust feed rate according to
qui doloratatas Enhanced voluptaFeeding seriam solorest Protocol voluptatis
to avoid modit
feeding explatur?deficits. Iqui blam faceprovit eaqui
pro enecta ! Stopnis etfeed quiasim 2hrs beforemoluptate
enimos and 2hrsvolo after quigiving
cus explam enteral asphenytoin. Feed que
accae dolo bersped
rate should be adjusted to ensure full target volume is delivered.
Nosam verferf! Onlyerferspit add water que to voluptatius
feeding rerum regimen remifutpatientomni utisaut res is aut lam
dehydrated withquia nempore
num harciishigh resturea offic & tem high autserum verroviti sodium(serum
opta doluptam,Na>146mMol/l). quibus di volut qui non reicil eosan-
! Consider insertion of fine bore NG tube after 10 days unless there
veligen diant.et are high quosgastricium, cusaspirates.cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
tae. Uptatio ! Follow dolorem SLT nusFlow sinctemChartfugit when introducing
iditatiorum vit voluptaoral fluids. porem quatusa pedionsequis
! Start food record charts if patient starts to take oral diet. Do not
ratur, omnihit removeincidusNG eatubeWessex untilNeuro full oral ICUdiet Guidelines
has been qui established.
quaerov itendae volor aligenime
turiasRefer
prepedi all trauma
taecerrovita patients to trauma
vit pelitatia con dietitian
perae voluptae on admission doluptia nimi, venis nemquame
volo iur?Volorent
Via eQuest ut ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
quunturio iumBleep: haruptatiis andem di quidem
1200; Extension: 6072 nulparchit velecte eos et quid ent vollaccuptae
Macintosh HD:Users:Family:Dropbox:Mat:NICU Fresh start:Fresh book red:Wessex NICU Enhanced Enteral Feeding Algorithm 2014.doc
P.T.O
Wessex NICU Enhanced Feeding Algorithm 2014
48
Chapter
solo 8
est, exeriae. Nusda nonsequo temolec Enteral erovitatenisfeeding & bowel
ribusandiste molora
Enteral
explautem eumFeeding
re cor aut omnisaround a vit,Surgical
Wessex Neuro / Airway Procedures
ICU Guidelines consecate consect
num Plans
et endiamust vendiensure
ipsandem that:

Busciis aceati
Patients are adequately fasted prior to any airway manipulation involving an
omnit laut airway,
unprotected autate Wessex
to minimiseNeuro the ICU Guidelines
risk of aspirationcon es magnam
of gastric in porrovit,
contents.

Any period of fasting is minimised

erorerum repe
qui doloratatas
Theconseque
after
nutritional nos
it, or aseriam
volupta
et debitatia
deficit
combination
idessum
is replaced,
solorest of voluptatis
est doluptur,
preferably before estthe min
fast,ped
but mod et resciunt,
otherwise
the two. modit explatur? Iqui blam faceprovit eaqui
pro enecta nis et quiasim enimos
Any surgical moluptate
procedure volo qui
is likely cus explam
to require as accae
increased opioid dolo bersped que
analgesia,
velese ma inctotawhich quiduntwillacest,
reduceidenihicti
gastric emptying,
im cus a and limit eatas
dolesto the feasibility
aut pel of is catching
dolesci tibus.
up any deficit after a procedure.
Stopping
veligen diant.et quosenteral ium, feed
cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
tae. IUptatio
ntubated patients with a gastric tube requiring non-airway surgery:
Stop gastric
dolorumquunt as feeding
dit mo cor immediately
sa porro etprior to transfer
volupti beatquotocus.Liqui
the operating
dolupidtheatre
molorand aspi-debis
sit vellis
rate the gastric tube to remove any residual gastric contents,
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime prior to procedure.
Intubated
expelleces mi, sam
patients (orotracheal
reriandic , nasotracheal
tenecus Wessex Neuro ICU or Guidelines
tracheostomy tube) requiring
any airway
rerspero manipulation
ommo ommolor posandi(e.ggnimus.Laborer
.tracheostomy, iaerupienis ET tube, planned
change of dolorehent extuba
lis eos doles -
volorib
tion):
Neuro StopICU gastric feed 6dolupta
Guidelines hours before
tureped anyullorepudam
procedure. Aspirate the gastric tubeUt
iunt, nulparciur?Perio. to de
remove
vendam,
all residual gastric contents immediately prior to the procedure.
turiasNon -intubated
prepedi patientsvitwho
taecerrovita are receiving
pelitatia con perae anvoluptae
oral dietdoluptia
or gastricnimi,feed : nemquame
venis
volo Fast
iur?Volorent
for 6 hours ut ut quetoetany
prior mi,elective
quas sin cum quidellandel
surgical incto quassit
procedure. These patientsfaccatur maximi,
must receive
all essential
quunturio medications
ium haruptatiis andem with dienough
quidem water to aid swallowing
nulparchit velecte eosand oesophageal
et quid tran-
ent vollaccuptae
sit at leastres
comnimusam 2 hours
que lab before procedure. di bla aut ut veria dignima gnihicimus suntiae ditiis
inis coreperum
fugit Recommencing
officiatis iur, sam, ut feed

On return from an operating theatre following non-abdominal surgery, feeds
should be resumed at the previous rate. This feeding rate should be aug-
mentedmoluptam
to make upeveris pratate
for any iliquas
deficit rem que nos endicitin est ipieneculpa sus
if necessary.
49
Wessex
solo NeuroNusda

explautem Patients
eum re cor thatauthave undergone
omnis abdominal
a vit, Wessex surgery,
Neuro ICU should
Guidelines usually have feed-
consecate consect
ing restarted at a reduced rate (10 - 25ml/h) until tolerance is established,
emoluptae then veribus am remasquid
increased per eatur assimillat.Wessex
the feeding Neuro guidance.
protocol or surgical ICU GuidelinesIn some Tis dolupti
ntibusande circumstances
natet atistibus,(eg. utem quosambowel
ischaemic reriberro od molende
or fistula) the surgical natemosame nonet odis
team may request
autatatque that enteral feeding
parchilitat.Ut eosamnot be re-started
suscias until further
aut qui volorum quamassessment.
hari odis et porersp ellaut la

Following
busaniae repreperum
the agreement
a plannedapidell
derovit,
endesec
extubation,
sitatium
of the critical nosam
ulloribus
feeding should deribus
only be di recommenced
ipsam harit quibus,
sinisci liquiat eaquias iminulpa is asitatia int.
care consultant.
with cori-
oditJejunal
hillorest, feeding

Jejunal
nosto erio. involving
feeding
Wessex Neuro
seriam
maysolorest
surgeryICU
voluptatis
be continued
Guidelines
on the
modit explatur?
throughout
Verum ipidunt
gastrointestinal
Iqui blam
all procedures, faceprovit
except those eaqui
tract. volor adit la doluptasit aut reiciet

A gastric tube should also be in situ to allow delivery of oral medication. This
gastric tube should be aspirated immediately prior to any planned procedure.

num harciisIfrestjejunal
officfeeding
tem aut has to be stopped,
verroviti
reduce the risk of it blocking.
the tubequibus
opta doluptam, must be di flushed
volut qui with
non water
reiciltoeosan-
re corrorporest quos No attempt should ever
eum nobistibus be made
nis evento tem to et aspirate
pratem. Ut a jejunal tube or enimolup-
rem eatenienis
deliver oral medication through it.
dolorumquunt asThese dit motubes
cor saareporro
longetwith
volupti beatquo
a narrow cus.Liqui
bore, which dolupid
makes them molorvery
sit vellis debis
proneeatoWessex
ratur, omnihit incidus blocking.Neuro
They ICU
are expensive
Guidelinesand qui difficult
quaerovtoitendae
insert. Patency
volor aligenime
quatem aspedit atatemmust beconsedia
maintained by continuous
volorerum et omniinfusion of enteral
od qui bearum feed. Flush
is estrunt the rehent
re volor
tube with water if feeding must be stopped at any time.
Bowel management
turias Constipation
prepedi taecerrovita vit pelitatia
is a frequent problem conencountered
perae voluptae withdoluptia
Neuro ICU nimi,patients,
venis nemquame
and is
voloassociated
iur?Volorent withut raised
ut queintra-abdominal
et mi, quas sin pressure
cum quidellandel
that can incto
lead quassit
to raisedfaccatur maximi,
intracranial
quunturio
pressure.ium haruptatiis andem di quidem nulparchit velecte eos et quid ent vollaccuptae
It is essential to minimise the risk of patients developing constipation, whilst avoid-
ing causing patients discomfort and frequent diarrhoea.
ad eum A fugia
tieredvolorpo
approach reptur? Et lam venda
to prescription non consediam
of laxatives aut es dolendipsum venis rerum a
is recommended.
50
Chapter
solo 8
est, exeriae. Nusda nonsequo temolec Enteral feeding
erovitatenis & bowel
ribusandiste molora
Patients
explautem eumwithout
re cor aut spinal
omnis cord
a vit, injury
Wessex Neuro ICU Guidelines consecate consect
On admission
Prescribe regular:
num et endia|vendi
ipsandem
| Senna 15mg apidell
PO/NGendesec
nocte (10ulloribus
ml syrup)deribus di ipsam harit quibus, cori-
|| Docusate sodium 50mg PO/NG tds
Prescribe PRN:
odit hillorest,|nusdand
quosa consequas acepe conest ut am, quo dis enia vitae. Perovit
| Magnesium Hydroxide 10ml PO/NG bd
|| Glycerol (glycerin) suppositories 8g PR od
nostoBowels
erio. Wessex Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
not opened for >48 hours:
Prescribe
velese ma inctota regular:
quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
Nosam verferf || erferspit
Sennaque 15mgvoluptatius rerum(10
PO/NG nocte remmlutsyrup)
omni ut aut res is aut lam qui nempore
num harciis | rest
|
offic tem aut
Docusate verroviti
sodium 100mgoptaPO/NG
doluptam,
tds quibus di volut qui non reicil eosan-
|| Magnesium Hydroxide 10ml PO/NG bd

re corrorporest
tae. Uptatio |
quos eum
Prescribe
dolorem
PRN:nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
nus sinctem fugit iditatiorum 8g
vit PR
volupta
| Glycerol (glycerin) suppositories od porem quatusa pedionsequis
|| Bisacodyl suppositories 10mg PR mane
Bowels not opened for >72 hours:

rerspero ommo Prescribe
ommolor regular:
posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non || con nullaut
Senna 15mgveratemo
PO/NGtem nocteaut(10
modipis cimint quia nonsequis aut et Wessex
ml syrup)
turias prepedi Glycerol (glycerin)
|| taecerrovita vit pelitatiasuppositories
con perae voluptae8g PRdoluptia
od nimi, venis nemquame
volo iur?Volorent
|| ut ut que etsuppositories
Bisacodyl mi, quas sin cum 10mg quidellandel
PR mane incto quassit faccatur maximi,

Prescribe PRN:
est ad magnam Phosphateescius
|| reresenient enemasequuntur
1 PR od sinullit assimporesse veliquam, omnihicit et
| sam, ut quaeperrovid
Movicol 1 sachet PO/NG ulparcitaqui
bd odit essint aut adis as commodi ctisit ant,
Bowels
quo testis maximus aecabore,(1-3
open regularly que daily
nonem ) Tes 4-5
yperepereped ut ut dolupta sundit, ad qui cullenim
De-escalate to admission prescription:
51
Wessex
solo NeuroNusda

emoluptae Prescribe
veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
regular:
|| Senna 15mg PO/NG nocte (10 ml syrup)

Prescribe PRN:
|| Glycerol (glycerin) suppositories 8g PR od
Bowels open excessively (>5 times daily) Type 6-7
nosto Suspend laxatives
erio. Wessex until
Neuro diarrhoea
ICU settled.
Guidelines Complete
Verum ipiduntappropriate risk
volor adit la assessment
doluptasit for
aut reiciet
pro C. nisand
difficile
enecta use of flexiseal.
et quiasim When diarrhoea
enimos moluptate volo quisettled for 24as
cus explam hours,
accaerestart laxativesque
dolo bersped
withma
velese admission
inctota prescription
quidunt acest,above.
idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
numSpinal
harciis cord injury
rest offic tem patients
aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
All patients with cervical or high thoracic (T6 and above) spinal cord injury must be kept
nil by mouth/NG tube for the first 48 hours because they will be suffering from ileus.
(This is caused by loss of sympathetic supply resulting in unopposed parasympathetic
innervation of the GI tract.)
quatem aspeditwith
Patients atatem consedia
complete volorerum
spinal et (T6
cord injury omniandod above)
qui bearum is estruntrequire
will inevitably re volordaily
rehent
expelleces
manual mi, sam reriandic
evacuation. Thosetenecus Wessex Neuro
with incomplete spinal ICU
cordGuidelines aut above)
injury (T6 and voloreperit
mayproris
also as
rerspero
requireommo
daily ommolor posandi gnimus.Laborer
manual evacuation. The aim is to iaerupienis dolorehent
avoid constipation lis eos
whilst doles that
ensuring volorib
usant. Quia do
patients nonnotcon nullautdiarrhoea,
develop veratemo which
tem aut modipis
would cimint quia
significantly nonsequis
increase their aut
risket
ofWessex
skin
Neuro ICU Guidelines dolupta tureped
breakdown and reduce nursing staff morale. ullorepudam iunt, nulparciur?Perio. Ut de vendam,
noneOnoption nat quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
admission

Prescribe regular:
quunturio ium Senna 15mg
|| haruptatiis andemPO/NG nocte (10
di quidem ml syrup)
nulparchit velecte eos et quid ent vollaccuptae
comnimusam || resDocusate
que lab inis coreperum
sodium 100mgdiPO/NG
bla auttds
ut veria dignima gnihicimus suntiae ditiis
|| Glycerol (glycerin) suppositories 8g PR mane

ad eum fugia Prescribe PRN: Et lam venda non consediam aut es dolendipsum venis rerum a
volorpo reptur?
quo testis maximus
|| aecabore,Hydroxide
Magnesium que nonem es PO/NG
10ml reperepedbd ut ut dolupta sundit, ad qui cullenim
|| Bisacodyl suppositories 10mg PR mane
52
Chapter
solo 8
est, exeriae. Nusda nonsequo temolec Enteral erovitatenisfeeding & bowel
ribusandiste molora
explautem eum ||
rePhosphate enema
cor aut omnis 1 PR
a vit, od
Bowels not opened for >72 hours:
Prescribe regular:
num et endia|vendi
ipsandem
| Senna 15mg apidell
PO/NGendesec
nocte (10ulloribus
ml syrup) deribus di ipsam harit quibus, cori-
||
seriatur?Pa sedioreped Glycerol (glycerin)
quosa suppositories
consequas 8g PR od
acepe conest ut am, quo dis enia vitae. Perovit
| antibusape
Magnesium nonsequ10ml
Hydroxide assequi
PO/NGdoluptatur?
bd Qui in eum aut aut ommolor
erorerum repe ||
conseque
Bisacodylnos suppositories
et debitatia idessum10mgest PRdoluptur,
mane est min ped mod et resciunt,
|| Phosphate enema 1 PR od
Bowels open regularly (1-3 daily) Type 4-5
NosamDe-escalate to admission
verferf erferspit prescription:
que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore

num harciis Prescribe
regular:
|| Senna 15mg PO/NG nocte (10 ml syrup)
re corrorporest || quos Docusate sodium 100mg
eum nobistibus PO/NG
nis evento temtds
| nus sinctem
Glycerol (glycerin)fugit iditatiorum 8g
suppositories vit PR
volupta
maneporem quatusa pedionsequis

Prescribe PRN:
quatem aspedit Magnesium
|| atatem Hydroxide
consedia volorerum 10mlet PO/NG
omni odbd qui bearum is estrunt re volor rehent
expelleces mi, || sam reriandicsuppositories
Bisacodyl tenecus Wessex 10mg Neuro ICU Guidelines aut voloreperit proris as
PR mane
rerspero ommo ||
ommolor
Phosphateposandi
enemagnimus.Laborer
1 PR od iaerupienis dolorehent lis eos doles volorib
Bowels dolupta (>5
open excessively tureped
timesullorepudam
daily) Type 6-7iunt, nulparciur?Perio. Ut de vendam,
Suspend laxatives until diarrhoea settled. Complete appropriate risk assessment for
C. difficile and use of flexiseal. When diarrhoea settled for 24 hours, restart laxatives
with admission prescription above.
53
9
Haematology, coagulation
and platelet function
oditHaemoglobin
hillorest, nusdand antibusape
and oxygen nonsequ assequi doluptatur? Qui in eum aut aut ommolor
carriage

nosto erio. AnyWessexacuteNeuro
trauma ICUpatient shouldVerum
Guidelines be transfused to a Hb10g/dl,
ipidunt volor
suffered significant haemorrhage. They should also be given adequate
if they have
adit la doluptasit aut reiciet
supplementation of platelets and FFP/cryoprecipitate to maintain a platelet
velese ma count>150x10
inctota quidunt9, acest,
INR<1.4, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
Fibrinogen>1.5.

The haemoglobin level should be maintained10g/dl until the patient is hae-
modynamically stable, on vasopressors if necessary for CPP management,
tium entis nima
with asitnormal
que eostiis
lactate.citam, eumet voluptasit posandu ntioreritem quam ad ma de

Critically ill patients on intensive care units will frequently develop the gradual
onset of a stable anaemia. There is no indication to transfuse blood into such
tae. Uptatiopatients
doloremwho nusare sinctem fugit iditatiorum
maintaining an adequate vit oxygen
volupta delivery,
as demonstrated
dolorumquunt by a asnormal
dit mo serum
cor sa porro
lactate.et volupti beatquo
This includes cus.Liqui
the dolupidofmolor
management sit vellis
patients with debis
traumatic brain or spinal cord injury.

quatem aspedit
expelleces mi,venous
atatem of
Transfusion consedia
bank blood
sam thromboembolism
volorerum
reriandic tenecus Wessex
et omniwith
into a patient od qui
Neuro ICU
and transfusion related
bearum
stable is estrunt
anaemia
Guidelines
re volor rehent
risks promoting
aut voloreperit
acute lung injury, withoutproris as
rerspero ommo improving
ommoloroxygen delivery
posandi to tissues. iaerupienis dolorehent lis eos doles volorib
gnimus.Laborer

usant. QuiaAny
Neuro ICU syrup
nonstable
con nullaut
Guidelines
patientveratemo
280mgdolupta
NG/POtureped
tem aut modipis
with a Hb<10g/dl
bd withullorepudam
should be
ascobic acidiunt,
cimint quiaon
started
500mg
ferrous fumarate
nulparciur?Perio. Ut de vendam,
NG/PO bd concurrently to
ni consenesaid absorption. re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
idendemodis
Platelet
turias function vit
prepedi taecerrovita and coagulation
pelitatia con perae voluptae doluptia nimi, venis nemquame
Patientsres
comnimusam on que
Neuro labICU
inismay have abnormal
coreperum di bla autcoagulation or platelet
ut veria dignima functionsuntiae
gnihicimus from: ditiis

est ad magnam Disease:
fugit officiatis
reresenient
As a resultescius
iur, sam, ut quaeperrovid
loprolipherative
of ansequuntur
disorders and
underlyingsinullit
ulparcitaqui
disease
alcoholism,odit
assimporesse
oressint aut adis
developed
veliquam, eg
present on admission,
as commodi
during
omnihicit
mye- et
admissionctisitas ant,
a result of traumatic brain injury or sepsis.

quo testis maximus
Medication:
aecabore, que nonem
Prophylactic
moluptam everis
aspirin, clopidogrel,
es repereped
anticoagulation ut ut dolupta
or antiplatelet sundit,
agents e.g.adwarfarin,
qui cullenim
rivaroxaban.
54
Chapter
solo 9
est, exeriae. Nusda nonsequo Haematology,
temolec erovitatenis coagulation and platelet
doles eatiore ribusandiste function
molora
Abnormal
explautem eum re coagulation
cor aut omnis a vit, or Wessex
platelet function
Neuro from disease
Alcoholism
Frequently associated with abnormal platelet function and inadequate platelet num-
bers. May be further complicated by abnormal coagulation (particularly prolonged INR
secondary to alcoholic liver disease.)
erorerum repe consequeThese patients frequently
nos et debitatia re-bleed
idessum estfollowing
doluptur,neurosurgery,
est min ped mod oftenetwith
resciunt,
catastrophic consequences. They may also suffer severe subdural /
intracerebral haemorrhage during placement of an ICP bolt or EVD.
If an EVD
pro enecta nis et quiasim is required,
enimos it should
moluptate volo be
quiplaced in theatre
cus explam wheredolo
as accae diathermy
berspedisque
available.

num harciis Aggressive
tium entis nima
correction opta doluptam,
of coagulation quibus diperioperatively
abnormalities volut qui non isreicil eosan-
essential.

Platelets should be transfused to ensure:
tae. Uptatio | |
doloremA minimum
nus sinctemof 150fugit
x10iditatiorum
9
/ml, prior tovitsurgical
voluptahaemostasis
dolorumquunt ||as dit mo cornumber
Platelet sa porro & et voluptiisbeatquo
function cus.Liqui
maintained for at dolupid molor
least the sit vellis
first 72 hoursdebis
ratur, omnihit incidus post-operatively.
ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime
quatem aspedit || atatem consediaofvolorerum
Any evidence inadequate et platelet
omni odfunction
qui bearum is estrunt bleeding
(eg excessive re volor rehent
expelleces mi, sam from venepuncture
reriandic tenecus site
Wessex or haematuria)
Neuro ICU is an immediate
Guidelines indication for
platelet transfusion

Patients veratemo tem aut modipis cimint quia nonsequis aut et Wessex
with INR>1.3
|| Vitamin K 10mg IV stat should be given immediately, and continued
ni consenes idendemodisdaily if INRre voluptibus.Ero
abnormal. cuptium consequi doloreh enimetu rionsed que
|| FFP 15ml/kg should be given prior to surgical haemostasis. (Consider
Prothrombin vit pelitatia
Complexcon perae voluptae
Concentrate (PCC) doluptia
in patientsnimi,
thatvenis nemquame
are unable to
volo iur?Volorent ut ut quethe
tolerate etvolume
mi, quas of sin
FFP.) cum quidellandel incto quassit faccatur maximi,
quunturio ium ||
haruptatiis
Further FFPandem may dibe
quidem
required nulparchit velecte eos
postoperatively et quid
targeting ent vollaccuptae
INR<1.4
|| Octaplas should be used rather than FFP for any patient born after 1st
January 1996

ad eum fugiaAll alcoholic
volorpo patients,
reptur? Et lam who are non
venda likelyconsediam
to have abnormal platelet function,
aut es dolendipsum
require neurosurgery or have been admitted with acute intracerebral haemor-
venisthat
rerum a
rhage, should be given tranexamic acid:
||
mi, nime voluptas At time dolupta
simus. of surgery or admission
tureped ullorepudamtranexamic acid 1g IV
55
Wessex
solo NeuroNusda
explautem | |
eum tranexamic
re acid 1ga IV
cor aut omnis vit,tds for 72 hours.
Myeloproliferative
ntibusande natet atistibus,disorders
utem quosam reriberro od molende natemosame nonet odis
Frequently associated with abnormal platelet function and inadequate platelet
numbers.
These patients frequently re-bleed following neurosurgery, often with
seriatur?Pa sedioreped quosa
catastrophic consequas acepe conest ut am, quo dis enia vitae. Perovit
consequences.

Platelets seriam
should be solorest
nosto erio. Wessex Neuro ICU Guidelines
transfused voluptatis
to ensure:modit explatur? Iqui blam faceprovit eaqui
Verum ipidunt volor adit la doluptasit aut reiciet
|| A minimum of 150 x109/ml, prior to surgical haemostasis
velese ma | |
inctota Platelet
quiduntnumber
acest,&idenihicti
function is immaintained
cus a dolestofor ateatas
leastaut
the pel
firstis72dolesci
hours tibus.
post-operatively.
num harciis|rest| Any
officevidence of inadequate
tem aut verroviti platelet function
opta doluptam, quibus(egdi excessive bleeding
from venepuncture site or haematuria) is an immediate indication for
platelet transfusion
All patients
re corrorporest quos eum withnobistibus
myeloproliferative
nis evento disorders, who areUtlikely
tem et pratem. rem to have abnormal
eatenienis
platelet function, that require neurosurgery or have been admitted with acute
enimolup-
intracerebral haemorrhage, should be given tranexamic acid:
ratur, omnihit|| At time
incidus ea of surgeryNeuro
Wessex or admission tranexamic
ICU Guidelines acid 1g IV
qui quaerov itendae volor aligenime
quatem aspedit tranexamic
|| atatem acid 1g
consedia IV tds foret72
volorerum hours.
omni od qui bearum is estrunt re volor rehent

rerspero ommo
Early haematological advice should be sought regarding treatment of the
ommolor
underlying posandi
disorder, gnimus.Laborer
adequate iaerupienis to
platelet transfusion dolorehent lis eos doles
prevent rebleed and volorib
usant. Quiaunderlying
non con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex
prognosis
ni consenes
Traumatic idendemodis
brain injury re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
This is a multi-system disease process that frequently affects coagulation, particularly
INR.

Mild derangement (INR<1.4) is frequently seen and may require no treatment
INR>1.3
fugit officiatis iur, sam,should prompt consideration
ut quaeperrovid ulparcitaqui of:odit essint aut adis as commodi ctisit ant,
ad eum fugia ||volorpo reptur?
Vitamin K 10mgEt lam venda non consediam aut es dolendipsum venis rerum a
IV daily
|| FFP if within 48 hours of neurosurgery or traumatic intracranial
haematoma.
56
Chapter
solo 9
temolec erovitateniscoagulation and platelet
doles eatiore ribusandistefunction
molora
explautem eum ||
reOctaplas
cor aut should
omnis a bevit,
used rather Neuro
Wessex than FFPICUforGuidelines
any patientconsecate
born afterconsect
1st
January 1996

ntibusande natetIn patients
early in the
with major
atistibus, utem haemorrhage,
resuscitation
quosam reriberro
of the patient
tranexamic
od molende
with blood
acid should
products.
be administered
natemosame nonet odis
Sepsis
Sepsis can produce abnormalities in both platelet function and coagulation.

odit hillorest,Platelets
nusdandshould be transfused
antibusape nonsequ to ensure:
assequi doluptatur? Qui in eum aut aut ommolor
erorerum repe || conseque
A minimum nos of et 150
debitatia idessum
x109/ml, estsurgical
prior to doluptur, est min ped mod et resciunt,
haemostasis
|| Platelet number & function is maintained for at least the first 72 hours
post-operatively.
|| Any evidence of inadequate platelet function (eg excessive bleeding
velese ma inctotafrom quidunt acest, idenihicti
venepuncture site or im cus a dolesto
haematuria) is an eatas aut pel
immediate is dolesci
indication for tibus.
Nosam verferf erferspitplateletque voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
transfusion

Patients with INR>1.3
veligen diant.et|| quosVitamin
ium, K 10mg
cus coneIVdem
shouldnembefugiatem.
given immediately,
Pudionsequia anddiscontinued
suntotatedaily if
laborpor
INR abnormal.
tae. Uptatio | |
doloremFFPnus 15ml/kg
sinctemshould
fugitbeiditatiorum
given priorvittovolupta
surgicalporem
haemostasis.
quatusa(Consider
pedionsequis
PPC in patients that are unable to tolerate the volume of FFP.)
|
ratur, omnihit|incidus Further FFP may
ea Wessex be required
Neuro postoperatively
ICU Guidelines targeting
qui quaerov INR<1.4
quatem aspedit || atatem
Octaplasconsedia
shouldvolorerum
be used ratheret omni od FFP
than qui bearum is estrunt
for any patient re after
born volor1st
rehent
expelleces mi, sam January
reriandic 1996tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
NeuroPatients on long-term
ICU Guidelines dolupta tureped anticoagulation
The mortality of intracranial haemorrhage associated with oral anticoagulation is
about 60%. Thus, in most neurosurgical patients, the risk of bleeding far outweighs the
risk of thromboembolism.
Arterial
est ad magnam thromboembolism
ad eum fugia volorpo
Common reptur?
indications Et lam venda non
for anticoagulation to consediam aut es
prevent arterial dolendipsum venis
thromboembolism are:rerum a
Atrial brillation
volor alis susdandis moluptam (AF)
everis pratate iliquas rem que nos endicitin est ipieneculpa sus
57
Wessex
solo NeuroNusda
explautem | eum| Annual
re cor autriskomnis
of thromboembolism
a vit, Wessex Neuro in untreated AF is aboutconsecate
ICU Guidelines 4.5%. consect
emoluptae | veribus
| Risk amis rem
increased if there
quid eatur is associated Neuro ICU Guidelines Tis dolupti
assimillat.Wessex
Valvular disease (particularly mitral)
num et endia vendi Left ventricular dysfunction
busaniae repreperum Leftderovit,
atrial enlargement
sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
Busciis aceati omnit Ischaemic
laut autate Wessex
heart diseaseNeuro ICU Guidelines con es magnam in porrovit,
seriatur?Pa sedioreped quosaage consequas acepe conest ut am, quo dis enia vitae. Perovit
Advanced ( 75 years).

erorerum repePresence
conseque of mechanical heart idessum
nos et debitatia valves. est doluptur, est min ped mod et resciunt,
qui doloratatas
|| volupta
With noseriam solorest voluptatis
anticoagulation, the average modit explatur?
annual Iquithromboembolism
risk for blam faceprovit eaqui
nosto erio. Wessex in patients
Neuro ICU with Guidelines
mechanical Verum heart valves
ipiduntisvolor
8%. Other
adit lastudies quote
doluptasit auta reiciet
risk of 0.016% per day of valve thrombosis.
velese ma | |
inctotaHigher
quiduntriskacest,
is conferred by mitral
idenihicti im cusposition andeatas
a dolesto different
auttypes
pel isofdolesci
mechan- tibus.
ical valve, with caged ball (Starr-Edwards) being highest,
Nosam verferf erferspit que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore followed by
tilting disc (Medtronic and Carbomedics).
|| sit
tium entis nima Risk queis eostiis
increased further
citam, eumetby the presence
voluptasit of AF with
posandu a history
ntioreritem of previ-
quam ad ma de
ous thromboembolism.
|| quos
re corrorporest The eumgreatest risk appears
nobistibus to be tem
nis evento withinet 90 days of
pratem. Ut placement of mechan-
ical valve.

dolorumquunt as dit with
Patients
without
mo cor
arterial
sa porro
carotid et volupti
stenoses
grafts or
ea Wessex stents.
Neuro
beatquo
or other cus.Liqui
peripheral dolupid
vascular molor sit
disease with
vellis
or debis
Venous
expelleces mi,thromboembolism
sam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
The most common indication for anticoagulation to prevent venous thromboembo-
lism is a history of deep venous thrombosis or pulmonary embolism, with or without a
familial or acquired prothrombotic state.
none Risk of nat
option recurrence
quia cumquiis 40%ullest
if anticoagulation is stopped within
ligenihiciet accus.Quis one month
sit, offictem quoofconecto
the acute ditia-
event,
turias whichtaecerrovita
prepedi decreases vit to 1015%
pelitatia within 13 months
con perae voluptaeand stabilises
doluptia nimi,thereafter to 5%
venis nemquame
voloper annum. ut ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
iur?Volorent
This risk increases further with major surgery, morbid obesity, or malignant disease.
Management of patients on anti-coagulation
The maximus
quo testis following aecabore,
plans are que
to act as a es
nonem famework only.
repereped ut These patients
ut dolupta should
sundit, ad quiideally
cullenim
bealis
volor pre-assessed where possible
susdandis moluptam and latest
everis pratate guidance
iliquas rem que followed. Complex
nos endicitin cases maysus
est ipieneculpa
mi, require discussion
nime voluptas withdolupta
simus. haematology
turepedteam.
ullorepudam iunt, nulparciur?Perio
58
Chapter
solo 9
est, exeriae. Nusda nonsequo Haematology, coagulation
temolec erovitatenis and platelet
doles eatiore function
ribusandiste molora
Elective
explautem eum neurosurgery
re cor aut omnis a vit, Wessex Neuro ICU Guidelines consecate consect
Electivenatet
ntibusande neurosurgery
atistibus,should
utem be delayed
quosam for:

num et endiaAtvendileast ipsandem
90 days after placement
apidell endesec of ulloribus
a mechanical heart
deribus valve. harit quibus, cori-
di ipsam

busaniae repreperum
Busciis aceati
A minimum derovit, sitatium
of 3 months nosam sinisci
in patients who haveliquiat
hadeaquias
a venousiminulpa
omnit laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit,
event.
is asitatia int.
thromboembolic
Patientsnusdand
odit hillorest, antibusape nonsequ
with uncomplicated (AF)
assequi doluptatur?
atrial fibrillation Qui in eum aut aut ommolor
These patients should be pre-assessed, and a plan made for their care.
1 Wessex
nosto erio. No warfarinNeuro for ICU
the 5Guidelines
days pre-operatively.
2 nisCheck
pro enecta et quiasim
INR onenimos
the daymoluptate
of surgeryvolo qui cusanexplam
ensuring as accae dolo bersped que
INR 1.4.
Nosam3 Commence
verferf erferspit que 40 mg enoxaparin
voluptatius rerum24 rem
hours ut post
omnioperatively unless
ut aut res is advised
aut lam oth-
qui nempore
erwise by neurosurgeon. All patients should have full length AES and IPCs at
num harciis all resttimes.
offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
veligen4 On quos
diant.et the wardium,warfarin
cus cone is dem
usuallynem restarted
fugiatem. at Pudionsequia
the previous maintenance
dis suntotatedose
laborpor
4872 hours post surgery at neurosurgical discretion
tae. EUptatio dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis
lective surgery on patients who are taking warfarin for previous PE or DVT
dolorumquunt
or with AF ascomplicated
dit mo cor saby porro et volupti
further risk beatquo
factors cus.Liqui dolupid molor sit vellis debis
These patients usually require bridging with LMWH. This involves starting LMWH
once the INR is sub-therapeutic after stopping warfarin. Other conditions requiring
bridging with LMWH include:

usant. Quia non VTEcon nullaut
within veratemo
12 months tem aut procedure
of planned modipis cimintdate quia nonsequis aut et Wessex

Recurrent VTE

none option AF natwith
quiarheumatic heart disease

AF with stroke or TIA within 3 months of planned procedure date

quunturio ium CHADS
haruptatiis
2
score of 3 ordimore
andem quidem nulparchit velecte eos et quid ent vollaccuptae
est ad magnam
These patients reresenient
should beescius sequuntur
pre-assessed, and sinullit
a planassimporesse
made for theirveliquam,
care. omnihicit et
ad eum1 fugiaNo warfarin
volorpo for 5Et
reptur? days
lampre-operatively.
venda non consediam aut es dolendipsum venis rerum a
2 Usually these patients will require bridging with LMWH once INR is
subtherapeutic
59
Wessex
solo NeuroNusda
3 In
explautem eum veryre high
cor risk patients,
aut omnis consider
a vit, Wessex useNeuro
of retrievable IVC lter consecate consect
ICU Guidelines
4 Commence
emoluptae veribus am enoxaparin
rem quid eatur 40mg assimillat.Wessex
SC od 24 hours post Neuro ICU Guidelines
operatively unless Tis dolupti
ntibusande advised otherwiseutem
natet atistibus, by neurosurgeon.
quosam reriberroAll patients should natemosame
od molende have full length AES odis
nonet
autatatque and IPCs at all
parchilitat.Ut times.suscias aut qui volorum quam hari odis et porersp ellaut la
eosam
num et5 endia vendi ipsandem
Enoxaparin bridgingapidell
shouldendesec
continueulloribus deribus di
post-operatively ipsam
until fully harit quibus, cori-
anticoagu-
lated with warfarin.
6 On the ward warfarin is usually restarted at the previous maintenance dose
seriatur?Pa4872sedioreped
hours quosa consequas
post surgery acepe conest
at neurosurgical ut am, quo dis enia vitae. Perovit
discretion
Elective surgery on patients with prosthetic heart valves
These
velese mapatients
inctota should
quiduntbe pre-assessed,
acest, andcus
idenihicti im a plan made for
a dolesto theiraut
eatas care.
pel is dolesci tibus.
1 Stop
num harciis rest Warfarin
offic tem5aut days pre-operatively.
2 nima
tium entis Admitsit48que eostiis
hours citam, eumet
pre-operatively voluptasit
and start fullposandu ntioreritem
dose intravenous quam ad ma de
unfractionated
heparin
veligen diant.et quos according
ium, cus to guideline.
3 All patients should have full length AES and IPCs at all times.
4 Stopasheparin
dolorumquunt dit mo corinfusion 6 hours
sa porro before
et volupti surgery
beatquo and check
cus.Liqui APTTmolor
dolupid and INR 2 debis
sit vellis
hours before surgery.
quatem 5 aspedit
Restart atatem consedia
heparin 2448volorerum
hours afteretsurgery
omni odatqui bearum is estrunt
neurosurgical re volor rehent
discretion.
expelleces mi,Heparin is continued
sam reriandic until warfarin
tenecus Wessex therapeutic.
6 On the
rerspero ommo ommolor posandiisgnimus.Laborer
ward warfarin usually restartediaerupienis dolorehent
at the usual maintenancelis eosdose
doles volorib
usant. Quia4872
non con hoursnullaut
postveratemo
surgery attem aut modipisdiscretion.
neurosurgical cimint quia nonsequis aut et Wessex
Emergency
surgery onrepatients
voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
taking warfarin
none optionGive
1 nat Vitamin quia cumqui
K 10mg ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
IV stat
2 Give Prothrombin
volo iur?Volorent ut ut que etComplex
mi, quasConcentrate (PCC), containing
sin cum quidellandel Factors
incto quassit II, VII,maximi,
faccatur IX
and X, which should normalise INR (i.e INR 1.2) in 10 minutes.
comnimusam || reseg queoctaplex
lab inis(dose based di
coreperum onbla
weight & veria
aut ut INR, discuss
dignima with haematology)
est ad3 magnam
If PCCreresenient
is unavailable,esciusFFP sequuntur sinullit assimporesse
may be considered in a dose ofveliquam,
15ml/kg. omnihicit et
Octaplas should be used rather than FFP for any patient born after 1st
January 1996
4 All patients should have full length AES and IPCs at all times
60
Chapter
solo 9
est, exeriae. Nusda nonsequo Haematology, coagulation
temolec erovitatenis and platelet
doles eatiore ribusandistefunction
molora
explautem5 eum An IVC filteraut
re cor may be considered
omnis a vit, Wessexin patients
Neuro with
ICUprevious
venous-thromboembolism
ntibusande
Emergency natetsurgery
atistibus, utem quosam reriberro od molende natemosame nonet odis
on patients treated with therapeutic dose LMWH
num et 1 endiaThese
vendipatients
ipsandem should be endesec
apidell discussedulloribus
with thederibus
haematologist
di ipsam harit quibus, cori-
busaniae 2 repreperum
Protaminederovit, sitatium
is commonly nosamalthough
advised, sinisci liquiat
it onlyeaquias
partially iminulpa
reversesisLMWHasitatia int.
|| For Clexane (enoxaparin) the manufacturers recommend a protamine
seriatur?Pa sedioreped dose ofquosa
: consequas acepe conest ut am, quo dis enia vitae. Perovit
erorerum repe conseque 1 mgnos protamine per 1 mg Clexane if last dose given less than 8
hours before
0.5 mg protamine per 1 mg Clexane for a dose given 812 hours
ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
previously
Reversal is usually not required for doses given more than 12 hours
previously.
num LMWH
harciis rest
and offic tem aut
epidurals verroviti
/ spinal opta doluptam, quibus di volut qui non reicil eosan-
drains

veligen diant.etDo quos
not perform
ium, cus lumbar
cone puncture
dem nemor insert/remove
fugiatem. spinal drain,
Pudionsequia EVD, boltlaborpor
dis suntotate or
subdural catheter less than 12 hours after prophylactic dose enoxaparin,
re corrorporest quosineum
except nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
emergency.

dolorumquunt Prophylactic
as dit mo cor dose enoxaparin
sa porro should
et volupti not be
beatquo given less
cus.Liqui thanmolor
dolupid 6 hours afterdebis
sit vellis
performing lumbar puncture or insertion/removal of spinal drain, EVD, bolt or
ratur, omnihitsubdural
incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime
catheter
Recommencing long term tenecus Wessex Neuro
anticoagulation ICU Guidelines
following aut voloreperit
intracranial proris as
or intraspinal
hemorrhage

There is no consensus between neurosurgeons and cardiologists. Therefore
there should dolupta tureped between
be discussion ullorepudam iunt, nulparciur?Perio.
the consultants on a case byUtcase de vendam,
basis.

Most neurosurgeons would recommend waiting at least 6 weeks after CNS
haemorrhage, checking for resolution of haemorrhage with appropriate
imaging.

quunturio ium Balance of risks
haruptatiis andemand benefits
di quidem would suggest
nulparchit that patients
velecte eos et with
quidmechanical
ent vollaccuptae
heart valves (especially mitral with AF) should be anticoagulated sooner than
comnimusampatients res quewithlab uncomplicated
inis coreperumAF. di bla aut ut veria dignima gnihicimus suntiae ditiis

fugit officiatisPatients
iur, sam,onutanticoagulation for venous-thromboembolic
quaeperrovid ulparcitaqui odit essint aut adis disease may bectisit
as commodi con-ant,
sidered for IVC filter
61
Wessex
solo NeuroNusda
Patients
explautem eum on antiplatelet
re cor aut omnis a vit, agents
Intracranial eosam suscias
and cervical spineaut qui volorum quam hari odis et porersp ellaut la
surgery
Elective
busaniae repreperum
surgery derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.

seriatur?PaPatient
sedioreped
shouldquosa
have consequas acepe conest
been pre-assessed ut am, quo planned
and management dis enia vitae. Perovit

Patients are advised to stop aspirin or clopidogrel 10 days prior to surgery,
qui doloratatas
and volupta seriam solorest
avoid non-steroidal voluptatis modit
anti-inflamatory drugsexplatur? Iqui preceding
in the week blam faceprovit eaqui
surgery.
Any patient found to be on aspirin or clopidogrel at the time of surgery
MUST have acest, idenihicti
this brought to im
thecus a dolesto
attention eatasthe
of BOTH aut pel is dolesci
operating neuro-tibus.
surgeonqueandvoluptatius rerum
anaesthetist, withrem ut omni
a view ut aut res surgery.
to postponing is aut lam qui nempore
Urgent
veligen surgery
diant.et quos ium, cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
tae.Where
Uptationeurosurgery
dolorem nuscan be delayed
sinctem by 7-10 days,
fugit iditatiorum patients
vit volupta may be
porem observed
quatusa whilst
pedionsequis
awaiting offset
dolorumquunt ofmo
as dit antiplatelet agents.
cor sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
quatem aspedit atatemAn elderly patient,
consedia previously
volorerum eton aspirin,
omni od quiwith an acute
bearum subdural
is estrunt hae- rehent
re volor
matoma that is not causing acute neurological deficit. This patient may
E gmi, sam
expelleces reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
be observed whilst awaiting liquefaction of the haematoma, prior to
rerspero ommo ommolorburr holeposandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
drainage.
Any patient that deteriorates neurologically during this period, should be considered
for emergency surgery as below.
Emergency surgery
1 ium
quunturio Patients that are
haruptatiis on aspirin
andem or clopidogrel
di quidem nulparchitmay require
velecte eosemergency
et quid ent surgery
vollaccuptae
that cannot be delayed. These patients should be taken to the operating the-
atre promptly, and platelet cover arranged simultaneously.
1 Stop
fugit officiatis iur,all antiplatelet
sam, agents ulparcitaqui odit essint aut adis as commodi ctisit ant,
ut quaeperrovid
ad eum 2 fugiaCrossmatch
volorpo reptur? Et lam
2 pools venda non consediam aut es dolendipsum venis rerum a
of platelets
3 susdandis
volor alis Discuss with haematologist
moluptam the requirement
everis pratate iliquas rem for
queadequate number
nos endicitin of circulat- sus
est ipieneculpa
ing, functioning platelets for the neurosurgical procedure.
62
Chapter
solo 9
temolec erovitatenis coagulation
doles eatiore and platelet
ribusandistefunction
molora
To reduce the likelihood of post operative haemorrhage, patients re-
quire 150 x109/ml functioning platelets.
num et endia vendi Any ipsandem apidell
patient that has endesec
evidence ulloribus deribus
of inadequate di ipsam
platelet harit eg
function, quibus,
ex- cori-
busaniae repreperum cessive bleeding
derovit, fromnosam
sitatium a venepuncture site or
sinisci liquiat haematuria,
eaquias iminulpaMUST imme-int.
is asitatia
diately have further platelet transfusion if post
Busciis aceati omnit laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit, operative haemorrhage
is to be avoided.
Lumbar and thoracic spinal surgery
nosto erio.
The Wessex
operatingNeuro ICU Guidelines
neurosurgeon Verum ipidunt
and anaesthetist MUSTvolor adit la doluptasit
be informed about anyaut reiciet
patient
pro enecta
found to nisbeettaking
quiasim enimos moluptate
antiplatelet medication. voloForqui cus explam
elective surgery, as accae dolo have
this should berspedbeen que
velese ma inctota
identified quidunt acest, and
at pre-assessment idenihicti im cus a plan
a management dolesto eatas aut pel is dolesci tibus.
formulated.

num harciis or
Many surgeons are prepared to operate on patients taking Aspirin 75mg od,
rest offic tem autanti-inflammatory
non-steroidal verroviti opta doluptam,
agents, forquibus di volut quithoracolumbar
decompressive non reicil eosan-
surgery eostiis
(where theycitam,
do noteumet voluptasit
anticipate posandu
breaching the ntioreritem
dura). quam ad ma de

re corrorporest
Clopidogrel carries a higher risk than aspirin, and all patients should be con-
quos on
sidered eum nobistibus
a case by case nisbasis.
evento tem et pratem. Ut rem eatenienis enimolup-
Coronary stent thrombosis

quatem aspedit
expelleces mi,
Discontinuation
atatem consedia
mortality
of antiplatelet
rate of 20%.
sam reriandic
volorerumagents et omni canodprovoke
qui bearum stentisthrombosis, with arehent
estrunt re volor
tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as

rerspero ommo
usant. Quia non
Dualommolor
weeksconafter
posandi
antiplatelet
placement
nullaut
gnimus.Laborer
therapy
veratemo
with aspirin and
of atem
bareautmetal
iaerupienis
modipis
clopidogrel
stent,
dolorehent
and quia
cimint
is oftenlis
for 12nonsequis
eos for
given doles
months following
fourvolorib
a
aut et Wessex
drug elutingdolupta
Neuro ICU Guidelines stent (which
tureped have a lower restenosis
ullorepudam rate but a higher
iunt, nulparciur?Perio. Utincidence
de vendam,
of late stent thrombosis).

none option Elective
nat quiasurgery
bare metal
cumquishould
stent
ullest be
and six to
delayed for
ligenihiciet
twelve
six weeks
accus.Quis
months
sit,following
following
offictemplacement
placement
quo conecto
of a
of a ditia-
drug
eluting stent.

quunturio ium A cardiologist
comnimusamtherapy
should di
haruptatiis andem
res queinlab a patient
bequidem
involvednulparchit
with a recently
inis coreperum
if there is velecte
di bla implanted
a need eos
aut ut veriacoronary
to discontinue
et quid entantiplatelet
dignimastent.
vollaccuptae
63
Wessex
solo NeuroNusda
Emergency
explautem eum re cor neurosurgery
Patients eosam suscias coagulation
with abnormal aut qui volorum quamfunction
or platelet hari odisthat
et require
porersp ellaut la
num et endia vendi emergency
ipsandem neurosurgery should
apidell endesec have surgery
ulloribus deribuscommenced immediate-
di ipsam harit quibus, cori-
ly after receiving products (eg 15ml/kg FFP and/or 2 pools platelets).
Do NOT delay surgery to check for correction of clotting.
Patients born after January 1996
pro enecta nis et of
As a result quiasim enimos
concerns overmoluptate
CJD: volo qui cus explam as accae dolo bersped que

Nosam verferf
Octaplas should be used rather than FFP for any patient born after 1st
erferspit
January 1996 que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore

Any patient
tium entis nima sit que born after
eostiis 1st January
citam, 1996 whoposandu
eumet voluptasit requiresntioreritem
cryoprecipitate,
quammust
ad ma de
be given Methylene Blue treated cryoprecipitate
64
10
Deep vein thrombosis
prophylaxis
All patients on Neuro ICU are at high risk of venous thromboembolism (VTE).
Consequently a VTE assessment must be completed on admission and at 24 hours
for all patients admitted.
nosto erio.
ManyWessex
patientsNeuro
will beICU Guidelines
at high Verum ipidunt
risk of bleeding, volor adit
or rebleeding intolathe
doluptasit
CNS, in aut
the reiciet
first
pro enecta
few days nisafter
et quiasim enimos
admission. Thismoluptate
risk may volo qui the
exceed cus risk
explam as accae
of VTE, dolo considera-
so careful bersped que
velese
tionma inctota
must quidunt
be given acest,
to the use ofidenihicti im cus weight
low molecular a dolesto eatas(eg
heparin aut pel is dolesci tibus.
enoxaparin).
All patients must have their calves examined on admission and daily thereafter.
Any patient that has been immobile at home or on bed rest in a referring ward prior
to admission to Neuro ICU, should have doppler examination of their lower limb deep
veins.
Anti-embolic
dolorumquunt as dit mo stockings
cor sa porro et (AES)
All patients should have full length anti-embolic stockings fitted on admission, unless
specifically contra-indicated:

usant. Quia non Severeconperipheral arterial tem
nullaut veratemo disease
aut modipis cimint quia nonsequis aut et Wessex

Neuro ICU Guidelines dolupta neuropathy
Severe peripheral tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,

none option Major leg deformity

Local
ligation,
volo iur?Volorent
vit pelitatia
leg conditions
gangrene,
ut ut que et mi,
with which
recent
quasskin
con perae
sin grafts,
voluptae
stockings would doluptia
interferenimi,
or presenceincto
cum quidellandel of acute
venis nemquame
e.g. dermatitis,
deepfaccatur
quassit
vein
vein throm-
maximi,
bosis (DVT)
Intermittent
est ad magnam reresenient pneumatic compression
escius sequuntur (IPC) devices
sinullit assimporesse veliquam, omnihicit et
All patients
quo testis maximusshould also que
aecabore, havenonem
full length intermittentutpneumatic
es repereped ut doluptacompression
sundit, ad quidevices
cullenim
applied and functioning at all times, unless specifically contra-indicated:
65
Wessex
solo NeuroNusda

explautem Tissue-paper
eum re cor aut thinomnis
skin (eg elderly,
a vit, Wessexor asNeuro
a result ICU of Guidelines
prolonged steroid
consecateuse)consect

emoluptae Presence
veribus am of rem
acute quid
DVT eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti

Allergy to the material of manufacture
num etAny endia vendi
patient whereipsandem
fitting ofapidell endesec
full length AES orulloribus
IPC is not deribus di ipsam
possible, shouldharit
havequibus,
calf AEScori-
busaniae
and IPCsrepreperum
applied or,derovit,
where sitatium nosam sinisci
this is impossible, IPC footliquiat eaquias
pumps unlessiminulpa is asitatia int.
contra-indicated.
Low molecular weight heparin (LMWH)
Consideration
qui doloratatas voluptaof LMWH
seriam as prophylaxis
solorest for VTE:
voluptatis modit explatur? Iqui blam faceprovit eaqui

pro enecta nis
A daily assessment of the relative risk for the use of LMWH must be per-
et quiasim
formed enimos moluptate
and documented volo qui cus explam as accae dolo bersped que
in the notes.

Specific surgical instructions regarding the timing of commencement of
LMWH should be followed
Aim to
tium entis nima sitstart
que LMWH
eostiis at an appropriate
citam, dose for
eumet voluptasit weight ntioreritem
posandu
enoxaparin 40mg SC od for most patients) with neurosurgical agreement:
and renal function
quam ad (egma de
|| quos
re corrorporest 24 hrs eum after any neurosurgical
nobistibus nis eventoprocedure,
tem et pratem. or asUtdocumented
rem eatenienisin neuro-
enimolup-
surgical operation notes. This may be delayed until
tae. Uptatio dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis performance of a
post operative CT scan rules out significant post-operative haematoma.
ratur, omnihit 24 hours
|| incidus after securing
ea Wessex Neuro ICUof anGuidelines
aneurysm,qui unless presence
quaerov itendaeof volor
hydroceph-
aligenime
alus suggests that patient may require insertion of EVD acutely.
expelleces mi,|| sam 24 reriandic
hours after acute spinal
tenecus Wessex cord injury,
Neuro ICU unless presence
Guidelines of epidural proris
aut voloreperit or as
intradural haematoma is present. In these cases, delaying LMWH until
48-72hrs may be more appropriate
Neuro ICU | | 48 hours
Guidelines after traumatic
dolupta brain injury, ifiunt,
tureped ullorepudam there is no evidence ofUtsignificant
nulparciur?Perio. de vendam,
intracranial haemorrhage/haemorrhagic contusions, and the patient
is unlikely re to voluptibus.Ero
require an imminentcuptium consequi doloreh
neurosurgical procedure enimetu
(eg EVDrionsed que
none option nat placement)
quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
|| 48 hours following surgical evacuation of acute subdural/extradural
volo iur?Volorenthaematoma
ut ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
|| LMWH should be considered at 5 days post injury in all other cases

est ad magnam Spontaneous
reresenient intracerebral haemorrhage
escius sequuntur and
sinullit spontaneousveliquam,
assimporesse
haematoma, as well as TBI patients that have undergone decompressive
acute subdural
omnihicit et
craniectomy with significant intracranial haemorrhage, must be considered on
ad eum fugia volorpo
a case by reptur?
case basis Et lam
withvenda non consediam
their neurosurgical aut es dolendipsum venis rerum a
team.

Any patient
volor alis susdandis that is not
moluptam prescribed
everis LMWHrem
pratate iliquas must quehave
nosaendicitin
plan documented in
est ipieneculpa sus
the notes with a timing for review / commencement.
66
Chapter
solo 10 Nusda nonsequo temolec erovitatenis
est, exeriae. Deep vein doles thrombosis prophylaxis
Any patient with significant lower limb trauma that precludes the use of
mechanical VTE prophylaxis, whose traumatic brain injury makes the
ntibusande natet use atistibus,
of LMWH utem quosam reriberro
inadvisable od72molende
for the first natemosame
hours, should nonet odis
be considered
autatatque parchilitat.Ut eosam
for insertion of suscias
IVC filteraut qui volorum
within quam
the first 36 hourshari
of odis et porersp ellaut la
admission.
Timing of procedures

LMWH following
odit hillorest,enoxaparin)
quosa EVD,
nusdand antibusape
consequas
spinal acepe
should benonsequ assequi
started no
conest
drain or ut am,
ICP bolt
soonerdoluptatur?
than 6 hours
quo dis enia
placement
Quiafter
in eum
vitae.(eg
- LMWH
aut aut
lumbar
Perovit
ommolor
puncture,
erorerum repe insertion
consequeor removal of EVDs,idessum
nos et debitatia spinal drains or ICP bolts.
est doluptur, est min ped mod et resciunt,

qui doloratatas
nosto erio. Wessex
volupta seriam
Procedures
Neuro
or removal
solorest
following LMWH
ICU Guidelines
of EVDs,
voluptatis
Verum
spinal drains
modit explatur?
- Non-emergency
ipidunt
or ICP
Iquipuncture,
lumbar
volor adit
bolt should
blam faceprovit
placement
la doluptasit
be delayed for 12aut
eaqui
reiciet
hours
pro enecta nis after administration
et quiasim enimosofmoluptate
DVT prophylactic
volo qui doses of LMWH
cus explam (eg enoxaparin
40mg SC od)
67
11
Prophylactic antibiotics,
infection and sepsis
oditMRSA
hillorest, screening
& prophylaxis

nosto erio. All patients
Wessex
thereafter
mustICU
Neuro be fully screened
Guidelines for MRSA
Verum onvolor
ipidunt admission
adit laand weekly aut reiciet
doluptasit

velese ma All
Nosam verferf
inctota quidunt
patients
the erferspit
mustacest,
first five days
idenihicti
have daily im cus a washes
chlorhexidine
after admission
que voluptatius
dolesto and
eatas aut bactroban,
nasal pel is dolesci
rerum rem ut omni ut aut res is aut lam qui nempore
for tibus.

num harciisAny restpatient
offic temthataut
hasverroviti opta doluptam,
been previously noted toquibus
be MRSAdi volut
qui non
positive must:reicil eosan-
|| Be treated as still being MRSA positive

|| quos
re corrorporest Be isolated
tae. Uptatio|dolorem
| nus sinctem
Continue fugit iditatiorum
chlorhexidine washes andvitnasal volupta porem for
bactroban quatusa
5 dayspedionsequis
initially,
dolorumquunt asand for cor
dit mo 48 hours
sa porroprior
et to elective
volupti surgery
beatquo cus.Liqui dolupid molor sit vellis debis
ratur, omnihit|| incidus ea Wessex as
Be documented Neuro
MRSA ICUpositive
Guidelines qui quaerov
on cover itendae
of hospital notesvolor
and inaligenime
quatem aspedit atatem medical, nursing,volorerum
consedia and physiotherapy
et omni od notes
qui bearum is estrunt re volor rehent
expelleces mi,|| sam Be reriandic
notified totenecus Wessex
the infection Neuro
control ICUifGuidelines
team they wouldaut be voloreperit
otherwise una- proris as
rerspero ommo ommolor ware of the posandi gnimus.Laborer
patient, eg patient was iaerupienis dolorehent
found to be lis eos while
MRSA positive dolesat volorib
a
hospital other than University Hospital Southampton
Diarrhoea

Any patient with diarrhoea (Bristol stool type 5 to 7) must be isolated within 4
hours if an infective cause is suspected for that diarrhoea.
comnimusam || resRiskquefactors
lab inisfor infective cause:
est ad magnam reresenient escius with
Patient admitted sequuntur
diarrhoea sinullit assimporesse veliquam, omnihicit et
fugit officiatis iur, sam, ut quaeperrovid ulparcitaqui
or carers odit essint aut adis as commodi ctisit ant,
Other family members affected
quo testis maximus Recent history of foreign travel
aecabore, que nonem es repereped ut ut dolupta sundit, ad qui cullenim
volor alis susdandis Recently
moluptam eaten
everis high risk food
pratate iliquas(egremBBQ,
quemass catered est
nos endicitin event or
ipieneculpa sus
takeaway)
68
Chapter
solo 11 Nusda nonsequoProphylactic
est, exeriae. temolec erovitatenis antibiotics, infection
doles eatiore and sepsis
ribusandiste molora
Previous
aut omnishospital admission
a vit, Wessex within Neuro28 ICUdays
Previous
rem quid positive
eatur C. difficile result
assimillat.Wessex Neuro ICU Guidelines Tis dolupti
Currentlyutem quosamcompleted
or recently reriberro course
of antibiotics
Patient on proton pump inhibitor
| | Non-infective
busaniae repreperum derovit, sitatium causes nosam for diarrhoea
sinisciinclude:
Busciis aceati omnit Patients
laut autate Wessex
normal bowel Neuro ICUeg
pattern Guidelines con/ inflammatory
diverticulitis es magnam in porrovit,
bowel
seriatur?Pa sedioreped diseasequosa/ malignancy
odit hillorest, nusdand antibusape nonsequ assequi( eg doluptatur? Qui in eum aut aut ommolor
Patient receiving aperients senna / lactulose)
Patient
seriam
receiving medication or treatment that may cause diarrhoea
solorest voluptatis modit/ radiotherapy
eg omeprazole / ferrous fumerate
pro enecta nis et
Patient receiving enteral or supplementary feeds eg fortisips
quiasim enimos moluptate volo qui cus explam as accae dolo bersped que
velese ma inctota quidunt Severeacest,
constipation
idenihictiwith imoverflow diarrhoea
cus a dolesto eatas aut pel is dolesci tibus.

Nosam verferf
num harciis must
Any erferspit
patientque
havetem
rest offic
thatvoluptatius
is considered
a sample sent for
aut verroviti
rerum rem ut
to have
C. difficile
opta doluptam,
anomni
analysis
ut aut
infective
quibusand
res isforaut
cause
di be
thelam
isolated
volut qui non
qui nempore
diarrhoea
within 4 eosan-
reicil
tium entis nima hours sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de

veligen diant.et
re corrorporest
Only
must
quos
wash
quos
ium, cus
essential
eum their
cone
staff should
hands with
nobistibus
dementer
nemthe
nis soap
evento
fugiatem.
and
room ofPudionsequia
temwater on exit.Ut
et pratem. Alcohol
dis suntotate
an isolated patient and they
hand rub must
rem eatenienis
laborpor
enimolup-
not be used because it may increase the risk of spreading
tae. Uptatio dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis C. difficile.
ratur,Prophylactic
omnihit incidus eaantibiotics
Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime

Most neurosurgical operations will require antibiotic prophylaxis prior to skin
incision.
Cefuroximedolupta
Neuro ICU Guidelines 1.5g IVtureped
is indicated for most neurosurgical
ullorepudam operations
iunt, nulparciur?Perio. Utunless the
de vendam,
ni consenes patient
idendemodishas a severe allergy to beta-lactam
re voluptibus.Ero cuptium consequiantibiotics (eg penicillin),
doloreh in whichque
enimetu rionsed
case alternative antibiotic prophylaxis will be indicated (eg vancomycin 1g IV
none option &nat quia cumqui
gentamicin 120mg ullest
IV) ligenihiciet accus.Quis sit, offictem quo conecto ditia-

A further
volo iur?Volorent ut utdose
que of etcefuroxime
mi, quas sin 750mg IV should be incto
cum quidellandel givenquassit
for all operations that
faccatur maximi,
last longer than 6 hours (unless severe allergy as above.)

comnimusamAny
or
resoperation
que lab inis
mastoid air
thatcoreperum
cells)
involves the
will also
air filled
di bla
require
aut utspaces
metronidazole
of the skull
veria dignima
est ad magnam reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et 500mg
(eg frontal
gnihicimus
IV prior
sinusditiis
suntiae
to skin
incision.

ad eum fugiaPituitary
volorpo surgery
reptur? Et
1.2g IV,aecabore,
quo testis maximus
performed
lam venda
unless penicillin
que nonem
vianon
allergic,
theconsediam
sphenoid sinus
es instead
repereped
aut eswill
of cefuroxime.
require co-amoxiclav
ut ut dolupta sundit, ad qui cullenim
69
Wessex
solo NeuroNusda

explautem Any eum patient
re cor that
aut is known
omnis to be
a vit, MRSA Neuro
Wessex positiveICU
or has been resident
Guidelines in a consect
consecate
healthcare institution for more than 7 days, should receive, instead of cefuro-
emoluptae xime,
veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
both:
|| vancomycin 1g IV over 1 hour, prior to skin incision. When possible this
should be given on the ward prior to surgery.
|| gentamicin 120mg IV, prior to skin incision

Busciis aceati
seriatur?Pa(eg
omnit lautand
Vancomycin autate
cranioplasties)
sedioreped
Wessexshould
gentamicin Neurobe ICU Guidelines
considered in con es magnam
all high in porrovit,
risk procedures

odit hillorest,
erorerum repe
nusdand antibusape
Neurosurgical
conseque
continued
consultants
nos further
for two
nonsequ
et debitatia
assequithat
may request
dosesidessum
doluptatur?
est doluptur,
post-operatively
Qui in eum
the prophylactic
or inest
highmin ped
risk
aut autbe
antibiotics
modfor
cases
ommolor
et two
resciunt,
days.

nosto erio. All
pro enecta nis
Wessex Neuroprocedures
CSF shunt
et quiasim
prophylactic
ICU Guidelines Verum
are very
enimos moluptate
antibiotics
high ipidunt
risk for volor adit In
infection. la addition
doluptasit
volo qui cus explam as accae dolo bersped que
outlined above:
to aut
the reiciet
|| Patients should be first on the operation list
|| All entrances to the operating theatre must be labelled with signs indi-
cating that a shunt insertion is in progress, and entry is restricted.
|| quos
veligen diant.et The procedure
ium, cus cone should
dembenemperformed
fugiatem. by Pudionsequia
two operators dis suntotate laborpor
re corrorporest
|| quos eumpersonnel
Theatre nobistibusandnismovement
evento temshouldet pratem. Ut rem eatenienis enimolup-
be minimised
tae. Uptatio|dolorem
| A CSF nus sinctem
sample mustfugit
be iditatiorum vit voluptafor
sent to microbiology porem quatusaC&S
microscopy, pedionsequis
|| All revision surgery should have intrathecal vancomycin (usually 20mg,
pre-prepared syringe) +/- gentamicin (usually 5mg of the intrathecal
preparation) givenvolorerum et omni od qui bearum is estrunt re volor rehent
at operation
Infection and sepsis

ni consenesThe
none optionwill
idendemodis
nat
vast majority
have
re of
quiaaspirated
cumqui at
voluptibus.Ero
the time
ullest
cuptium
patients admitted consequi
to Neuro
of deterioration
ligenihiciet accus.Quis
ICU doloreh
intubated
in conscious
sit, offictem
enimetu rionsed que
and ventilated
level.
quo conecto ditia-
turias prepedi|| taecerrovita vit pelitatia
This will cause conpneumonitis
aspiration perae voluptae doluptia nimi, venis nemquame
|| This may become infected over the following days
|| Antibiotics are not indicated unless the overall clinical assessment is of
lower respiratory tract infection, which should be suspected in a patient
est ad magnam with reresenient escius of:
a combination sequuntur sinullit assimporesse veliquam, omnihicit et
ad eum fugia volorpo Fever
reptur? Et lam venda non consediam aut es dolendipsum venis rerum a
quo testis maximus Rise in CRPque nonem es repereped ut ut dolupta sundit, ad qui cullenim
aecabore,
volor alis susdandis Purulent
moluptam everis pratate iliquas rem que nos endicitin est ipieneculpa sus
sputum
70
Chapter
ribusandiste molora
Abnormal
aut omnis signs a on
vit, respiratory
Wessex Neuro examination of spontaneously
ICU Guidelines consecate breath-
consect
ing patients.
Increased respiratory
utem quosamsupport reriberroto achieve
od molende the target oxygenation
Chesteosam
autatatque parchilitat.Ut x-ray suscias
changesaut qui volorum
suggestive quam hari odis et porersp ellaut la
of consolidation
num et endia|vendi|
ipsandem
Lower apidell
respiratory endesec
tract infectionulloribus
occurring deribus
in thedifirst
ipsam
4 daysharitofquibus,
admis- cori-
busaniae repreperum sion derovit, sitatium
is likely to respond nosam sinisci liquiat
to antibiotics eaquias iminulpa
for community acquired isinfection
asitatia int.
Busciis aceati omnit eg laut
co-amoxiclav,
autate Wessex chloramphenicol, or cefuroxime
Neuro ICU Guidelines con es magnam in porrovit,
seriatur?Pa sedioreped quosa consequas acepeofconest
rash toutpenicillin
am, quoshoulddis enia vitae. Perovit
Patients who have a history receive
odit hillorest, nusdand cefuroxime
antibusape +/-nonsequ
metronidazoleassequiinstead of co-amoxiclav.
doluptatur? Qui in eumPatients who
aut aut ommolor
have a history of anaphylaxis to penicillin should
erorerum repe conseque nos et debitatia idessum est doluptur, est min ped mod et resciunt, be discussed with
the microbiologist.
||
nosto erio. Wessex Thereafter,
Neuro ICU pneumonia
Guidelines should
Verum be ipidunt
treatedvolor
with antibiotics for hospital
acquired (eg ventilator associated) pneumonia, e.g. tazocin 4.5g IV tds
(provided patient is not penicillin allergic) +/- single dose gentamicin IV
velese ma inctota5mg/kg.quidunt Other
acest,options
idenihicti im cus
include a dolesto or
meropenem eatas aut pel is dolesci
the combination of vanco-tibus.
Nosam verferf erferspitmycinqueandvoluptatius
ciprofloxacin. rerum remshould
These ut omni beutdiscussed
aut res iswith
aut lam qui nempore
the Neuro ICU
num harciis rest offic consultant
tem autbefore commencement.
tium entis nima sit que eostiis citam, eumet voluptasit posandu ntioreritem
in septic quam ad ma de
Vancomycin should be started at higher doses patients.
veligen diant.et quosInium, a patient
cus conewithdem normalnemrenal function,
fugiatem. a good urine
Pudionsequia disoutput and laborpor
suntotate
re corrorporest quos MAP>65mmHg,
eum nobistibus nis vancomycin
evento tem should be initially
et pratem. prescribed
Ut rem eatenienis at 1.5g iv
enimolup-
tds.
dolorumquunt as dit mo
Target
cor vancomycin troughbeatquo
sa porro et volupti level of cus.Liqui
15-20, taken aftermolor
dolupid 3rd dose.
sit vellis debis
Further levels are only required if dose changed or renal function
deteriorates.
Any patient who is treated with ciprofloxacin should have IV
preparation changed to oral/ng as soon as they are absorbing. If
ciprofloxacin is given NG in a iaerupienis dolorehent
patient receiving enterallis feed,
eos doles volorib
the dose
usant. Quia non con should nullaut beveratemo
increased temtoaut modipis
750mg NG cimint quia stopping
bd without nonsequis aut etfeed.
enteral Wessex
Neuro ICU Guidelines (The proportion
dolupta tureped of drug absorbediunt,
ullorepudam is reduced by binding to
nulparciur?Perio. Utdivalent
de vendam,
cations in enteral feed. Avoid giving ferrous fumarate near time of
ciprofloxacin administration.)
Any patient
turias prepedi taecerrovita treatedcon
vit pelitatia withperae
rifampacin
voluptaeshould be given
doluptia nimi,thevenis
PO/NG nemquame
preparation provided they are absorbing feed. Rifampacin has 100%
volo iur?Volorent ut oral ut que et mi, quas sin cum quidellandel incto quassit faccatur maximi,
bioavailability.
|| Antibiotic treatment should be guided by microbiolobical results and
sensitivities. This will usually involve discussion on a microbiological
ward round.escius sequuntur sinullit assimporesse veliquam, omnihicit et

All patients that develop a fever must be considered to have an infection and
undergo a septic screen, which includes:
||
volor alis susdandis Chest x-ray everis pratate iliquas rem que nos endicitin est ipieneculpa sus
moluptam
mi, nime voluptas
|| Sputum sampletureped
simus. dolupta or endotracheal
ullorepudam aspirate
iunt, for culture and sensitivity
nulparciur?Perio
71
Wessex
solo NeuroNusda
explautem | eum| Urine
re cordipstick
aut omnis followed
a vit,by M,C&S.Neuro
Wessex State ICU
fever or septic consecate
Guidelines screen on consect
the
request form to ensure the sample is processed.
ntibusande |natet| Blood cultures:
atistibus, utem both peripheral
quosam and via
reriberro odany lines present
molende natemosame e.g. central/
nonet odis
arterial/long lines, which should be labelled as line samples appropri-
ately (central/arterial/long line sample)
|| CSF sample from an external ventricular drain or ventriculoperitoneal
shunt or consideration for a lumbar puncture
| Swab from
seriatur?Pa|sedioreped quosaanyconsequas
wound or vascular accessutsite
acepe conest am, that
quo looks
dis clinically
enia vitae. Perovit
infected

erorerum repe Central/long/arterial
qui doloratatas
conseque nos etcatheters
of time on Neuro
volupta seriam ICU. All such
solorest
are not routinely
debitatia idessum
catheters
voluptatis should
modit
replaced
est doluptur, est min
be removed
explatur?
afterped
Iqui blam
anymod
as soon
set length
et resciunt,
as they
faceprovit eaqui
are no longer required. (However, femoral vascular access catheters must be
nosto erio. removed
Wessex Neuro within 48 ICUhoursGuidelines Verum ipidunt volor adit la doluptasit aut reiciet
of insertion)

velese ma Femoral coolingacest,
inctota quidunt lines may need to
idenihicti im be
cus kept in situ for
a dolesto many
eatas
raised ICP in traumatic brain injury. Consequently, the vascular access ports
autdayspel tois control
dolesci tibus.
on the cooling line should be flushed on insertion, then capped off and not
num harciisused rest except
offic tem foraut verroviti
taking specificopta doluptam,
blood culturesquibus
from the di volut
line (as quipart
nonofreicil eosan-
a septic
screen)
tium entis nima or foreostiis
sit que emergency
citam, resuscitation.
eumet voluptasit posandu ntioreritem quam ad ma de

New onset of sepsis, particularly if associated with a requirement for a vaso-
re corrorporest quosoreum
pressor nobistibus
increase in the nis evento
dose, musttem et pratem.
be treated as aUtmedical
rem eatenienis
emergency: enimolup-
|| A full septic screen must be performed immediately
ratur, omnihit The Neuro
|| incidus ea Wessex ICU consultant
Neuro ICUmust be informed
Guidelines immediately
quatem aspedit|| atatem consedia
Appropriate broad volorerum
spectrumetantibiotics
omni od qui must bearum
be given is estrunt
within one re volor
hourrehent
of
diagnosis, e.g. tazocin 4.5g IV tds and gentamicin
expelleces mi, sam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as IV 5mg/kg
In anyposandi
patient withgnimus.Laborer
normal renaliaerupienis dolorehent can
function, gentamicin lis eosbe doles
given volorib
at
usant. Quia non cona nullautdose ofveratemo
5mg/kg daily tem without delaying
aut modipis cimintadministration
quia nonsequis by waiting for
aut et Wessex
levels. In many patients with normal renal function
Neuro ICU Guidelines dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam, it may be consid-
ered unnecessary to perform levels.
none option nat quia Anycumqui
vascular access
ullest device that
ligenihiciet is considered
accus.Quis to be the
sit, offictem most
quo likely ditia-
conecto
source of infection must be removed within one hour
||
volo iur?Volorent Where possible,
ut ut que et mi,no newsin
quas vascular access device
cum quidellandel inctoshould
quassit be faccatur
inserted maximi,
until after infusion of the antimicrobials (eg antibiotics or antifungals) to
minimise the risk of colonisation of the new catheter. This is particularly
comnimusam resimportantque lab inis if a coreperum
fungal infectiondi blaisaut ut veria dignima gnihicimus suntiae ditiis
suspected.
72
Chapter
ribusandiste molora
Ventriculitis
explautem eum re cor&aut cerebral
omnis a vit, abscess

Whilst meningitis will usually be associated with a significant elevation
of CRP and eosam peripheralsuscias
WBCaut qui the
count, volorum quam hari
development odisintracerebral
of an et porersp ellaut la
num et endiaabscess or ventriculitis
vendi ipsandem apidellwillendesec
frequently not be deribus
ulloribus associated with either
di ipsam harit of these.cori-
quibus,

Busciis aceati
Fever, deterioration in conscious level or neurology, or unexplained tachycar-
dia,omnit laut autate
particularly Wessex
in the presence Neuroof anICU Guidelines
external con es
ventricular magnam
drain (EVD),inmustporrovit,
always prompt: quosa consequas acepe conest ut am, quo dis enia vitae. Perovit
| antibusape
Examination nonsequ
of the patientassequi
for signsdoluptatur?
of meningism Qui egin eum
neckaut aut ommolor
stiffness
|| Immediate sending of a CSF sample for microscopy, culture and
sensitivity
|| Consider using antibiotics at doses appropriate for CNS infection if the
CSF WBC count is significantly increased from previous values (usually
velese ma inctotawith quidunt acest, idenihicti
predominance im cus ae.g.
of neutrophils) dolesto eatas aut
cefotaxime 2g IV pel4 hourly
is dolesci tibus.
num harciis rest offic Meropenem 2g IV 8 hourly (CNS dose), is reserved as 2nd line anti-
biotic managementopta
tem aut verroviti of CNS doluptam,
infection.quibus di volut
It should onlyqui non reicil
be started eosan-
after
tium entis nima sit que eostiis citam,
discussion with the eumet
duty voluptasit posandu ntioreritem quam ad ma de
microbiologist.
|| Informing the neurosurgical team of the deterioration and potential pres-
re corrorporest quos enceeum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
of ventriculitis

Significant positive CSF cultures must always be treated immediately with
CNS dose IV antibiotics and may also require intrathecal antibiotics to be
ratur, omnihitinstilled
incidusdaily
ea Wessex Neuroaccording
via the EVD, ICU Guidelines qui quaerovadvice
to microbiological itendae volor aligenime

If CSF gram stain microscopy is +ve for organisms, repeat CSF sample
should be sent to check the result before starting antimicrobials. If patient
appears posandi
seriously gnimus.Laborer
unwell, iaerupienis
start antimicrobials dolorehent
immediately lis eos
after doles
taking thatvolorib
usant. Quia non sample.con nullaut
Consider veratemo
instillingtem aut modipis(usually
IT vancomycin cimint quia20mg nonsequis aut et Wessex
from an aseptically
pre-prepared
Neuro ICU Guidelines syringe
dolupta for gram
tureped +ve cocci) iunt,
ullorepudam or gentamicin (usually 5mg
nulparciur?Perio. Ut deofvendam,
intrathecal preparation for gram -ve rods) at that time.

none option Ifnat
turias prepedi
thequia
CSFcumqui
consideration
or EVD ullest
taecerrovitamust
ligenihiciet
continues
be given,
vit pelitatia con in perae
accus.Quis
to be infected
conjunction
despite
voluptae
sit,antibiotic
offictem treatment,
withdoluptia
the microbiologist
quo conecto
nimi, venisand
then
neu-
nemquame
ditia-
rosurgical team, to the removal of the EVD and its replacement via a new
access site or management of communicating hydrocephalus by serial lum-
quunturio ium barharuptatiis
puncturesandem di quidem nulparchit velecte eos et quid ent vollaccuptae

est ad magnam If thereresenient
patient is EVDesciusdependent
sequuntur andsinullit
will require a VP shunt
assimporesse insertion:omnihicit et
veliquam,
fugit officiatis|iur, Appropriate
| sam, antibiotics
ut quaeperrovid must be continued
ulparcitaqui odit essint until
autCSFadisshows no organ-
isms on microscopy nor growth on culture for
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a>48 hours
quo testis maximus
|| aecabore, queadvice
Microbiological nonem es repereped
should be sought uttoutagree
dolupta sundit, prophylaxis
antibiotic ad qui cullenim
volor alis susdandis formoluptam
insertion of the VP
everis shunt
73
Wessex
solo NeuroNusda
explautem | eum| CSF
re corshould be sent
aut omnis for aWessex
a vit, protein Neuro
level asICU wellGuidelines
as for microscopy
consecate to help
consect
determine the timing of any VP shunt insertion.
Requesting
autatatque microbiological
parchilitat.Ut eosam suscias advice
aut qui volorum quam hari odis et porersp ellaut la

num et endia Thesevendi ipsandemshould
guidelines
infection control
busaniae repreperum
apidell
andsitatium
derovit,
beendesec
treatment
ulloribus deribus
used in conjunction di ipsam
with Trust harit quibus,
guidelines
nosam sinisci liquiat eaquias iminulpa is asitatia int.
on cori-

Busciis aceatiMost
seriatur?Paably
omnit laut autate decisions
microbiological
sedioreped
as part ofquosa
Wessex Neuro
consequas acepe
the microbiological
shouldICU be Guidelines
wardconest
taken duringcon es magnam
daylight in porrovit,
hours, prefer-
round. ut am, quo dis enia vitae. Perovit

Plans should be made for appropriate antimicrobial treatment in case of
patient deterioration

nosto erio. IfWessex
a patient deteriorates
Neuro
must be informed.
out of hours
ICU Guidelines Verum withipidunt
sepsis,volor
the Neuro
adit laICU consultant

velese ma The
Nosam verferf
inctota
hours
quidunt
on-call
withoutque
erferspit
acest, microbiologist
consultant idenihicti im cus
firstvoluptatius
discussingrerum the patient
a dolesto
should
rem utwith
not beeatas
omni
calledaut
theutNeuro
aut res
for pel
ICU
is dolesci
advice
consultant.
is aut
out of tibus.
lam qui nempore
tiumHIV
entisTesting
nima sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de

HIV testing is indicated in any patient that has, or is suspected to have, the
re corrorporest quos conditions:
following eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
|| Cerebral toxoplasmosis
ratur, omnihit Cryptococcal
|| incidus ea Wessex meningitis
Neuro ICU Guidelines qui quaerov itendae volor aligenime
quatem aspedit|| atatem
Primaryconsedia
cerebral volorerum
lymphomaet omni od qui bearum is estrunt re volor rehent
expelleces mi,||
Leucoencephalopathy
|| Aseptic meningitis / encephalitis
Neuro ICU | | Cerebral
Guidelines abcess
| Other AIDS re defining
voluptibus.Ero cuptium
conditions consequi doloreh enimetu rionsed que
(eg pneumocystis)

In patients that have capacity to consent, a pre-test discussion to estab-
lish informed consent is recommended. Written consent is unnecessary, as
volo iur?Volorent
is lengthyut utpretest
que etcounselling.
mi, quas sin cum
The quidellandel
benefits incto
of testing quassit
to the faccatur
individual, themaximi,
quunturio ium reason that theandem
haruptatiis test is recommended
di quidem nulparchitand details
velecteof eos
how etthequid
result
entwill be
vollaccuptae
comnimusam given, mustlab
res que beinis
discussed
coreperum with di
thebla
patient.
aut ut This
veriashould
dignimabegnihicimus
documented in theditiis
suntiae
patients notes.

fugit officiatis
In iur,
absence
sam, that
patients
of
ut quaeperrovid
any
are unconscious
valid advance
ulparcitaqui
or lack
statement,
odit essint aut
capacity
testing
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis
adis as commodi
to consent,
should be
in the ctisit ant,
performed where
rerum a
this is in the best interests of the patient. The result should be communicated
to the patient at an appropriate time if/when capacity has been regained.
Followingmoluptam
the deatheveris
of anypratate
patientiliquas
that has rembeen
que tested,
nos endicitin
onward estdisclosure
ipieneculpa to sus
mi, nime voluptas
others simus. dolupta
at risk may tureped ullorepudam iunt, nulparciur?Perio
be appropriate.
74
12
Seizure management
Patients with known epilepsy must continue all of their usual drugs at their prescribed
doses and times. Insert a NG tube if necessary for drugs that have no parenteral
preparation.
Diagnosing
pro enecta nis et quiasim seizures
enimos moluptate volo qui cus explam as accae dolo bersped que
Beware labelling all abnormal patient movement as seizures - All that twitches is
not epilepsy!
veligenDissociative
diant.et quosseizures
ium, cus(pseudoseizures) need to bePudionsequia
cone dem nem fugiatem. considered indis treatment resistant
suntotate laborpor
status.
dolorumquunt
Factors as dit mo
that cor sa porro
support et volupti beatquo
a diagnosis of seizurescus.Liqui dolupid molor sit vellis debis

Tonic clonic movements that are stereotypical of grand mal epilepsy and are
usually associated with:
rerspero ommo || loss of consciousness
ommolor posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non || con incontinence
nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex
|| tongue dolupta
biting tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
|| abnormal pupils
turias prepedi post ictal phase
|| taecerrovita vit pelitatia con perae voluptae doluptia nimi, venis nemquame

volo iur?Volorent
quunturio ium
Focalutseizures
ut que affecting
theharuptatiis
face. These
et mi, quas
andem
onesin
sidecum quidellandel
of the
di quidemtonulparchit
may progress
incto limb,
body, a single
generalised velecte
quassit
eos Focal
seizures.
faccatur to
or confined
et quidseizures
maximi,
ent vollaccuptae
cause
comnimusammotor, res que sensory or coreperum
lab inis alterations di
of bla
levelautof ut
consciousness
veria dignimawith automations

Supratentorial
fugit officiatisalitis,
iur, sam,
escius sequuntur
pathological
ut quaeperrovid
haematoma, contusion
processsinullit
ulparcitaqui
assimporesse
of the brain
or depressed odit essint
eg tumour, veliquam,
infection,omnihicit
enceph- et
aut adis as commodi ctisit ant,
skull fracture.

Recent neurosurgery above the tentorium cerebelli
EEG confirmation
volor alis susdandis of previous
moluptam everis seizures
75
Wessex
solo NeuroNusda

explautem Previous
eum re cor history of epilepsy
Factorsnatet
ntibusande thatatistibus,
make a utem diagnosis
quosamofreriberro
seizures od unlikely

autatatque Atypical
parchilitat.Ut eosam that
movements suscias
do notautfollow
qui volorum
any of thequam hari patterns
normal odis et porersp
ellaut la
of epilepsy.
|| Opisthotonous: Generalised extension of the body with arching of the
back. This may occur during a hydrocephalic attack.
|| Parkinsonian tremor may occur as a result of the side-effects of
anti-psychotics (NB these may be given for other actions eg as
antiemetics nonsequ assequi
metoclopramide, doluptatur? Qui
prochlorperazine), in eum aut
particularly aut ommolor
in young
patients. nos et debitatia idessum est doluptur, est min ped mod et resciunt,
qui doloratatas
||
volupta
Rigors:seriam
These solorest voluptatis
will usually modit explatur?
be associated with severeIquiinfection
blam faceprovit eaqui
|| Acute withdrawal of opioid or sedative agents, particularly in patients
that were previously dependent, and had developed tolerance to them
|| Tremor resulting from anxiety in the awake patient

num harciisPosterior
rest officfossa
because
tium entis nima
tem aut
anyeostiis
sit que abnormal
verroviti
disease
citam,
and opta
surgery
electrical
doluptam,
eumet activity
voluptasitwould
quibus di
is very unlikely to volut
be unable
posandu
causequi non reicil eosan-
seizures
to generalise
ntioreritem quam ad ma de
Any significant nis evento
neurological tem et pratem.
deterioration Ut rem eatenienis
(eg reduction enimolup-
in GCS) after
tae. Uptatio doloremposterior
nus fossa
sinctemsurgery or in a patient
fugit iditatiorum with significant
vit volupta porem pathology of the
quatusa pedionsequis
posterior fossa, MUST be assumed to be from hydrocephalus
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis and
NOT from seizures. The patient should be given hyperosmolar therapy
(mannitol Neurosaline)
/ hypertonic ICU Guidelines
and takenqui forquaerov itendaeCT
an emergency volor aligenime
scan.
This may consedia
indicatevolorerum
requirement et omni od qui
for EVD bearum
insertion +/-isposterior
estrunt re volor rehent
fossa
expelleces mi, sam decompression.
reriandic tenecus Failure to identify
Wessex Neuro a ICU
hydrocephalic
Guidelinescrisis may resultproris
aut voloreperit in as
the patient coning.
Management of generalised seizures
turias 1
prepedi taecerrovita
Assessment vit pelitatia con perae voluptae doluptia nimi, venis nemquame
of patient
A Airway : ensure that airway is clear and maintained
B Breathing: Ensure adequate oxygenation and ventilation. Monitor SpO2
and capnography where possible. Consider arterial blood gas.
C iur,Circulation:
fugit officiatis Monitor heart
sam, ut quaeperrovid rate & blood
ulparcitaqui pressure.
odit essint Treat
aut adis ashypotension
commodi ctisitor ant,
arrhythmia as indicated. Ensure adequate IV access.
D Disability:
quo testis maximus aecabore, Monitor neurology
que nonem and pupils.ut ut dolupta sundit, ad qui cullenim
es repereped
76
Chapter
solo 12 Nusda nonsequo temolec erovitatenis doles eatiore
est, exeriae. Seizure management
ribusandiste molora
explautem eum E reMeasure
cor aut blood
omnis glucose, and treat
a vit, Wessex Neuro hypoglycaemia
ICU Guidelines withconsecate
50% glucose consect
IV (usually 20-50ml depending on severity of hypoglycaemia). If this
emoluptae veribusmay ambe rem quid eatur
associated assimillat.Wessex
with alcohol abuse orNeuro ICU Guidelines
malnutrition, pabrinex 1Tis dolupti
pair IV
ntibusande natet must atistibus, utemat quosam
be given the samereriberro
time. od molende natemosame nonet odis
2 Ensure
num et endiaensure
the patient is safe from harming themselves (eg where possible
vendi aipsandem apidell endesec
clear space around them).ulloribus deribus di ipsam harit quibus, cori-
Busciis3 aceatiObserve
omnit laut for up to 5 Wessex
autate minutes in caseICU
Neuro the seizure
Guidelinesself con
terminates
es magnam (>90%in porrovit,
self-terminate in 5min)
4 Ifnusdand
odit hillorest, seizure continues
antibusape>5minutes without clear
nonsequ assequi signs ofQui
doluptatur? selfintermination:
eum aut aut ommolor
erorerum repe a conseque
Administer nos aetbenzodiazepine:
debitatia idessum est doluptur, est min ped mod et resciunt,
Lorazepam titrated 0.5 mg IV every minute, against response, up to a
ICUofGuidelines Verum ipidunt volor adit la doluptasit aut reiciet
maximum 0.1mg/kg in the first 10 minutes
Alternatively diazemuls 1mg every minute against response, up to
20mg, or midazolam 0.5mg every minute against response up to a
Nosam verferf erferspit que voluptatius
maximum of 10mg rerum rem ut omni ut aut res is aut lam qui nempore
tium entis nima sit queIn patients without IV access diazepam may be given rectally in a
eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de
dose of 10-20mg or midazolam 10mg buccally or IM
b Administer phenytoin, unless already in therapeutic range
tae. Uptatio dolorem Innus a patient
sinctem notfugit
already receiving
iditatiorum vit regular
voluptaphenytoin,
porem quatusa a loading dose of
pedionsequis
20mg/kg diluted in 0.9% saline to produce a solution with a maximum
concentration of 10mg/ml should be infused over 1 hour (Phenytoin
ratur, omnihit incidus20mg/kg
ea Wessex Neuro to
IV diluted ICU Guidelines
250mls with 0.9%qui quaerov itendaeover
saline infused volor aligenime
1 hour).
quatem aspedit atatem Give consedia volorerum
via a dedicated IV et omni od
cannula qui
that bearum
has is estrunt
been flushed re 0.9%
with volor rehent
saline to avoid chemical interaction with
expelleces mi, sam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit any other drug. This should
proris as
be followed by a phenytoin level 2 hours following the infusion to
ensure that a therapeutic level has been achieved (corrected pheny-
usant. Quia non con toin nullaut
levelveratemo
10-20mg/l).tem aut modipis cimint quia nonsequis aut et Wessex
pH of parenteral phenytoin = 10-12.3
Avoid extravasation and IM administration because of risk of severe
none option nat quia tissuecumqui
damage. ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
IV preparation vit pelitatia con as
is supplied perae voluptae
50mg/ml doluptia
in 5ml ampoules,nimi, i.e.
venis nemquame
250mg in
volo iur?Volorent each ut ut 5ml
que ampoule.
Phenytoin should be administered IV as an infusion over 1 hour.
comnimusam res Rapid que labIVinis coreperum
infusion di bla aut
of phenytoin may utcause
veria dignima gnihicimus suntiae
severe hypotension and ditiis
cardiac arrhythmias.
IV use is contraindicated in patients with sinus bradycardia, SA block,
second or third degree AV block, Stokes-Adams syndrome.
volor alis susdandis In moluptam
obese patients everisideal
pratate
body iliquas
weight rem que nos
should endicitin
be used est ipieneculpa sus
for dosing.
77
Wessex
solo NeuroNusda
explautem eum re Incora aut
patient
omnis whoaisvit,onWessex
regular phenytoin,
Neuro ICUwhich is known
Guidelines to be
consecate consect
sub-therapeutic, a further loading dose of 1g over 1 hour should be
emoluptae veribus given am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
The loading dose of phenytoin as prophylaxis in neurosurgery or
num et endia vendi severeipsandem
traumatic apidell
brainendesec
injury is ulloribus deribus di1gipsam
usually phenytoin harit to
IV diluted quibus, cori-
busaniae repreperum 100mls derovit,
with 0.9%sitatium
Saline nosam
infusedsinisci
overliquiat
1 hour.eaquias iminulpa is asitatia int.
In aantibusape
patient who is known to have phenytoin at a therapeutic level,
they should be nonsequloaded with assequi
eitherdoluptatur?
levetiracetam Qui(load
in eumwithaut1gautIV, ommolor
fol-
erorerum repe conseque lowed nos et debitatia
by 500mg bd) oridessum est doluptur,
phenobarbitone (loadestwithmin ped mod etatresciunt,
10-15mg/kg rate
qui doloratatas volupta of 100mg/min)
seriam solorestor sodium valproate
voluptatis modit(load with 1g,
explatur? Iquifollowed by 500mg
bd.)
The maintenance
enimos moluptate dose for adults
volo is usually
qui cus explam Phenytoin
as accae300mg IV
dolo bersped que
or NG OD. Phenytoin should only be administered
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus. enterally when
patient has excellent absorption (eg NG aspirates <100ml per 4
Nosam verferf erferspit hours que
withvoluptatius
no discards rerum rem
for 24 ut omni
hours) andutcan
auttolerate
res is aut thelam qui nempore
increased
num harciis rest offic ratetem aut verroviti
of feeding opta doluptam,
necessary to allow forquibus di volut
the period qui non reicil eosan-
of fasting.
Stop
enteral feed for 2 hours before and after administration of
enteralcus
ium, cone dem
phenytoin. nemfeed
Where fugiatem. Pudionsequia
is stopped for phenytoin dis suntotate
administra- laborpor
re corrorporest quos tion,
eum ornobistibus
any procedure, the rate
nis evento temover the remainder
et pratem. Ut remof the 24 hour
eatenienis enimolup-
period should be augmented to ensure full feeding.
dolorumquunt asPhenobarbitone
dit mo cor sa porro canetbevolupti
givenbeatquo cus.Liqui
most rapidly, and dolupid
may avert molor
the sitneedvellis
fordebis
intubation.
ratur, omnihit incidus Levetiracetam
ea Wessex Neuro ICU & sodium
Guidelines valproate requireitendae
qui quaerov a longer loading
volor aligenime
quatem aspedit atatemtime, and will normally
consedia be given
volorerum following
et omni od quiintubation.
bearum isThere estrunt is re
greater
volor rehent
evidence supporting the use of sodium valproate in the treatment of
status, but it may interfere with platelet function, and should not given
rerspero ommo ommolor posandi patients.
to neurosurgical gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
5 A idendemodis
patient that remains in status epilepticus despite a benzodiazepine and
ni consenesphenytoin re voluptibus.Ero cuptiumanaesthesia
consequi doloreh
loading, should have general inducedenimetu
by an anaes-rionsed que
none optionthetist
/ intensivist.
turias prepedia taecerrovita
Induction ofvitanaesthesia:
This should
be with thiopentone 3-5mg/kg
andem di quidem nulparchit velecte eos et quid ent vollaccuptae
comnimusam res que Alternatively a combination
lab inis coreperum di blaof autpropofol
ut veriaand midazolam
dignima may be
gnihicimus used ditiis
suntiae
est ad magnam reresenient escius
b Maintenance sequuntur
of sedation sinullit control
and seizure assimporesse
should be veliquam, omnihicit et
with an infusion
fugit officiatis iur,of propofol
sam, initially. If not
ut quaeperrovid adequately
ulparcitaqui controlled
odit essint aut with
adispropofol
as commodi4mg/kg/hrctisit ant,
then add in midazolam infusion
c Consider
quo testis maximus aecabore, que nonem
emergency es repereped
CT Brain scan in allutpatients
ut dolupta withsundit,
new onsetad quisei-cullenim
zures, particularly post-operative patients
78
Chapter
ribusandiste molora
explautem eum d reIf cor
the patient
aut omnisis not already
a vit, Wessexon Neuro
NeuroICU,ICUthey should be
Guidelines transferred
consecate consect
there, preferably after their CT scan
6 natet
ntibusande Upon atistibus,
transfer toutemNeuroquosam
ICU, inform the neurologist
reriberro od molende or neurosurgeon
natemosame respon-nonet odis
sible for the patient of their admission and any new
autatatque parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp abnormality seen onellaut
CT. la
Perform the following investigations:
a Standard
busaniae repreperum admission
derovit, sitatiumblood
nosam tests
Busciis aceati b omnit laut autate
Consider LP orWessex
obtaining Neuro
CSF ICUfromGuidelines
EVD/VP shunt con ifespresent
magnam in porrovit,
c Consider quosa
use consequas
of Cerebral acepe
Function conest ut am,
Monitor (CFM)quoordis
BISenia vitae.set
monitor Perovit
to
odit hillorest, nusdandshowantibusape
raw EEG nonsequ assequi doluptatur? Qui in eum aut aut ommolor
d Perform a formal EEG during daylight hours to confirm that no seizure
qui doloratatas voluptaactivity seriam solorest
is present. Thisvoluptatis
initial EEG modit explatur?
should Iqui blam
be performed faceprovit
prior to reduc- eaqui
nosto erio. Wessex ingNeuro
sedation.
ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
7 Where a CNS infection is suspected as the cause for the seizures, then
appropriate acest, idenihicti
antimicrobial agentsimshould
cus abe dolesto eatas
started. aut pel is dolesci
(eg cefotaxime 2g IV tibus.
4hrly, que 10mg/kg
acyclovir voluptatiusIV rerum
8hrly) rem ut omni ut aut res is aut lam qui nempore
8 Commence a fit chart, recording all episodes of seizure activity
veligen9 Further
diant.et quosanti-epileptic
ium, cus cone drugs
demandnemdoses should
fugiatem. be guided bydis
Pudionsequia a neurologist.
suntotate laborpor
10 In general:
a Continue regular phenytoin (eg 300mg nocte IV/NG/PO) and perform
daily phenytoin levels, which should be corrected for albumin level (g/l)
quatem aspedit atatem consedia correctedvolorerum
phenytoin et =omni od qui bearum
measured is estrunt
phenytoin level re volor rehent
expelleces mi, sam reriandic tenecus Wessex Neuro(0.02 ICU Guidelines
x albumin)aut voloreperit proris as
+ 0.1
usant. Quia non b con Sedation
nullautshould
veratemobe continued withoutcimint
tem aut modipis neuromuscular blockade
quia nonsequis aut to
et Wessex
assess for ongoing seizure activity. A formal EEG should be gained as
Neuro ICU Guidelines soon as dolupta tureped
possible ullorepudam
to confirm abolitioniunt, nulparciur?Perio.
of seizure activity. Ut de vendam,
c If seizures continuing, abolish with adequate sedation and add in an
additional agent. Options include:
volo iur?Volorent
Levetiracetam, load with 1g IV followed by 500mg IV bd. (Preferred
agent for neurosurgical patients)
comnimusam res que Sodium
lab inisvalproate,
coreperum load withaut
di bla 1g,utfollowed by 500mg
veria dignima bd. (Preferred
agent for neurological patients. Should not to be given to neurosurgi-
est ad magnam reresenient cal patientsescius sequuntur
because sinullitwith
it interferes assimporesse veliquam, omnihicit et
platelet function.)
ad eum fugia volorpo Phenobarbitone, load with10-15mg/kg at rate of 100mg/min.
79
Wessex
solo NeuroNusda
explautem eum re Lamotrigine
cor aut omnis starting
a vit, atWessex
25mg NG Neurood may
ICU be used in patients
Guidelines that consect
consecate
develop seizures from cerebral tumours. It is usually started at a low
emoluptae veribus dose, am rem andquid eatur
titrated assimillat.Wessex
slowly up over weeks,Neuro so mayICUnotGuidelines Tis dolupti
be appropriate
for the rapidutem quosam
control of newreriberro od molende
onset seizures natemosame
on Neuro ICU. nonet odis
d If any evidence of ongoing seizure activity despite propofol infusion at
4mg/kg/hr, addapidell endesec ulloribus
in a midazolam infusion. deribus di ipsam harit quibus, cori-
e Consideration of establishing thiopentone coma should occur once:
Statusquosa
seriatur?Pa sedioreped epilepticus has been
consequas acepe confirmed
conest ut onam,
formal
quoEEGdis enia vitae. Perovit
There
odit hillorest, nusdand is concern
antibusape of ongoing
nonsequ seizure
assequi activity despite
doluptatur? propofol
Qui in eum & mida-
aut aut ommolor
zolam infuson
Phenytoin
qui doloratatas volupta seriamissolorest voluptatislevel
at a therapeutic modit explatur? Iqui blam faceprovit eaqui
nosto erio. WessexAnother Neuro ICU Guidelines Verum ipidunt volor adit la(egdoluptasit aut reiciet

anti-epileptic drug has been commenced levetiracetam,
sodiumenimos
valproate moluptate volo qui cus explam as accae dolo bersped que
or phenobarbitone)
Investigation of new onset status epilepticus
veligen1 diant.et
CT scan
quoswithium,IVcuscontrast
cone demas soonnemas patient stabilised
re corrorporest
|| quos eum
If clear nobistibus
structural nis evento
abnormality egtem et pratem.
tumour Ut rem
/ abcess, eatenienis
discuss enimolup-
with neuro-
tae. Uptatio dolorem surgery nusandsinctem
agreefugit iditatiorumplan
management vit volupta porem quatusa pedionsequis
2 MRI scan if CT scan inconclusive
quatem 3 aspedit
If imaging
atatem is consedia
non-diagnostic:
expelleces mi,a sam reriandic
Perform lumbartenecus Wessex
puncture Neuro no
(provided ICU Guidelines aut voloreperit
contra-indication eg on imagingproris as
rerspero ommo ommolor/ coagulation
posandiscreen). Opening and
gnimus.Laborer closing pressure
iaerupienis dolorehentshould be doles
lis eos meas-volorib
ured. Samples should be collected separately for:
Neuro ICU Guidelines Microscopy,
dolupta tureped
culture &ullorepudam iunt, nulparciur?Perio. Ut de vendam,
sensitivites (M,C&S)
Cytology
Immunology
volo iur?Volorent utVirology
Proteinandem di quidem nulparchit velecte eos et quid ent vollaccuptae
est ad magnam
Glucose (fluoride bottle)
Sample for storage ulparcitaqui odit essint aut adis as commodi ctisit ant,
ut quaeperrovid
ad eum fugia b volorpo
Bloodreptur?
samples should
Et lam be taken
venda for:
non consediam aut es dolendipsum venis rerum a
quo testis maximusAmmonia aecabore,level que (alert
nonem labestechnician
reperepedand ut ut doluptaon sundit,
ice) ad qui cullenim
transport
mi, nime voluptas simus.
Vasculitis screen (eg ANCA, ESR, CRP)
dolupta tureped ullorepudam iunt, nulparciur?Perio
80
Chapter
ribusandiste molora
Auto-antibody
aut omnis ascreen (eg ANA,
vit, Wessex dsDNA,
Neuro ICU NMDA receptor
Guidelines antibodies)
consecate consect
c Urine
emoluptae veribus should
am rem beeatur
quid dipstick tested and sent Neuro
assimillat.Wessex for M,C&S
autatatque parchilitat.Utof
Management eosam
focalsuscias aut qui volorum quam hari odis et porersp ellaut la
seizures
BusciisAssessment
aceati omnitoflaut cause of seizures
autate Wessex Neuro ICU Guidelines con es magnam in porrovit,
1 Clinical assessment
seriatur?Pa sedioreped quosa consequas acepe conest
of patient looking for any ut am,
new quo dis enia
neurological vitae. Perovit
deficit
erorerum 2 repe Investigations:
conseque nos et debitatia idessum est doluptur, est min ped mod et resciunt,
qui doloratatas a volupta
Checkseriam
/ perform routine
solorest blood tests
nosto erio. Wessex
b CTNeuro ICU Guidelines
brain scan Verum ipidunt volor adit la doluptasit aut reiciet
with IV contrast
c Consider lumbar puncture or obtaining CSF from EVD / VP shunt
Nosam verferf d erferspit
Formal EEG
que during daylight
voluptatius hours
3 Discuss
num harciis rest offictreatment
tem aut verroviti optathe
options with doluptam,
patientsquibus di volut or
neurosurgeon quineurologist
non reicil eosan-
veligen4
Commence a fit chart, recording all episodes of seizure activity
81
13
Post-operative care
odit hillorest,
Patientsnusdand
may be antibusape
admitted to nonsequ
Neuro ICU assequi doluptatur?for:
post operatively Qui in eum aut aut ommolor

Premorbid medical conditions (eg obstructive sleep apnoea)

nosto erio. Neurosurgical
Wessex Neuroconsiderations
ICU Guidelines (egVerum
unstable neurology)
ipidunt volor adit la doluptasit aut reiciet

Requirement for continued ventilation

Nosam verferf Vasoactive
erferspitagent for blood pressure
que voluptatius rerum rem control
ut omni ut aut res is aut lam qui nempore

num harciisMajorrest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
haemorrhage
Admission process

ratur, omnihitRoutine
incidusadmission
ea Wessex procedure
Neuro ICU(seeGuidelines
earlier chapter)

quatem aspedit
expelleces mi,
Ensure
andsam
atatem consedia volorerum
post-operative
reriandic
followed
surgical andet omni od qui instructions
anaesthetic bearum is estrunt re volor rehent
are documented
including:
|| Antibiotics / steroids / anticonvulsants
Neuro ICU | | Wounddolupta
Guidelines drain management
| Timing of post operative CT cuptium
re voluptibus.Ero scan consequi doloreh enimetu rionsed que
none option||nat Timing quia cumqui ullest ligenihiciet
of administration accus.Quis
of low-molecular sit, offictem
weight heparin quo conecto ditia-
|| External ventricular / lumbar spinal drain management (eg EVD height /
volo iur?VolorentCSF ut utdraining
que et volume)
mi, quas sin cum quidellandel incto quassit faccatur maximi,
|| Haemodynamic & ventilator parameters

est ad magnam Patients
rosurgery.
fugit officiatis
will commonly
reresenient
iur, sam,These
esciushave
will generally
ut quaeperrovid
cannulae
sequuntur
have been
ulparcitaqui
placed
sinullit in the lower limbs
assimporesse
removed
odit in recovery.
essint aut
for neu-
veliquam, omnihicit et
However,
adis as commodi ctisit ant,
if cannulae are still present in the lower limbs on arrival to Neuro ICU, do
not remove them until adequate IV access has been achieved in the upper
quo testis maximus
limbs andaecabore,
the patient que nonem
is no longeres at
repereped
high risk ut
of ut doluptatosundit,
returning theatreadas
qui
ancullenim
emergency.
82
Chapter
est, exeriae. Post-operative
ribusandiste moloracare
Analgesia

All patients should have their pain controlled at all times.

num et endiaAllvendi patients
times.
must be
ipsandem able to
apidell have their
endesec GCS and
ulloribus neurology
deribus di ipsamassessed at all cori-
harit quibus,

Busciis aceati Noomnit
drug laut autate
should
from the sitequosa
seriatur?Pa sedioreped of surgery
Wessex Neuro
be prescribed
or the GI
consequas
that mayICUincrease
Guidelines
tract,conest
acepe
thecon
withoututagreement
risk es magnam in porrovit,
of haemorrhage
am, quo dis from their
enia vitae. Perovit
consultant.
Awake patients:

nosto erio. Wessex
Prescribe Neuro ICU Guidelines
paracetamol 1g PO/IV Verum
qds toipidunt volor unless
all patients adit la contra-indicated.

Prescribe
velese ma inctota morphine
quidunt acest,1mg IV PRN
idenihicti im(15 cusmins) to all patients
a dolesto eatas autunless
contra-indicated.

num harciis Prescribe
rest offic tema morphine infusion
aut verroviti opta03 mg/hr IVquibus
doluptam, if 1mg diboluses arenon
volut qui inadequate.
reicil eosan-

veligen diant.et
PCA morphine 1 mg / 5 min (prescribe as 2 mg/ml, 0.5 ml bolus, lockout 5
mins)quosmayium,
be cus cone dem
prescribed for nem
patientsfugiatem.
with GCSPudionsequia
15/15. Thedis suntotate
bolus dose may laborpor
re corrorporest need to be
quos eumincreased
nobistibus to 2nismgevento
in patients
tem etwith severe
pratem. Utpain.

dolorumquunt
NSAIDs should only be prescribed with agreement from the consultant sur-
as dit
geon andmoNeuro
cor saICUporro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
consultant

Patients with neuropathic pain may benet from novel opioids (e.g. oxyco-
done) and adjuncts e.g. amitriptyline 10mg PO/NG nocte and gabapentin
300mg PO/NG od tenecus
(300mg Wessex
on DayNeuro 1) ICU Guidelines aut voloreperit proris as

Avoid codeine and compound analgesic preparations.
Neuro ICU Guidelines dolupta
Tramadol lowerstureped ullorepudam
the seizure thresholdiunt, nulparciur?Perio.
(i.e. makes it more likelyUt deforvendam,
a
ni consenes idendemodis patient torefit)voluptibus.Ero
and should becuptium avoidedconsequi
in any patient post
doloreh craniotomy
enimetu or que
rionsed
who is at risk of seizures.
volo Sedated
iur?Volorent patients:

Prescribe andem di 1quidem
paracetamol g PO/IVnulparchit
qds to allvelecte
patientseos et quid
unless
ent vollaccuptae
contra-indicated.

est ad magnam Prescribe fentanyl
reresenient 50200
escius microgams/hr
sequuntur sinullitIV, in addition toveliquam,
assimporesse propofol. omnihicit et

fugit officiatisoriur, sam, ut quaeperrovid
Prescribe
ad eum fugiapropofol.
morphine infusion ulparcitaqui odit essint
120 mg/hr aut adis to
IV, in addition
volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a
asmidazolam
commodi ctisit or ant,
83
Wessex
solo NeuroNusda
Sedation
explautem eum re & cor
ventilation
aut omnis asettings
vit, Wessex Neuro ICU Guidelines consecate consect
Patients may be admitted to Neuro ICU for ventilation overnight, following a long or
otherwise complicated procedure.
Sedation

seriatur?PaUse sedioreped
propofol quosa
ventilation
odit hillorest,
consequas
24 mg/kg/hr
nusdand planned.
(1030 acepe
ml/hrconest
for an ut am, quo
average dis ifenia
adult)
vitae. Perovit
overnight

Midazolam
qui doloratatas
upnos
to 20etmg/hr
debitatia
in anidessum
average est doluptur,
adult estventilation
if longer min ped mod et resciunt,
anticipated.
Paralysis

Atracurium 0.5 mg/kg/hr if paralysis indicated (45 ml/hr in an average adult).
Check
tium entis nima sittrain
que of four, using
eostiis citam,aeumet
peripheral nerveposandu
voluptasit stimulator, aiming forquam
ntioreritem
1 twitch
ad ma de
Ventilationquos eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
re corrorporest
Initial settings :

PCV/VG

FiO2 0.5

rerspero ommo Tidalommolor
volume 7posandi
ml/kg gnimus.Laborer iaerupienis dolorehent lis eos doles volorib

usant. QuiaRatenon con
1218 nullaut
/min veratemo tem aut modipis cimint quia nonsequis aut et Wessex

ni consenesPEEP 510 cmre
idendemodis H2voluptibus.Ero
0 cuptium consequi doloreh enimetu rionsed que

none optionTargets
|| PaO2 > 12 kPa
quunturio ium || PaCO2 4.5-5.5
haruptatiis andem kPa
di quidem nulparchit velecte eos et quid ent vollaccuptae
comnimusam || respH que 7.357.45
lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
Patients who are post op transphenoidal pituitary surgery must not re-
fugit officiatis iur,ceive
sam, non-invasive
ut quaeperrovid ulparcitaqui
ventilation. Thisodit
will essint aut adis
force gas as commodi
intracranially ctisit ant,
though
ad eum fugia volorpo the surgical
reptur? approach
Et lam vendain the nasopharynx.
non consediam aut Anyessuch patient must
dolendipsum bererum a
venis
quo testis maximus considered
aecabore, forque
early intubation
nonem if failing toutoxygenate
es repereped ut dolupta or ventilate
sundit, ade-
ad qui cullenim
quately on a face mask. (Birding by the physio may also be possible.)
84
Chapter
est, exeriae. Post-operative care
ribusandiste molora
Haemodynamic
explautem eum re cor aut & haematological
omnis a vit, Wessex Neuro management
Initial targets:

num et endiaHeart vendirate 50100 apidell
ipsandem bpm endesec ulloribus deribus di ipsam harit quibus, cori-

busaniae repreperum
Mean arterial derovit,
blood sitatium
pressurenosam sinisci unless:
>60mmHg, liquiat eaquias iminulpa is asitatia int.
|| Alternative set by surgeon / anaesthetist
|
odit hillorest,|nusdand Cerebral perfusion
antibusape pressure
nonsequ targetdoluptatur?
assequi set (eg >60mmHg)
Qui in eum aut aut ommolor

Urine output nos
> 0.5etml/kg/hr
debitatiaonidessum
averageestoverdoluptur,
4 hoursest min ped mod et resciunt,

Hb 8g/dl
nosto erio. Wessex Neuro(unless
ICUchronically
Guidelinesanaemic)

pro enecta nis APTRet quiasim
& INR enimos
< 1.4 moluptate volo qui cus explam as accae dolo bersped que

velese ma inctota quidunt acest, idenihicti
Platelet count > 150 x109/ml
im cus a dolesto eatas aut pel is dolesci tibus.
tium Fluid administration
entis nima sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de

veligen diant.et
re corrorporest
Startquos ium,feeding
enteral
appropriate
cus cone as dem
soonnem fugiatem. Pudionsequia
as haemodynamically stabledis
andsuntotate
quos eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
laborpor
neurologically
Patients who are post op transphenoidal surgery must not have NG
dolorumquunt as dit mo inserted,
tubes cor sa porro et volupti
unless beatquo
they are placedcus.Liqui dolupid
under direct molor
vision sit vellis debis
endoscopi-
ratur, omnihit incidus cally.

expelleces mi,
Initial intravenous fluid should be 0.9% saline with 0.3% KCl at 125ml/hr
sam reriandic
(100ml/hr tenecus
in patients >70Wessex
years) Neuro ICU Guidelines aut voloreperit proris as
Hypotonic fluids (including hartmanns) must be avoided, to reduce risk
Neuro ICU Guidelines dolupta
of cerebral tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
oedema.

turias prepedi Further fluid according
taecerrovita
45 mmol/l).
volo iur?Volorent
to electrolyte
vit pelitatia con peraeresults (aimdoluptia
voluptae for Na 135145
nimi, venis
mmol/l, K
nemquame
Tranexamic
comnimusam acid
Patients with a history of alcohol abuse or antiplatelet agents that have received
tranexamic acid per-operatively should be considered for continuation at 1g tds for 4-7
days. NB this is contra-indicated in patients with subarachnoid haemorrhage.
85
14
Traumatic brain injury
oditIntroduction
hillorest, nusdand antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
nosto The
erio.initial
Wessexstabilization
Neuro ICUof patients should
Guidelines haveipidunt
Verum followed ATLS
volor guidelines
adit and patients
pro should
enectasatisfy the admission
nis et quiasim enimoscriteria for trauma
moluptate patients
volo qui (see above).
cus explam as accae dolo bersped que
veleseAllma inctotarequire
patients quiduntadequate
acest, idenihicti
imaging ofim their
cus spine
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Management
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1 Rapid assessment of patient including pupils and monitoring parameters
A Airway : COET tube type & length
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sinisci volume.
liquiat Bilateral
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absence of any acute spinal injury. Transfer patient onto Neuro ICU bed
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ni consenes c EtCO2 4.0-4.5
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Neuro ICU consultant.
6 Sedation
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b Appropriate analgesia according to injuries : fentanyl 50-200mcg/hr
7 nis
pro enecta Take etfull handover
quiasim enimos frommoluptate
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of injury
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c Initial and post resuscitation GCS scores, with breakdown of score
(Eyes, Voice & Motor). Pupils & lateralising signs.
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Neuro ICU j Guidelines
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of patient tureped ullorepudam
and relatives iunt, nulparciur?Perio. Ut de vendam,
if known.
8 Full
none optionitized.
examination of patient to ensure that all injuries are assessed and prior-
nat quia
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drugsGuidelines
to include:Verum ipidunt volor adit la doluptasit aut reiciet
a Gut protection (ranitidine 50mg IV tds initially, unless on a proton pump
velese ma inctotainhibitor
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di volut quibrain
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tium entis nima sitofque eostiis
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and Docusate
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head up. Initially this may odit essinthead
require aut adis asofcommodi
up tilt whole bed, ctisit ant,
ad eum fugia volorpo until reptur?
spinal management
Et lam vendaalgorithm
non consediamcomplete.aut es dolendipsum venis rerum a
quo testis maximus
|| aecabore,
Ensure head and que neck
nonem es repereped
position ut ut dolupta
and alignment. Flexion sundit,
of neck/ad qui cullenim
twisting
volor alis susdandis of head may compromise
moluptam everis pratate venous
iliquasdrainage
rem que via nosinternal
endicitinjugular veins,
est ipieneculpa sus
increasing ICP.
92
Chapter
ribusandiste molora
||
explautem eum reTube
cor ties should abevit,
aut omnis secure but not
Wessex constricting.
Neuro ICU Guidelines consecate consect
emoluptae veribus
|| Ensure
am rem cervical collar assimillat.Wessex
quid eatur is not so tight fittingNeuro
that itICU
raises ICP.

Adequate sedation with midazolam
|| High dose midazolam is the preferred sedative on Neuro ICU for
patients undergoing ICP control. Midazolam reduces cerebral metabolic
busaniae repreperum derovit,
rate and raisessitatium
seizure nosam sinisci liquiat eaquias iminulpa is asitatia int.
threshold.
When changing the sedation from propofol to midazolam, as part of
ICP control, the propofol must be continued for 1 hour after starting the
midazolam nonsequ
infusion. Stopping assequi doluptatur?
the propofol Qui in eum
immediately mayautresult
aut ommolor
in
erorerum repe conseque nos et debitatia idessum est doluptur, est
the patient becoming inadequately sedated, and their ICP increasing.min ped mod et resciunt,
|| For patients <60yrs
pro enecta nis et
Start at 20mg/hr (10ml/hr of double strength midazolam)
velese ma inctota quiduntEscalate as necessary
acest, idenihicti to imobtund response
cus a dolesto to interventions
Up queto a voluptatius
maximal dose rerum rem ut omni
of 120mg/hr ut aut res
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[4mg/ml]).
tium entis nima ||
sitFor
quepatients
eostiis 60yrs
citam, eumet voluptasit posandu ntioreritem quam ad ma de
re corrorporest quos Start at 10mg/hr
tae. Uptatio dolorem Ensure that dose
nus sinctem fugitdoes not escalate
iditatiorum excessively.
vit volupta porem quatusa pedionsequis

dolorumquunt as dit mo cor
Appropriate sa porrowith
analgesia et volupti
morphine beatquo cus.Liqui dolupid molor sit vellis debis
|| Morphine is the preferred intravenous analgesic on Neuro ICU and
quatem aspedit atatem shouldconsedia
be titrated volorerum
to injuries et and
omniresponse
od qui bearum is estrunt re volor rehent
to interventions.
|| For patients <60 years:
usant. Quia non con Start
nullautat veratemo
5mg/hr tem aut modipis cimint quia nonsequis aut et Wessex
Neuro ICU Guidelines doluptatotureped
10mg/hrullorepudam
if respondingiunt, nulparciur?Perio. Ut de vendam,
Escalate to interventions
none option nat quia Only escalate further ( up to a maximum of 25mg/hr) if injuries
cumqui ullest ligenihiciet accus.Quis sit, offictem
expected to cause severe pain (eg unstable rib/pelvicquo conecto ditia-
fractures)
|| For patients 60 years:
Start at
quunturio ium haruptatiis 2mg/hr
comnimusam res que lab inisthat
Ensure coreperum
dose does di not
bla escalate
aut ut veria dignima gnihicimus suntiae ditiis
excessively.

Maintain PaO213kPa
| | PaO
ad eum fugia volorpo reptur?2
is related
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to mean pressure aut
non consediam andes FiOdolendipsum
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|| aecabore,
Set que nonem
PEEP appropriate to es repereped
lung pathology ut(eg
ut dolupta
collapsesundit, ad qui cullenim
/ consolidation on
CXR) and body habitus.
93
Wessex
solo NeuroNusda
explautem eum re Eg
corstart with PEEP
aut omnis a vit,atWessex
5cm in patients
Neuro ICU with Guidelines
a BMI<30 and a normal
consecate consect
CXR
|
ntibusande |natet Increase
atistibus, PEEPutemincrementally
quosam reriberroensuring odICP is not affected
molende natemosame adversely
nonet to odis
a maximum of 15cmH2O. (Up to 20cmH2O in extreme cases)
num et endia || vendiSet ipsandem
FiO2 to achieve
apidellPaO 13kPa
endesec
2 ulloribus deribus di ipsam harit quibus, cori-
busaniae repreperum
|| derovit, sitatium
As oxygenation nosam
improves, sinisci
initially reduce liquiat
FiOeaquias
2
iminulpa
sequentially is asitatia int.
down
Busciis aceati omnit to 28%,
laut maintaining
autate Wessex PEEP.
NeuroOnlyICU reduce PEEP once
Guidelines con esFiOmagnam
2
<0.3 with in porrovit,
seriatur?Pa sediorepedPaO 2
>13kPa.
odit hillorest, Consider
||nusdand antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
erorerum repe conseque nos etof debitatia idessum estsalbutamol
doluptur, est min ped mod et resciunt,
Treatment bronchospasm with nebulisers
nosto erio. Wessex Fibreoptic bronchoscopy if segmental or lobar collapse
Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
pro enecta nis et quiasimDrainage of pneumothorax
enimos moluptate volo / haemothorax

velese ma Target
inctota PaCO
quidunt4.5-5.0kPa
2
|| PaCO2 is inversely related to minute ventilation (minute ventilation=tidal
num harciis rest volumeoffic tem aut verrovitirate)
x respiratory opta doluptam, quibus di volut qui non reicil eosan-
|| Set tidal volume appropriate to lung pathology (eg collapse / consolida-
tion on CXR) and body habitus.
tae. Uptatio dolorem Patients with lung pathology require lower tidal volumes to prevent
exacerbating lung injury. Aim for 6ml/kg
In ea
ratur, omnihit incidus patients
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no evidence of lung injury,
ICU Guidelines aim foritendae
qui quaerov 7-8ml/kg volor aligenime
quatem aspedit Set respiratory
|| atatem consediarate to control
volorerum et PaCO
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. Start at 12 breaths/minute
qui bearum is estrunt re volor(rangerehent
10-24 breaths/min)
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blood flow gnimus.Laborer
is usually halved iaerupienis
during the dolorehent lis eosofdoles volorib
first 24 hours
usant. Quia non traumatic
con nullaut brain injury (TBI).
veratemo tem aut Therefore,
modipis cimint patients whose
quia ICP remains
Neuro ICU Guidelines <15mmHg for the
dolupta first 24-48
tureped hours, may
ullorepudam iunt,benulparciur?Perio.
ventilated to normocapnia
Ut de vendam,
(PaCO2 5-6 kPa). This will maximise cerebral blood flow during this
critical period, minimise ventilator damage to injured lungs, and allow
none option nat moderate
quia cumqui ullest ligenihiciet
hyperventilation accus.Quis option
as a therapeutic sit, offictem
to help quo conecto
control ICP ditia-
if it should rise
turias prepedi taecerrovita >20mmHg
vit pelitatia conthereafter,
perae voluptae when hyperaemia
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quunturio ium
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|| 0.9% moluptam
saline iseveris
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fluidque nos endicitin est ipieneculpa sus
challenges
94
Chapter
ribusandiste molora
explautem eum ||
re0.9%
cor autsaline with a0.3%
omnis vit, KCl
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fluid ofICU choice for maintenance
Guidelines consecate (125ml/
consect
hr)
ntibusande natet|| 1.8% saline
atistibus, may quosam
utem be infused peripherally
reriberro up to 70ml/hr
|| 5% saline eosam maysuscias
only be aut qui volorum
infused centrallyquam harion
and only odis et porersp
Neuro ellaut la
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num et endia vendi antipsandem
instructionapidell endesec ulloribus deribus di ipsam harit quibus, cori-
Busciis aceati omnit lauthypotonic
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solutionsNeuro ICU Guidelines
(dextrose, con esand
dextrose saline magnam in porrovit,
hartmanns)
seriatur?Pa sedioreped which will quosaresult in worsening
consequas acepe cerebral
conestoedema.
ut am, quo dis enia vitae. Perovit
|| Changes in sodium should not occur faster than 1mmol every 2 hours
nosto erio. Wessex
|| These
Neuro patients may develop
ICU Guidelines Verumdiabetes
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volor aditwithlaresulting
doluptasitrapid
aut rise
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in sodium.
pro enecta nis et quiasim Regular
enimos checking
moluptate voloof qui
sodium on bloodasgases
cus explam accaeisdolo
essential,
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with stopping of hypertonic saline if rising too fast. These patients may
velese ma inctotarequire quiduntDDAVP acest, 0.5mcg
idenihictiIVim cus a dolesto eatas aut pel is dolesci tibus.
stat.

num harciis Target
rest officCPP tem of aut
60mmHg
tium entis nima || sitEvidence
que eostiis citam, that
suggests eumet voluptasit posandu
a CPP<60mmHg and /ntioreritem
or ICP>25mmHg quam ad is ma de
veligen diant.et quos associated
ium, cuswith conea worse
dem nem outcome in patients
fugiatem. with traumatic
Pudionsequia head injury
re corrorporest || quos eum nobistibus
In patients that are nis evento
globally tem et pratem.
autoregulating, Ut rem
modest eatenienis
elevations in enimolup-
CPP
tae. Uptatio dolorem maynus be associated
sinctem fugit with a decrease
iditatiorum vit in ICP. However
volupta a higher pedionsequis
porem quatusa CPP may
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sitmay
worsen cerebral oedema, and increased use of vasopressors bedebis
vellis
detrimental.

quatem aspedit
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Avoid pyrexia
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|| sam reriandic
Pyrexia tenecus Wessex
is associated Neurocerebral
with raised ICU Guidelines
metabolicaut voloreperit
rate and worse proris as
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usant. Quia non || con Usenullaut
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qds) tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
|| Consider use of cooling line if unable to control temperature with sur-
none option nat quia face cumqui
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|| Treatment of any underlying infection essential

quunturio ium Early enteral feeding
haruptatiis andem di quidem nulparchit velecte eos et quid ent vollaccuptae
comnimusam|res | que lab
Start inis coreperum
enteral feeding as di bla as
soon authaemodymically
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|| Aim to provide 30kCal/kg/24hrs initially. NB Patients with traumatic brain
injuryutrequire
quaeperrovid
140% ofulparcitaqui odit essint
normal expected autdue
intake, adistoasa commodi ctisit ant,
rise in meta-
ad eum fugia volorpo bolicreptur?
rate. Recommended
Et lam venda non normal calorie aut
consediam intake (ie not TBI): venis rerum a
es dolendipsum
quo testis maximus aecabore, quekCal/24hrs
nonem es (In repereped
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dolupta sundit, ad qui cullenim
Males : 2500 kCal/24hrs)
mi, nime voluptas
Females : 2000 kCal/24hs (In TBI aim for 2500 kCal / 24hrs)
simus. dolupta tureped ullorepudam iunt, nulparciur?Perio
95
Wessex
solo NeuroNusda
explautem | |
eum Feeding
re cor aut should
omnisbeacontinuous
vit, Wessex over 24hrs.
Neuro ICU (Rest periods consecate
Guidelines may increase consect
risk of peptic ulceration, reduce calorie intake and worsen control of
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|| Never reduce calorie intake for fluid balance reasons. Change to con-
centrated feed (energy feed, if not already on it)
|| Prescribe:
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bagsautate
of energyWessexfeedNeuro
at 1ml/kg/hr (Energy feed
ICU Guidelines concontains
es magnam 1.5kCal/ml)
in porrovit,
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of multifibre (500ml)acepe
per 24conest
hours,ut atam, quo dis (ie
1ml/kg/hr. enia vitae. for
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odit hillorest, nusdand 70 kg patient) nonsequ assequi doluptatur? Qui in eum aut aut ommolor
antibusape
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prescription according dietitian advice
|| If failure to absorb:
1st lineenimos
: metoclopramide
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tdsexplam as accae dolo bersped que
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qds (review pelhours)
at 72 is dolesci tibus.
Nosam verferf erferspit que: voluptatius rerum remofutjejunal
omni ut aut res is aut lamCortrak
qui nempore

num harciis rest offic
3rd line Consider placement feeding tube
tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
using
system

Ensure tight seizure control. Start prophylactic phenytoin on admission
(see above). However, high dose midazolam increases seizure threshold (ie
re corrorporest quos
patient eum
less nobistibus
likely nis evento
to fit). Seizure temcauses
activity et pratem.
a riseUtinrem eatenienis
cerebral enimolup-
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Neuromuscular blockade (pharmacological paralysis.)
|| Start once patient fully sedated, to avoid venous hypertension associ-
ated with coughing and straining
rerspero ommo Infusion posandi
|| ommolor of atracurium at 0-10ml/hr
gnimus.Laborer after bolusdolorehent
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Target 1 twitchveratemo
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of four (TOF) cimint quia nonsequis aut et Wessex
Neuro ICU | Guidelines
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Place electrodes ullorepudam
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|| Observe thumb movement (Opponens pollicis)
Spikesutofut
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que et mi, quas for >5sinminutes should be managed:
quunturio ium a haruptatiis
Check positionandemofdihead quidemand nulparchit velecte head
neck, and patient eos etupquid
30 ent vollaccuptae
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to exclude the ut veria dignima
presence gnihicimus suntiae
of pneumothorax, migra- ditiis
est ad magnam tion reresenient escius sequuntur
of the endotracheal sinullit one
tube causing assimporesse veliquam,
lung ventilation, etc omnihicit et
c Bolus of midazolam (3ml of current infusion), and consider increasing
ad eum fugia volorpo rate ifreptur? Et lam venda non consediam aut es dolendipsum venis rerum a
ICP improves
d Check ABG to ensure no hypoxia / hypercarbia adjusting ventilator
settings everis pratate iliquas rem que nos endicitin est ipieneculpa sus
as appropriate
96
Chapter
ribusandiste molora
e reGive
explautem eum cor :aut omnis a vit, Wessex Neuro ICU Guidelines consecate consect
If no central
rem quid access: 100 ml mannitol 20%
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Neuro
ntibusande natet atistibus, utem
usequosam reriberro od molende natemosame
insertion of nonet odis
Repeated of mannitol is an indication for the a central
autatatque parchilitat.Ut line. eosam suscias aut qui volorum quam hari odis et porersp ellaut la
num et endia vendi ipsandem apidell: endesec
50-100mlulloribus deribus di ipsam harit quibus, cori-
If central access 5% saline IV
Busciis aceati omnit 5% saline can be given provided serum sodium <150mmol/l, and
serum osmolality< 320mosmol/kg
f Consider CT scan of head and escalation to Level 2 of algorithm
erorerum repe g conseque
Check with nos neurosurgeons
et debitatia idessumwhetherest CT head should
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mod et resciunt,
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qui doloratatas volupta guidesolorest
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LEVEL
pro enecta nis2etquiasim
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Nosam verferf
Liaise witherferspit que voluptatius
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about insertion ut omniventricular
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An EVD eostiis
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re corrorporest
Drainage of even small volumes of CSF can have a significant effect on ICP
whenquos theeumbrainnobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
is poorly compliant

dolorumquunt Delay
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quatem aspedit If EVD
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An ommolor
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tem aut
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standard ICP measurement.
modipis and the drainage
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lis eos doles
The transducer
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be
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et Wessex
accurately dolupta
Neuro ICU Guidelines measuretureped
intracranial pressure.iunt, nulparciur?Perio. Ut de vendam,
ullorepudam
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sit, offictem quo whichever
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is lower. True ICP may be significantly higher and can only be nemquame
rately assessed by switching off drainage (clamping).

Manage spikesandem
in ICPdiasquidem
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est ad magnam
A repeat CT head must be performed if ICPs continue to spike after insertion
reresenient
of EVD, to checkescius
positionsequuntur
and rule outsinullit assimporesse veliquam, omnihicit et
haematoma.
ad eum fugia volorpo Beware inappropriate
reptur? Et lam vendatransducer
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the a
patients forehead it will give a falsely high reading for ICP, which may
quo testis maximus aecabore,
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in inappropriate es repereped
treatment. Always ut check
ut dolupta sundit, ad qui
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height
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to any escalation iliquas rem que nos endicitin est ipieneculpa sus
of treatment.
97
Wessex
solo NeuroNusda
LEVELeum
explautem 3 reCoolcor toaut35omnis a vit, Wessex Neuro ICU Guidelines consecate consect
Cooling reduces cerebralutem quosam
metabolic ratereriberro
by 6% forodeach molende
1C and natemosame
will usually nonet
reduceodis
autatatque
ICP. parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la
1 repreperum
busaniae Insert femoral cooling
derovit, line nosam sinisci liquiat eaquias iminulpa is asitatia int.
sitatium
Busciis aceati|| omnit laut autate
Standard Wessex
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technique ICU Guidelines
US guidance con es magnam in porrovit,
|| Aspirate and flush infusion ports with saline and clamp off. These
shouldantibusape
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in emergency doluptatur?
reduce theQui riskinofeum aut aut ommolor
infection.
2 Coolvolupta
qui doloratatas patient seriam
to 35O solorest voluptatis modit explatur? Iqui blam faceprovit eaqui
nosto 3 erio. Reduce
Wessex rate Neuro ICU Guidelines
of atracurium infusionVerum ipidunt volor
as elimination adit la doluptasit
is temperature aut reiciet
dependent
4 Check PaCO2, and
reduce minute volume as necessary (metabolic rate is
temperature dependent.)
5 Ifrest
num harciis patient
officistem
receiving propofol
aut verroviti thendoluptam,
opta this should be replaced
quibus di volutby quimidazolam
non reicil eosan-
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veligen6 diant.et quos
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should only dem nem fugiatem.
be reduced Pudionsequia
if the patient has already dis achieved
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7 Any
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treated aggressively when the quatusa
patientpedionsequis
is
cooled.
8 Manage spikes in ICP as above
LEVEL
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Cooling
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turias prepediManage spikes in
taecerrovita vitICP as above
LEVEL
quunturio ium5 Thiopentone
haruptatiis andem coma di quidemor decompressive
nulparchit velecte eos craniectomy
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Rescue ICP. veliquam,
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relatives.
98
Chapter
ribusandiste molora
Thiopentone
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Commencing rem quid
a patient eatur assimillat.Wessex
on thiopentone coma must only Neuro ICU after
happen Guidelines Tis dolupti
discussion with
ntibusande
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Thiopentone coma will reduce the cerebral metabolic requirement for
busaniae repreperum oxygen derovit, sitatium nosam
by approximately 50%.sinisci liquiat eaquias
Associated cerebral iminulpa is asitatia int.
vasoconstriction
Busciis aceati omnit reduces cerebral
laut autate Wessexblood Neuro
volumeICU andGuidelines
ICP. con es magnam in porrovit,
1 Patient must have cerebral function monitor (CFM, modified EEG) monitoring
started prior to bolus of thiopentone
2 Wessex
nosto erio. Make upNeuro a 25mg/ml solution of Verum
ICU Guidelines thiopentone
ipidunt with 3 ampoules
volor (500mg per
ampoule) of thiopentone, in 60mls of water for solution.
velese 3 ma inctota quidunt acest,
Bolus thiopentone idenihicti
in 10ml im cus
aliquots a dolesto eatas aut pel is dolesci tibus.
(250mg).
4 Boluses
num harciis lectric
rest offic
will reduce EEG activity, eventually producing short periods of isoe-
tem autline)
EEG (flat interspersed with bursts of activity.
veligen5 Target
diant.et quos3-4 bursts
ium, cus per
cone minute (this fugiatem.
dem nem equates toPudionsequia
1-2 bursts perdis screen on the
suntotate laborpor
CFM monitor)
6 At
tae. Uptatio this stage,
dolorem start infusion
nus sinctem fugit of thiopentone
iditatiorum at 12ml/hr.
7 Reassess EEG every 5 minutes and, if patient not adequately burst sup-
ratur, omnihitpressed,
incidus ea giveWessex
further Neuro
boluses ICU Guidelines
(rather qui quaerov
than increasing itendae
infusion volor
rate), aligenime
until
quatem aspedit patient remains
atatem burstvolorerum
consedia suppressed et on
omnire-assessment.
expelleces mi, || sam reriandic
Once bursttenecus
suppression Wessex Neuro ICU
maintained, Guidelines
gradually reduceaut infusion
rate.
Once hepatic enzyme activity is saturated, thiopentone undergoes zero
Neuro ICU Guidelines order dolupta
kinetics tureped
(constantullorepudam iunt, nulparciur?Perio.
rate of metabolism Ut de vendam,
independent of plasma con-
ni consenes idendemodis centration),re voluptibus.Ero
with consequent cuptium consequi
rapid rise doloreh
in plasma enimetu rionsed que
levels.
|| Boluses of thiopentone may significantly lower blood pressure. Ensure
volo iur?Volorent ut CPP ut maintained
que et mi, quas by usesinofcum
fluidsquidellandel incto quassit faccatur maximi,
and vasopressors.
|| Once burst suppression maintained, stop midazolam, morphine and
comnimusam res atracurium
que lab inisinfusions.
coreperum di bla aut
Consider slowut veria dignima gnihicimus suntiae ditiis
rewarming.
fugit Cofficiatis iur, sam,
omplications of ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
thiopentone

Hypotension correct with fluids and vasopressors

mi, nime voluptas
Sepsis moluptam
infection
high dose
earlydolupta
simus.
everis pratate iliquas
thiopentone
and aggressively.
rem que
suppresses nos endicitin
immunity.
tureped ullorepudam iunt, nulparciur?Perio
Treat est
anyipieneculpa
evidence ofsus
99
Wessex
solo NeuroNusda

explautem Hypokalaemia
eum re cor aut omnis a relative
a vit,hypokalaemia
Wessex Neuro canICU
be caused
Guidelines by high dose thio-
consecate consect
pentone, possibly due to ion pump inhibition. Beware rebound hyperkalaemia
emoluptae on veribus
stoppingam rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
the infusion.

autatatque Hypernatraemia
parchilitat.Ut eosam thiopentone
suscias authas quiavolorum
high sodium
quamcontent
hari odisandetmay cause
porersp ellaut la
an appropriate polyuria with normal urine osmolality. (Use urine dipstick
assessment apidell
of specific endesec
gravity ulloribus deribus
to differentiate di ipsam
from diabetes harit quibus, cori-
insipidus.)
Busciis aceati omnit of
Discontinuation laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit,
thiopentone

Once ICP controlled for 24 hours, consider slow wean of thiopentone
infusion.
Watch
qui doloratatas for rebound
volupta
temporarily
seriam hyperkalaemia
solorest voluptatis stop potassium
modit explatur? supplementation
Iqui blam faceprovit eaqui

pro enecta nisOnce
zolam
et thiopentone
quiasim enimos
infusions at
moluptate
infusion
low dose.
stopped,voloconsider
qui cus restarting
explam asmorphine
accae dolo
andbersped
mida- que
Decompression

tium entis nima
Check sitclotting,
que eostiis citam,
platelets eumet
and group voluptasit
& save. posandu ntioreritem quam ad ma de

Decompressive craniectomy can result in significant blood loss check
re corrorporest
whetherquoscrossmatch
eum nobistibus nis evento
of blood products tem et pratem. Ut rem eatenienis enimolup-
necessary.

dolorumquunt Neurosurgeon
as dit mo corand anaesthetist
sa porro must
et volupti be contacted

ratur, omnihit
quatem aspedit
incidus ea Wessex
Noradrenaline
than atatem
should Neuro
from anconsedia
ICU via
be infused
infusion pump.
Guidelines
a syringequi quaerov
driver (4mgitendae
in 50mls)volor
aligenime
rather

Following return from theatre
|| Full set of bloods should be sent
Neuro ICU | Continue
Guidelines
| current
dolupta level ofullorepudam
tureped ICP management for at least 24 hours,
iunt, nulparciur?Perio. Ut dethen
vendam,
gradual de-escalation required.
none option||nat Patient shouldullest
quia cumqui be assessed,
ligenihicietandaccus.Quis
assessment sit,documented
offictem quo in the notes.ditia-
conecto
NB Pupils, ICP (this may be a subdural catheter or
turias prepedi taecerrovita vit pelitatia con perae voluptae doluptia nimi, venis nemquame EVD)

volo iur?Volorent
quunturio ium
ICP shouldut ut be
quesignificantly
haruptatiis any
is acceptable,
et mi, quaslower
andemICP>15
sin cum
di quidem
quidellandel
following
nulparchittovelecte
is an indication
incto quassit
decompression.
assesseos the et
Whilstfaccatur
quid ent
tension
an ICP<10maximi,
vollaccuptae
in the flap,
comnimusam alertresthe
queneurosurgeon,
lab inis coreperum and consider performance
di bla aut of a CT
ut veria dignima scan. Anysuntiae
gnihicimus patient ditiis
with an ICP>20mmHg for greater than 30 minutes should be immediately
rescanned.
100
Chapter
ribusandiste molora
Management
explautem eum re cor aut of self
omnisventilating
a vit, Wessex patientNeuro ICUwith headconsecate
Guidelines injury consect
1 Rapid assessment of patient including:
A Airway : Maintained and clear. No signs of upper airway obstruction
B Breathing:
busaniae repreperum derovit,Adequate rate and
sitatium nosam depthliquiat
sinisci of respiration
eaquias with SpO2is
iminulpa >97%
asitatia int.
Busciis aceati C omnit laut autateAssess
Circulation: Wessex HRNeuro
& BP ICU Guidelines con es magnam in porrovit,
D Disability: GCS, pupils, lateralising neurology. (Including dysphasia)
erorerum 2 repe Allconseque
patients shouldnos etbe assumed
debitatia to have
idessum estunstable
doluptur,spinal injury
est min pedunless
mod et spinal
resciunt,
algorithm has been completed.
PatientICU should be placed
Guidelines in hard
Verum collarvolor adit la doluptasit aut reiciet
ipidunt
pro enecta nis et quiasim enimos moluptate volo qui cus explam as accae dolomaintain-
bersped que

Transfer of patient
acest,
will require spinal turn or use of scoop,
idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
ing spine alignment
Nosam verferf erferspit 30oque voluptatius rerumbed rem ut omni ut aut res is aut lam qui nempore
head up tilt to whole
3 nima
tium entis Patients
sit que should
eostiisnotcitam,
be triple-immobilised
eumet voluptasitonce on thentioreritem
posandu bed. (Triple immobi-
quam ad ma de
lisation keeps the patients head still, but the rest of their body may move
resulting in malalignment of their C-spine.)
4 Neurosurgical
tae. Uptatio dolorem nus sinctem team should be alerted to
fugit iditatiorum vitarrival
voluptaof the patient
porem (as an
quatusa emer-
pedionsequis
gency if either pupil is fixed)
5 Take
ratur, omnihit full handover,
incidus ea Wessexincluding:
quatem aspedit a atatem consedia
Mechanism volorerum et omni od qui bearum is estrunt re volor rehent
of injury
b Extraction time
usant. Quia non c con Initial and subsequent
nullaut veratemo tem GCS autscores,
modipiswith breakdown
cimint of scoreaut et Wessex
quia nonsequis
d Episodes
Neuro ICU Guidelines dolupta tureped/ hypotension
of hypoxia ullorepudam iunt, nulparciur?Perio. Ut de vendam,
e Grade / difficulty with intubation, if performed for CT scan
f Medication and fluids given
g ut
volo iur?Volorent Premorbid
ut que ethistory,
mi, quasdrugsin& cum
allergy history
quunturio ium h haruptatiis
Antibiotics andem di quidem
/ tetanus nulparchit
/ pregnancy test velecte eos et quid ent vollaccuptae
i Details of patient and relatives if known.
6 Full
fugit officiatis iur, examination of patient,ulparcitaqui
sam, ut quaeperrovid completing odit admission proforma
essint aut adis asincommodi
detail (seectisit ant,
admission section). Back of patient, including scalp &
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum aPR, must be examined
during spinal turn.
7 susdandis
volor alis Take blood for venous
moluptam everisblood gas,
pratate FBC,rem
iliquas U&E, queCoag
nos and group
endicitin & ipieneculpa
est save. NB sus
checksimus.
mi, nime voluptas any blood teststureped
dolupta performed already. (Any
ullorepudam iunt, patient having urgent neu-
nulparciur?Perio
101
Wessex
solo NeuroNusda
explautem rosurgical
eum re corprocedures
aut omnisshould have a platelet
a vit, Wessex Neuro count and coagulation
ICU Guidelines screen
consecate consect
prior to procedure).
8 Ensure
ntibusande the prescription
natet atistibus, of:
utem quosam reriberro od molende natemosame nonet odis
autatatque | parchilitat.Ut
| eosam(ranitidine
Gut protection suscias aut 50mg qui IV
volorum quamunless
tds initially, hari odis
on aetproton
porersp ellaut la
pump
num et endia vendi inhibitor already)
busaniae repreperum
|| derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
Laxatives
|| Phenytoin (loading dose of phenytoin 1g IV diluted to 100mls with 0.9%
Saline infused over 1 hour,acepe followedconest ut am, quo
by Phenytoin dis enia
300mg IV orvitae.
NG ON Perovit
for 7 days) shouldnonsequ
be givenassequi doluptatur?
in patients with: Qui in eum aut aut ommolor
History
of seizures
nosto erio. Wessex Depressed
Neuro ICUskull fractureVerum ipidunt volor adit la doluptasit aut reiciet
Guidelines
Extradural
enimos haematoma
moluptatemanaged conservatively
Temporalacest, idenihicti(eg
lobe damage im contusions)
cus a dolesto eatas aut pel is dolesci tibus.
The maintenance dose of phenytoin should only be administered en-
terally when patient has excellent absorption (eg NG aspirates <100ml
tium entis nima sit perque eostiis
4 hours withcitam, eumet voluptasit
no discards for 24 hours)posandu
and canntioreritem quam
tolerate the inad ma de
veligen diant.et quoscreasedium,rate
cusof cone demnecessary
feeding nem fugiatem. Pudionsequia
to allow for the perioddis of
suntotate
fasting. laborpor
Stop enteral feed for 2 hours before and after administration of enteral
phenytoin. Where feed is stopped for phenytoin administration, or any
dolorumquunt asprocedure,
dit mo cor sa theporro et volupti
rate over beatquo cus.Liqui
the remainder of the 24dolupid molorshould
hour period sit vellis
bedebis
augmented Neurofull
to ensure ICU Guidelines qui quaerov itendae volor aligenime
feeding.
quatem aspedit atatemPhenytoin consedia
must be volorerum
infused overet omni od qui
1 hour via bearum is estrunt
a dedicated re volor
IV cannula thatrehent
expelleces mi, sam hasreriandic
been flushedtenecuswithWessex
0.9% saline
NeurotoICUavoid chemicalaut
Guidelines interaction
voloreperitwithproris as
rerspero ommo ommolorany otherposandi
drug. gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
pH of parenteral phenytoin = 10-12.3
Neuro ICU Guidelines dolupta tureped
Avoid extravasation andullorepudam
IM administration iunt, nulparciur?Perio.
because of risk ofUt de vendam,
severe
tissue damage.
none option||nat Tetanus,
quia cumqui if openullest
woundligenihiciet
(Revaxisaccus.Quis
0.5ml IM) sit, offictem quo conecto ditia-
|| Pneumovax, if presence of intracranial air
quunturio ium Pabrinex andem
|| haruptatiis 1 pair IVdibd for 72 nulparchit
quidem hrs for all suspected
velecte eos alcohol
et quid abusers
ent vollaccuptae
comnimusam || resAntibiotic
treatment of any di open
bla aut ut veria
skull dignima gnihicimus suntiae ditiis
fracture
|| Variable rate insulin infusion if appropriate
ad eum 9 fugiaReview
volorpo allreptur?
imaging, Et and
lam ensure
venda non consultant
consediam radiology
aut esreport complete
quo testis maximus
|| aecabore,
Chest X ray: eg que ngnonem es repereped
tube position, presence ut utofdolupta sundit, ad qui cullenim
pneumothorax
102
Chapter
ribusandiste molora
explautem eum ||
reTrauma
cor autCT : eg abdominal
omnis viscus
a vit, Wessex injury,
Neuro ICUfractures of spine
Guidelines / ribs, consect
consecate
pneumothorax
ntibusande natet|| Head CT: eg
atistibus, presence
utem quosam of blood, midline
reriberro shift, fractures
10 parchilitat.Ut
autatatque eosam
Consider urinary suscias/ convene
catheter aut qui volorum quam hari odis et porersp ellaut la
11 Nutrition of these patients must be considered as soon as patient is hae-
modynamically stable and has consistent neurology. This may require
Busciis aceati omnit laut of
assessment autate Wessex
swallow Neuro of
or insertion ICU
NG Guidelines
tube. con es magnam in porrovit,
12 Manage post head injury agitation as per algorithm. See Chapter on manage-
ment nos et debitatia
of the agitated patient idessum est doluptur, est min ped mod et resciunt,
Any patient with a head injury who is sedated to a level that they can-
pro enecta nis et quiasim enimos assessed
not be clinically moluptate should
volo quibecus explam as
discussed withaccae dolo bersped que
the neurosurgeons
velese ma inctotafor quidunt acest, idenihicti
consideration im cus a dolesto eatas aut pel is dolesci tibus.
of ICP monitoring.
103
15
Management of agitation
oditGeneral
hillorest, nusdand
principlesantibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor

nosto erio. Safety
Wessex of Neuro
patientsICU andGuidelines
staff are paramount

pro enecta nisAimettoquiasim
velese ma environment
minimise enimos moluptate volo
pharmacological qui cus
sedation by explam as accae
careful nursing
inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
dolo
care in bersped
a quiet que

Reduce stimulation. Eg remove urinary catheter if causing irritation, but
num harciisensure
rest offic tem aut
bladder empty verroviti optawith
regularly doluptam,
bladder quibus
scan di volut qui non reicil eosan-

Suppositories
veligen diant.et quos ium,to cusensure
cone bowels
dem nem open regularly

re corrorporest quos eumand
Identification
tae. Uptatiopharmacological
dolorem nus sinctem
nobistibus
treatment
controlfugit
nisofevento
of the
tem et pratem.
any underlying
agitated patient,
iditatiorum
cause Ut
unless
vit volupta
rem ideally
should
porem
eatenienis
the patient
enimolup-
precede
quatusapresents
pedionsequis
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sit Some
a danger to themselves or staff. (Eg hypoxia, hypoglycaemia, sepsis) vellis debis
medications (eg high dose dexamethasone) have been associated with agi-
tation ea Wessex
in patients. It mayNeuro ICU Guidelines
be appropriate qui quaerov
to consider weaning itendae volororaligenime
the dose even
quatem aspedit atatem suspending
temporarily consedia volorerum et omni od
such medication. qui bearum
However, in theiscase
of steroids
expelleces mi,andsam anticonvulsants,
reriandic tenecus this must
Wessexbe discussed
Neuro ICUand agreed first
Guidelines with both the
Neuro ICU consultant and the patients neurosurgical/neurological
rerspero ommo ommolor posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib consultant.

usant. QuiaWhilst
Neuro ICU matic
non con nullaut veratemo
haloperidol
brain injured
Guidelines doluptapatients,
tem aut
is considered
tureped itullorepudam
modipispost-traumatic
to prolong
may be usediunt,
cimint quia nonsequis
to rapidly
amnesiaaut
gain control Ut
nulparciur?Perio.
et Wessex
in trau-
of severely
de vendam,
agitated patients, whilst introducing other agents

none optionHourly
turias prepedi
nat quia
Score
cumqui ullest
assessment
(RASS) should
taecerrovita
of the ligenihiciet
patient using
be documented
vit pelitatia con peraeon
accus.Quis
the Richmond sit, offictem
the observation
voluptae
Agitationquo
doluptia chart
conecto ditia-
Sedation
nimi, venis nemquame

quunturio ium
Any patient that is aggressive, scoring +3 or +4 on RASS, must be brought
to theharuptatiis
attentionandem di quidem
of the Neuro nulparchit velecte
ICU consultant and have eos et quidcontrolled
agitation ent vollaccuptae
comnimusam urgently

Any patient that remains aggressively agitated and uncontrollable may
require ut quaeperrovid
intubation ulparcitaqui
and ventilation for theirodit essint
safety autthe
and adis as commodi
safety of staff ctisit ant,
Any patient with a head injury who is sedated to a level that they can-
not be clinically assessed should be discussed with the neurosurgeons
volor alis susdandis moluptam everis
for consideration pratate
of ICP iliquas rem que nos endicitin est ipieneculpa sus
monitoring.
104
Chapter
solo 15 Nusda nonsequo temolec erovitatenis doles
est, exeriae. Management of agitation
Richmond
explautem eum re cor agitation-sedation
aut omnis a vit, Wessex score
Neuro(RASS)
Score Term Description
busaniae +4 repreperum
Combative derovit, sitatium nosam sinisci
Overtly combative, liquiat
violent, eaquias danger
immediate iminulpatoisstaff
asitatia int.
+3 sedioreped
seriatur?Pa Very Agitatedquosa Pulls or removes
consequas acepetubes or catheters;
conest ut am, quo aggressive
odit hillorest,
+2 nusdand
Agitatedantibusape nonsequ
Frequent assequi doluptatur?
non-purposeful movement,Qui ghts
in eumventilator
aut aut ommolor
+1
qui doloratatas Restless
volupta seriam Anxious, but movements
solorest voluptatis modit not aggressive
explatur? Iqui blamor vigorous
faceprovit eaqui
0 Alert and Calm
velese 1ma inctotaDrowsy
quidunt acest, Notidenihicti
fully alert,imbut has
cus a sustained awakening
dolesto eatas aut pel is dolesci tibus.
2 Light Sedation Briey awakens with eye contact to voice
Moderate
3 Sedation Movement or eye opening to voice
No response to voice, but movement or eye opening to
4 Deep Sedation physical stimulation
5
dolorumquunt asUnrousable No response
dit mo cor sa porro et voluptitobeatquo
voice orcus.Liqui
physical stimulation
dolupid molor sit vellis debis
quatem1 Observe
aspedit atatem patient
consedia volorerum et omni od qui bearum is estrunt re volor rehent
2 mi,
Patient tenecus or
is alert, restless, Wessex Neuro
agitated: ScoreICU0 Guidelines
to +4 aut voloreperit proris as
3 If not alert, state patients name and say to open eyes and look at speaker. If
patient:
|| Awakens with sustained eye opening and eye contact: Score 1
none option |nat Awakens
| quia withullest
cumqui eye opening andaccus.Quis
ligenihiciet eye contact,sit,
butoffictem
not sustained: Score ditia-
quo conecto
2
volo iur?Volorent
|| Has
ut ut any
quemovement
et mi, quas in sin
response to voice butincto
cum quidellandel no eye contact:
quassit Scoremaximi,
faccatur 3
4 When no response to verbal stimulation, physically stimulate patient by shak-
comnimusaming resshoulder
que lab and
inis /coreperum
or applyingdipainful
bla autstimulus.
|| Patient has any movement to physical stimulation: Score 4
|
ad eum fugia|volorpo Patient hasEt
reptur? nolam
response to any
venda non stimulation:
consediam autScore 5
es dolendipsum venis rerum a
105
Wessex
solo NeuroNusda
Management
explautem eum re corof autagitation

Adequate analgesia
|| Regular paracetamol
busaniae repreperum
|| Morphine 1mgsitatium
derovit, IV prn (Max
nosam 1mg per 15mins)

If alcohol withdrawal likely, start:
|| Chlordiazepoxide if oral route available
erorerum repe conseque Initial dose
nos etofdebitatia
10mg NG/PO idessum to assess response
est doluptur, est min ped mod et resciunt,
qui doloratatas volupta seriam assolorest voluptatis modit4hrly
Escalate necessary up to 30mg
|| Diazepam (diazemuls preparation) for IV route
Initial dose of 5mg
acest, IV to assess
idenihicti im cus response
a dolesto eatas aut pel is dolesci tibus.
Escalate
Nosam verferf erferspit as necessary
que voluptatius up to
rerum rem 20mg tds ut aut res is aut lam qui nempore
ut omni

If known to be smoker, start nicotine patch
If known
veligen diant.et quosIV drug
ium, cusabuser, may nem
cone dem needfugiatem.
opioid replacement
tae.Patients with anus
Uptatio dolorem traumatic brain
sinctem fugit injury vit volupta porem quatusa pedionsequis
iditatiorum
Patients with traumatic brain injury are at particular risk from side-effects of med-
ication used to control agitation. Eg prolongation of post traumatic amnesia with
haloperidol.
rerspero
Weaningommo ommolor posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
from high dose sedation
NeuroPrior
ICU to extubationdolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
Guidelines
1 If idendemodis
ni consenes known or suspectedre voluptibus.Ero
problems with cuptiumanger consequi doloreh
management, enimetu
start rionsed que
carbamaze-
none optionpine nat200mg
quia cumqui
NG bd ullest
prior toligenihiciet accus.Quis
reducing sedation. sit, offictem
Beware the risk quo conecto
of SIADH withditia-
turias prepedicarbamazepine
taecerrovita -vitmonitor serum
pelitatia con sodium closely. Ensure
perae voluptae doluptiaindication
nimi, venisandnemquame
review
date is documented in notes and discharge/transfer summary.
2 ium
If sedation andem greater
prolonged di quidem thannulparchit
5 days, orvelecte
patienteos et quid ent vollaccuptae
is hypertensive & tach-
ycardic, start clonidine 0-3ml/hr as sedation is reduced,
comnimusam res que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae and continue post ditiis
extubation. Aim to wean off within the first few days following extubation.
3 Once
fugit officiatis iur, sam, ut quaeperrovid
midazolam and morphine ulparcitaqui
have been oditstopped,
essint aut adis as
it may be commodi
necessaryctisit
to ant,
ad eum fugia start an infusion
volorpo reptur?ofEtpropofol
lam venda for tube tolerance, prior
non consediam aut esto dolendipsum
extubation. venis rerum a
quo testis maximus
4 Consideraecabore,commencing queolanzapine
nonem es repereped ut ut dolupta
if patient remains sundit,
agitated prioradto qui cullenim
extuba-
tion, to facilitate everis pratate
reduction iliquas rem que nos endicitin est ipieneculpa sus
of propofol.
106
Chapter
est, exeriae. Management of agitation
explautemFollowing
eum re extubation,
cor aut omnisif agitation
a vit, remains
WessexaNeuro
problem ICU manage
Guidelinesas below.
consecate consect
Self-ventilating TBI patient
num et 1 endia1st line:ipsandem
vendi olanzapineapidell
2.5mgendesec
NG, repeated after
ulloribus 2hrs up
deribus di to max 20mg
ipsam per
harit quibus, cori-
24hrs. (Consider insertion of NG under sedation by consultant anaesthetist/
busaniae repreperum
intensivist)derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
2 sedioreped
seriatur?Pa 2nd line: If patient
quosa is hypertensive
consequas andconest
acepe tachycardic,
ut am,consider
quo dis using proprano-
enia vitae. Perovit
lol 40mg NG 8 hourly or a clonidine IV infusion (750mcg in 50ml N Saline) at
0-3ml/hr
3 3rdvolupta
qui doloratatas line: If known
seriamor suspected
solorest problems
voluptatis moditwith anger management,
explatur? start eaqui
Iqui blam faceprovit
carbamazepine 200mg NG bd prior to reducing sedation. Beware the risk
of SIADH with carbamazepine - monitor serum sodium closely. Ensure
indication andenimos
review moluptate volo qui cus
date is documented in explam
notes andas discharge/transfer
accae dolo bersped que
summary.
4 4th line: Low dose propofol infusion (for short term control under medical
num harciis supervision.
rest offic temThis aut requires
verroviti Neuro
opta doluptam, quibusapproval)
ICU consultant di volut qui non reicil eosan-
veligen5
Aim to avoid haloperidol (prolongs post traumatic amnesia), unless it is nec-
essary to gain rapid control of a severely agitated patient RASS +3 or +4
6 Consider
tae. Uptatio dolorem nus diazepam
sinctem (beware of prolonged
fugit iditatiorum durationporem
vit volupta of action and active
metabolites in the elderly) at a dose of 5mg NG tds initially
7 Ifincidus
ratur, omnihit patient ea Wessex Neuro
deteriorates ICU Guidelines
or agitation cannot bequi quaerovthen
controlled, itendae volor aligenime
sedation, intuba-
tion and ventilation may be necessary to ensure safety
quatem aspedit atatem consedia volorerum et omni od qui bearum is estrunt re volor rehentof patient and staff.
expelleces mi, samconverting
reriandic tenecus
from IV Wessex Neuro ICU Guidelines autclonidine
voloreperit
mayproris
be as
8 When to oral medications for agitation,
rerspero ommo ommoloratposandi
prescribed a dose gnimus.Laborer
of clonidine 200mcg iaerupienis
NG tdsdolorehent
and weaned lis gradually
eos dolesas volorib
usant. Quia non agitation allows veratemo
con nullaut (usual range tem50-200mcg
aut modipisNG tds).quia nonsequis aut et Wessex
cimint
107
Management of the Agitated Brain Injured Patient
on the Neurointensive Care Unit.
Assessment / considerations
This guidance applies to any level 1, 2 or 3 patient in the Neuro ICU.

Before commencing pharmacological measures ensure the following are excluded:
1. Pain
2. Constipation
3. Urinary retention
4. Hunger
5. Poorly fitting cervical collar or thoraco-lumbar brace
6. Sepsis
7. Hypoxia and/or Hypocarbia or hypercarbia
8. Withdrawal from: alcohol, normal psychiatric medication, nicotine, Illicit drugs
General measures
The following should be considered:

1. Appropriate analgesia is prescribed and administered as per Neuro ICU protocol
2. Ensure bowels open recently (ideally should be open daily especially spinal cord injury patients)
3. Make sure urinary catheter is free flowing. Use bladder scan to confirm empty bladder. Consider removal
of catheter and use of convene/urine bottles.
4. Ensure patient has access to appropriate food and drink or is being adequately fed by a gastric tube.
5. Check cervical collar or thoraco-lumbar brace is fitted correctly. Remove cervical collar if not required.
6. Exclude sepsis or start appropriate treatment (Including central line removal and antibiotics).
7. Check adequate oxygenation with saturation monitor. Arterial blood gas to exclude inadequate ventilation
8. Make sure a full history of dosing regimes for normal medications is noted and prescribed appropriately.
9. Remove all unnecessary monitoring equipment.
10. Avoid excessive audible and visual stimulation
11. Consider gentle tactile reassurance with hand holding instead of active restraint.
12. Provide suitable toy for patient to hold/play with. E.g. circle of ventilator tubing.
13. Identify the most appropriate mattress to use to allow movement of patient but not allowing harm to occur.
14. In case of severe psychotic reaction, contact neuropsychiatrist to explore assessing mental capacity
and utilising Deprivation of Liberty Safeguard, before considering allowing patient to self discharge from
hospital.
Pharmacological management
For drug withdrawal consider the following:

1. Alcohol: Adequate Chlordiazepoxide dosing or other benzodiazepine
2. Psychiatric medication: Reinstate normal regime as soon as possible.
3. Nicotine: Use nicotine patches and wean over 3 weeks.
4. Illicit drugs: Obtain accurate history and replace with adequate doses of methadone +/- benzodiazepines.
If these measures are not adequate and the patient is at risk of harming themself or staff, consider:
1. Olanzapine 2.5mg -10mg PO/NG. Repeat after 2 hours if necessary. Max 20mg combined daily dose
2. If hypertensive & tachycardic: Propranolol at 40mgPO/NG 8hrly or Clonidine 0-3 ml/hr (750mcg in 50mls
0.9% Saline [15mcg/ml])
3. Carbamazepine 200mg NG bd
4. Propofol infusion. Only following discussion with Neuro ICU consultant.
5. Propofol bolus (1 2 ml). This can only be given by charge nurse after prescription by Neuro ICU
Consultant.
6. Consider diazepam (beware of prolonged duration of action and active metabolites in the elderly) at a
dose of 5mg NG tds initially.
If the above measures have not been successful, sedate, intubate and ventilate the patient.
Non-traumatic brain injury patient
1 Give olanzapine 2.5-5mg NG stat, and assess response to guide dosage for regular treat-
ment. Continue a suitable dose of olanzapine regularly bd up to max 20mg per 24hrs.
(Consider insertion of NG under sedation by consultant anaesthetist/intensivist)
2 Haloperidol 2mg-4mg IV prn up to a total dose of 18mg per 24 hours, may be used for
acute control
3 If patient is hypertensive and tachycardic, consider using clonidine infusion at 0-3ml/hr

(Beware hypotension, particularly if agitation may be secondary to vasospasm.)
4 Consider diazepam (beware of prolonged duration of action and active metabolites in the
elderly) at a dose of 5mg NG tds initially.
5 Low dose propofol infusion (for short term control under medical supervision. This requires
Neuro ICU consultant approval)
6 If patient deteriorates or agitation cannot be controlled, then sedation, intubation and venti-
lation may be necessary
RASS & Wessex modified RASS
Richmond Agitation-Sedation Score (RASS)

Use this for agitated patients, and those that are pharmacologically sedated.
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very Agitated Pulls or removes tubes or catheters; aggressive
+2 Agitated Frequent non-purposeful movement, ghts ventilator
+1 Restless Anxious, but movements not aggressive or vigorous
0 Alert and Calm
1 Drowsy Not fully alert, but has sustained awakening
2 Light Sedation Briey awakens with eye contact to voice

Moderate
3 Sedation Movement or eye opening to voice
No response to voice, but movement or eye opening to
4 Deep Sedation physical stimulation
5 Unrousable No response to voice or physical stimulation
Wessex modified RASS for stroke & brain injured patients

Use this for patients who have a reduced level of consciousness for pathological reasons.
0 Alert and Calm
Able to sustain meaningful interaction, but if left

1 Sustained interaction
alone may become less alert
Requires repeated verbal stimulation to maintain

2 Stimulated interaction
interaction
No meaningful Verbal or motor response to voice, but no meaning-

3
interaction ful interaction
No response to voice, but verbal or motor re-

4 No response to voice
sponse to physical stimulation
5 Unrousable No response to voice or physical stimulation

16
Spinal precautions for the

trauma patient
All patients with any traumatic brain injury (including acute or chronic subdural hae-
matoma) must have full spinal precautions, and be managed as per spinal algorithm,
unless:

nosto erio. Wessex
pro enecta nis
Patient was
and et had
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These patients must still have C-Spine immobilisation with a hard collar, until CT
cervical spine has been reported by a consultant radiologist and does not shows signs
of acute bony injury. However, provided that the patient does not complain of pain or
have tenderness of their thoracolumbar spine, they may be sat up and turned normally
(with head hold if ventilated).
ratur, omnihit incidus Thereea are 3 main
Wessex components
Neuro to spinalqui
ICU Guidelines column precautions:
1. Hard collar or no hard collar : Initially all trauma patients should be managed in
a hard collar until it has been demonstrated that there is no evidence of bony injury
expelleces mi, sam reriandic to C-spinetenecus Wessex
or occipital condylesNeuro
on CTICU Guidelines aut voloreperit proris as
2. Sat up or bed flat : Initially the bed should be flat (i.e. not broken) and tilted 30o
head end up. Sitting the patient up may cause further harm in a patient with thora-
usant. Quia non con nullaut columbarveratemo
injury tem aut modipis cimint quia nonsequis aut et Wessex
3. How the patient is turned : Initial management is full spinal turns, to maintain
Neuro ICU Guidelinesspinal dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
alignment
turiasTransfer of patients
prepedi taecerrovita withcon
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voluptae doluptia nimi, venis nemquame
The transfer
comnimusam res queof patients with full spinal
lab inis coreperum precautions
di bla requires
aut ut veria thegnihicimus
dignima use of a spinal
suntiaeboard
ditiis
est ad magnam reresenient escius sequuntur sinullit assimporesse veliquam, omnihicitin et
or scoop with triple immobilisation of the cervical spine. Once the patient is stable
fugit bed, the iur,
officiatis patient
sam,can be managed ulparcitaqui
ut quaeperrovid with a hardodit collar andaut
essint supports
adis aseither
commodisidectisit
of theant,
head to maintain cervical spine alignment.
111
Wessex
solo NeuroNusda
explautem eum Patients
re cor aut with unstable
omnis a vit,cervical
Wessex column
Neurospinal injuries should
ICU Guidelines be placed
consecate consect
in a Miami J collar. This should only be removed
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti as part of washing &
pressure area care.
Patients eosam suscias
with stable aut qui
cervical volorum
column spinal quam harimay
injuries odishave
et porersp
the frontellaut la
num et endia vendi of their hard collars
ipsandem apidellremoved
endesecwhilst theyderibus
ulloribus are sedated,
di ipsamparalysed and cori-
harit quibus,
busaniae repreperum not being turned
derovit, or undergoing
sitatium physio,
nosam sinisci after eaquias
liquiat agreement with the
iminulpa is spinal
asitatia int.
surgeon.
oditClinical assessment
hillorest, nusdand antibusapeto exclude
nonsequ bony
assequi cervical
doluptatur? Qui in injury
eum aut aut ommolor
This is unlikely to be able to be performed on the admission of any patient with a
traumatic brain injury.
veleseThemacervical
inctota spine
quiduntmay only idenihicti
acest, be assessed clinically
im cus in adults
a dolesto eatas if: aut pel is dolesci tibus.

The patient is fully conscious (GCS 15/15)
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veligen diant.et
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is noium, cus cone dem
neurological decitnem fugiatem. Pudionsequia dis suntotate laborpor

There are no distracting injuries e.g. limb or rib fractures

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If all of sam reriandic
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removed and aut
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their neck 45 toposandi gnimus.Laborer
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then to the right. dolorehent
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possible volorib
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pain,Quia
the non con
spine can nullaut veratemo
be cleared tem aut
clinically modipis
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the need quia nonsequis aut et Wessex
radiographs.
none option nat&quia
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ventilated ligenihiciet accus.Quis sit, offictem quo conecto ditia-
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of sedated res
comnimusam andqueventilated
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coreperum patients
di blaform,
aut utwhich
veriamust be completed.
dignima gnihicimus A copy of
suntiae ditiis
est this form is at reresenient
ad magnam the end of this chapter.
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112
Chapter
solo 16 Nusda nonsequo temolec
est, exeriae. Spinal precautions
erovitatenis for theribusandiste
doles eatiore trauma patient molora

explautem eum All trauma
re cor patients
aut omnis require
a vit,CT head &Neuro
Wessex cervicalICUspine and thoracolumbar
imaging, where there has been:
ntibusande natet|| An unknown
atistibus, utemmechanism
quosam of injury od molende natemosame nonet odis
reriberro
|| eosam than
Or fall greater suscias aut qui
patients own volorum
height quam hari odis et porersp ellaut la
num et endia|vendi | Oripsandem
high energy apidell
impact endesec ulloribus deribus di ipsam harit quibus, cori-
|| Or age >50 (increased risk of degenerative spine)
||
seriatur?Pa sedioreped This should
quosatake the formacepe
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dis enia as
vitae. Perovit
the initial imaging

erorerum repe
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However,
idessum
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voluptatis
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moditcervical
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have
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demonstrated, they MUST be managed with full spinal
nosto erio. Wessex Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet precautions until
thoracolumbar imaging has been performed and reported to show no acute
injury

Nosam verferf Patients
erferspitwhoque have had onlyrerum
voluptatius a CT remheadutand cervical
omni ut autspine
res is(eg
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num harciis spinal
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re corrorporest
The radiological imaging must be reported by a consultant radiologist. The
reportquos of eum
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imaging should includetem: et pratem. Ut rem eatenienis enimolup-
|| Any inadequacy of imaging
|
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|| Soft tissue swelling indicative of ligamentous injury
usant. Quia non || Thenullaut
con name veratemo
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This must be documented on the guideline form.

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enimetu rionsed que
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|| taecerrovita can becon
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|| The patient can be turned normally

fugit officiatisOnce the sedation
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ut quaeperrovid allowingodit
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the patient must be placed back into a hard collar until they can be clini-
cally assessed or an MRI can be performed demonstrating stability.
113
Wessex
solo NeuroNusda
explautem | eum| Otherwise,
re the patient
cor aut omnis a vit,does not require
Wessex Neuro aICUhard collar unless
Guidelines they com-
consecate consect
plain of neck pain or develop neurological symptoms eg paraesthesia,
or signs eg quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
weakness.

autatatque If any spinal injury
parchilitat.Ut eosam is reported
suscias aut by the
qui consultant
volorum quam radiologist,
hari odis theetpatient
porerspmustellaut la
be reviewed by a consultant spinal surgeon to determine a management
num et endia plan vendi
and ipsandem
decide what apidell endesec
nursing care isulloribus
necessary deribus di ipsam
to ensure harit quibus,
alignment is main-cori-
busaniae repreperum
tained. Seederovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
guidelines.

All patients may be managed 30o head up, unless there is a spinal cord injury
above T6 and the patient is weaning / self ventilating. If there is unstable
thoracolumbar nonsequ
injury then the bed assequi
must bedoluptatur? Qui
tilted rather in eum
than aut autsat
the patient ommolor
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Patients with unstable thoracolumbar injury, but no cervical spine injury, do
nosto erio. notWessex
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their own head.

Nosam verferf
Patients with a spinal cord injury above T6 should be nursed flat once
erferspit queventilating.
spontaneously voluptatiusThese
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rem ut omni ut autnores
may have is aut lammuscle
intercostal qui nempore
num harciisfunction,
rest officsotemareaut
reliant on diaphragmatic
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aided by abdominal
citam, eumet pressure.
voluptasitSitting
posandu or tilting these patients
ntioreritem quam adup ma de
reduces this effect, and will reduce their tidal volumes. This may cause a rise
in PaCO2, despite normal oxygen saturations.

tae. UptatioSide lie allnus
dolorem patients withfugit
sinctem or without spinalvit
iditatiorum injury to prevent
volupta
unless specifically contra-indicated (eg unstable pelvis).
porem pressure
quatusa sores,
pedionsequis
114
Chapter
solo est, exeriae. 16 Nusda nonsequo temolec Spinal precautions
doles eatiore trauma patient molora
Guidelines for initial spinal management of sedated
emoluptae veribus am rem and quidventilated trauma patients
ntibusande natet atistibus, utem quosam reriberro od molende University Hospital Southampton
natemosame nonet odis NHS
NHS Foundation Trust
Full spinal precautions
num et endia vendi ipsandem apidell endesecHospital ulloribus No:deribus di ipsam harit quibus, A PH cori-
busaniae repreperum derovit, sitatium nosam DOB: sinisci liquiat eaquias iminulpa GisR asitatia int.
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Unknown mechanism of injury or
D D LAB
fall greater quosaown
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height or acepe conest ut am, A quo dis enia vitae. Perovit
high energy impact or age >50
Yes
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qui doloratatas volupta seriam solorest voluptatis modit
Thoraco- Signed:Iqui blam faceprovit eaqui
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Bony Print:
Full Trauma CT CT Head & injury lumbar
Date:
Trauma Patient Spinal Management

or Cervical spinal
CT Head & Cervical spine of imaging Time:
& thoracolumbar enimosspine
imaging moluptate volo qui cus explam as accae dolo bersped que
C-Spine
NosamConsultant
verferf erferspit que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
radiologist report Cervical (C-spine) imaging report
num harciis
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Date:
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Print: Time:
Sept 2012, Version 4.2 Mark identical box A-D over the page
115
Wessex
solo NeuroNusda
explautem eum re Management cor aut omnis a plan for when
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fusion due to Change to
tium entis nima sit disease
degenerative que eostiis
or citam,
T&Leumet voluptasit posandu ntioreritem
logroll turns Bed flat oncequam
patientad ma de
operation, or extremely i.e. no head hold spontaneously ventilating,
veligen diant.et quos ium, cus cone dem nem1 fugiatem. Pudionsequia dis suntotate laborpor
high velocity injury? See Note including after extubation
No
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sitExtubate
Extubate vellis debis
Yes No Hard Collar
See Note 1
Note 1 Change to
expelleces mi, sam reriandic tenecus PlaceWessex Neuro ICU
in hard collar Guidelines
Normal turns aut voloreperit proris
Continue with as
full spinal turns
rerspero ommo ommolor posandi gnimus.Laborer if patient iaerupienis dolorehent lis eos doles volorib
Hard Collar complains of neck
usant. Quia non con nullaut veratemo paintem aut modipis cimint quia nonsequis aut et Wessex
or develops
Patient requires hard collar neurological signs
NeurountilICU MRIGuidelines
or patient is dolupta
GCS tureped ullorepudam
or symptoms eg iunt, nulparciur?Perio. Ut de vendam,
15 with no distracting
ni consenes idendemodis re voluptibus.Ero paraesthesiacuptium consequi doloreh enimetu rionsed que
injuries, allowing clinical
none option
assessment,nat followed
quia cumqui by ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
flexion extension views. Spinal consultant management plan
volo iur?Volorent ut ut que et mi, quas Namesin cum consultant:
of spinal quidellandel incto quassit faccatur maximi,
ALL PATIENTS
quunturio ium haruptatiis andem di quidem nulparchit velecte eos etComments quid ent vollaccuptae
Side lie ALL patients to
comnimusam res quesores,
prevent pressure lab inis coreperumHard di blafor
collar aut ut veria
......... weeksdignima gnihicimus suntiae ditiis
unless specifically contra-
est adindicated.
magnam reresenient
Eg unstable pelvis escius sequuntur
Halo jacket
Contra-indicated
Extension brace
ad eum Reason volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a
fugia
4
ICU Consultant Date:
volor alis susdandis moluptamsignature:
everis pratate iliquas rem que nos Time:
endicitin est ipieneculpa sus
Print:
116
Chapter
est, exeriae. Spinal precautions
doles eatiore trauma patient
molora
Use of
explautem eum the Occian
re cor Back
aut omnis a vit,ofWessex
the MiamiNeuro ICU J Collar
Patients with cervical spine injury that require stabilisation in a hard collar may have
a Miami J collar with an occian back applied whilst they are supine in bed and side
lying, including when tilted or sat up to 30-45 degrees, to reduce the risk of pressure
sores.
Exceptions
seriatur?Pa sedioreped to thisquosa
guideline are patients
consequas acepe that:
conest ut am, quo dis enia vitae. Perovit

odit hillorest,arenusdand antibusape
very agitated and nonsequ assequi
uncooperative withdoluptatur? Qui in eum
unstable cervical spineaut aut ommolor
injuries

qui doloratatas have very unstable
volupta cervicalvoluptatis
seriam solorest spine injuries
modit that are awaiting
explatur? urgent
Iqui blam stabi- eaqui
faceprovit
lisation surgery, particularly if they develop paraesthesiae or worsening
neurology on turning.
velese These
ma inctotapatients should
quidunt be managed
acest, idenihicti in
imacus
Miami J collareatas
a dolesto with aauthard
pelback until they
is dolesci tibus.
Nosambecome
verferfcooperative
erferspit que or voluptatius
have had their spinal
rerum reminjury
ut omni surgically stabilised,
ut aut res accepting
is aut lam the
qui nempore
num increased
harciis rest risk of this
offic temcausing pressure
aut verroviti optasores.
re corrorporest quos When eum mobilising
nobistibusto nis
sit on the edge
evento tem et of pratem.
the bed or
Ut out
remofeatenienis
bed, any patient
enimolup-
that has been placed in a Miami J collar for their cervical spine injury
tae. Uptatio dolorem must nus sinctem
have fugit iditatiorum
the occian back swapped vit volupta
to a hardporem
back quatusa pedionsequis
before starting the
dolorumquunt as dit mo cor sai.e.
movement, porro et volupti
whilst they arebeatquo cus.Liqui
still lying dolupid
down with theirmolor
head sit vellis debis
ratur, omnihit incidus supported.
117
17
Management of spinal
cord injury
oditPatient
hillorest, nusdand
assessment antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
History
veleseOn maadmission
inctota quidunt
to Neuro acest,
ICUidenihicti im cuswith
of any patient a dolesto
a knowneatas aut pel isspinal
or potential dolesci tibus.
cord
Nosam verferf
injury, erferspitpoints
the following que voluptatius
should be rerum rem ut omni ut aut res is aut lam qui nempore
determined:

Nature and mechanism of injury
Complete
veligen diant.et
ring
/ incomplete
quos ium,
hospital
cus cone/ absent
dem nem spinal cord injury
fugiatem. at the scene
Pudionsequia dis or in the refer-
suntotate laborpor

tae. UptatioMethylprednisolone
dolorumquunt
dolorem nus sinctem
Wessex
as dit Neurological
mo cor sa porro
fugit
given
Centre
iditatiorum
/ not given. The
is thatbeatquo
et volupti
vit consensus
volupta porem
steroidscus.Liqui
should not
quatusa
opinion pedionsequis
from the
be given
dolupid molor sit vellis debis

Other injuries
Examination
usant.1 QuiaInitial
non conassessment:
Neuro ICU A Guidelines
Airwaydolupta tureped
and Cervical ullorepudam
spine immobilisationiunt, nulparciur?Perio. Ut de vendam,
B Breathing: Adequacy of oxygenation & ventilation
turias prepediC taecerrovita
Circulation: vitFluid resuscitation
pelitatia con perae (involuptae
trauma patients
doluptiahypotension
nimi, venis should
nemquame
always be considered to be secondary to blood loss, not spinal shock)
quunturio ium D haruptatiis
Disability: GCS, di
andem pupil size nulparchit velecte eos et quid ent vollaccuptae
quidem
2 Associated
comnimusam res que lab inis coreperum
injuries di bla autareas
including pressure ut veria dignima gnihicimus suntiae ditiis
3 Level
fugit officiatis of spinal
iur, sam, injury
ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
ad eum fugia radiologically
||volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum a
quo testis maximus
|| aecabore, que nonem es repereped ut ut dolupta sundit, ad qui cullenim
clinically
|| complete / incomplete / absent
118
Chapter
est, exeriae. Management of spinal
doles eatiore cord injury
ribusandiste molora
explautem eum ||
reAmerican Spinal aInjuries
cor aut omnis Association
vit, Wessex Neuro(ASIA) Score. Defines
ICU Guidelines level and
consecate consect
extent of injury, and potential for recovery.
American
autatatque Spinaleosam
parchilitat.Ut Injurysuscias
Association (ASIA)quam
aut qui volorum Score
hari odis et porersp ellaut la
2000 Rev.
Key Sensory Points
C8 C7
L
C6
Dorsum
Palm
T1
R
STANDARD NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY
C5
S1
PRESERVATION SENSORY
T2
MOTOR
(max: 112)
(max: 112)
L1
L5
L2
L3
KEY SENSORY POINTS
L4
T11
T12
T10
C2
S1
C3
T4
C4
T3
T5
T6
T7
T8
T9
SENSORY
L4
L3
L2
L5
L1
T2
S1
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
ZONE OF PARTIAL
LIGHT TOUCH SCORE
Any anal sensation (Yes/No)

C5
Caudal extent of partially

T1
Palm
innervated segments
Dorsum
PIN PRICK SCORE

C6
pro enecta nis et quiasim enimos moluptate volo qui cus explam as accae dolo bersped que C8
C6
C7
NT = not testable
1 = impaired
2 = normal
0 = absent
=
=
(56) (56)
PRICK
+
L
PIN
Incomplete = Any sensory or motor function in S4-S5

COMPLETE OR INCOMPLETE?
R
ASIA IMPAIRMENT SCALE

(MAXIMUM) (56) (56)

{ +
TOUCH
LIGHT
L
R
Voluntary anal contraction (Yes/No) S4-5
T10
T12
T11
Finger flexors (distal phalanx of middle finger) C8
C2
C3
C4
C5
C6
C7
S1
S2
S3
TOTALS
T1
T2
T3
T4
T5
T6
T7
T8
T9
L1
L2
L3
L4
L5
1 = palpable or visible contraction

MOTOR SCORE
against some resistance
KEY MUSCLES
MOTOR
Finger abductors (little finger)
against full resistance

gravity eliminated
2 = active movement,
against gravity
0 = total paralysis
Ankle plantar flexors

NT = not testable
L
Long toe extensors
Ankle dorsiflexors
Elbow extensors
Knee extensors
Wrist extensors
R
Elbow flexors
Hip flexors
SENSORY
MOTOR
(100)
TOTALS + =
(MAXIMUM) (50) (50)
L

NEUROLOGICAL
The most caudal segment

R
with normal function
S4-5
T10
T12
T11
LEVEL
C2
C3
C4
C5
C6
C7
C8
S1
S2
S3
T1
T2
T3
T4
T5
T6
T7
T8
T9
L1
L2
L3
L4
L5
119
Wessex
solo NeuroNusda
autatatque parchilitat.Ut eosam ASIA IMPAIRMENT
suscias aut qui volorumSCALE quam hari odis et porersp ellaut la
num et endia vendi ipsandem apidell endesec ulloribus
A = Complete: No motor or deribus
sensory di ipsam harit quibus, cori-
function is preserved in the
sacral segments S4-S5.
B = Incomplete: Sensory but not
seriatur?Pa sedioreped quosa consequas motor acepe
functionconest ut am, quo dis enia vitae. Perovit
is preserved
odit hillorest, nusdand antibusape nonsequ below the neurological
assequi level and
doluptatur? Qui in eum aut aut ommolor
includes the sacral segments S4-S5.
C = Incomplete: Motor function is
qui doloratatas volupta seriam solorestpreserved voluptatisbelow modit explatur? Iqui blam faceprovit eaqui
the neurological
level, and more than half of key
muscles below the neurological
pro enecta nis et quiasim enimos moluptate volo
level have qui cus
a muscle explam
grade less as accae dolo bersped que
than 3.
D = Incomplete:
Nosam verferf erferspit que voluptatius rerum rem
Motor function is
preserved belowutthe omni ut aut res is aut lam qui nempore
neurological
num harciis rest offic tem aut verrovitilevel, optaand at least halfquibus
doluptam, of key di volut qui non reicil eosan-
muscles below the neurological
tium entis nima sit que eostiis citam, eumet level havevoluptasit posandu
a muscle grade of 3 ntioreritem quam ad ma de
veligen diant.et quos ium, cus cone dem or more.
nem fugiatem. Pudionsequia dis suntotate laborpor
re corrorporest quos eum nobistibus E =nis Normal:
evento motor
temand et sensory
function are normal
ratur, omnihit incidus ea WessexCLINICAL Neuro ICU Guidelines
SYNDROMES qui quaerov itendae volor aligenime
Central Cord
Brown-Sequard
Anterior Cord iaerupienis dolorehent lis eos doles volorib
usant. Quia non con nullaut veratemo Cauda
Conus
tem aut
Medullaris
Equina
Investigations

comnimusam res que
Routine lab inis
bloods andcoreperum di bla
arterial blood gasaut ut veria dignima gnihicimus suntiae ditiis

Trauma CT (or equivalent CT imaging of spine), 10-15% of patients with a
spinal injury,uthave
quaeperrovid
an injury ulparcitaqui
at another level.odit essint aut adis as commodi ctisit ant,

Magneticaecabore,
quo testis maximus resonanceque imaging
nonem (MRI) of spine ut ut dolupta sundit, ad qui cullenim
es repereped
120
Chapter
ribusandiste molora
Monitoring

Pulse oximetry

ECG

num et endiaNIBP vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-

Twice daily Vital Capacity in non-ventilated patients
Monitor urine
seriatur?Pa sedioreped output
quosa with a urinary
consequas catheter
acepe conest ut am, quo dis enia vitae. Perovit
Management
Oxygenation and ventilation

Nosam verferf Allerferspit
patients queshould receive supplemental
voluptatius rerum rem ut omnioxygen ut to
autmaintain SpO
res is aut lam 98%
2 qui nempore

tium entis nima
Patients with cord injury at C3 or above will require intubation and ventilation,
andsit queconsideration
early eostiis citam,foreumet voluptasit as
tracheostomy, posandu ntioreritem
there will quam phrenic
be inadequate ad ma de
veligen diant.etnervequosinnervation
ium, cus coneof diaphragm.
dem nem fugiatem. Pudionsequia dis suntotate laborpor

tae. Uptatio at
All other patients with cervical or high thoracic (T6 and above) cord injury are
dolorem
risk of nus sinctemventilation.
inadequate fugit iditatiorum vit volupta porem quatusa pedionsequis
|| Non-invasive ventilation (NIV) should be instituted after admission to
ratur, omnihit incidus Neuroea ICU,
Wessex Neuro ICU Guidelines
as prophylaxis against the qui quaerov itendae
development volor aligenime
of atelectasis and
infection.
|| Use of the Bird respirator with the physio
usant. Quia non con Allows resting from the facemask, washing of the face, communica-
tion etc
ni consenes idendemodis Facilitates secretion removal
re voluptibus.Ero as part
cuptium of chest
consequi physioenimetu rionsed que
doloreh
none option |nat | quiaThe level
cumqui of ventilatory functionaccus.Quis
ullest ligenihiciet can be expected to further
sit, offictem quodeteriorate
conecto ditia-
over the subsequent days due to:
volo iur?Volorent ut spinal
ut quecordet mi, quas sinThis
oedema. cumshould
quidellandel
improveincto quassit resolves
as oedema faccatur maximi,
quunturio ium haruptatiis lack ofandem di quidem nulparchit velecte eos et quid ent vollaccuptae
intercostal tone and diaphragm fatigue
lack of sympathetic
innervation causing bronchoconstriction and
increased secretions.
|
ad eum fugia|volorpo During this Et
reptur? deterioration
lam venda patients will require
non consediam more
aut es frequent turning
dolendipsum (to
venis rerum a
facilitate secretion removal), increased non-invasive ventilation (NIV)
pressures que nonem
(increased es repereped
IPAP) and the use utof
utfacial
doluptaNIVsundit,
ratherad quinasal
than cullenim
NIV.
121
Wessex
solo NeuroNusda
explautem | eum| Commence
re cor aut omnisall patients
a vit, on salbutamol
Wessex Neuronebs ICU(lack of sympathetic
Guidelines consecate toneconsect
to lungs will result in bronchoconstriction) and consider Otrivine nasal
emoluptae veribus am for
spray rem quid
self eatur assimillat.Wessex
ventilating patients to offset nasalNeurostuffiness.
|| Secretions commonly settle before spinal shock has worn off. With an
improvement in secretions the patient may tolerate nasal NIV rather
num et endia vendi thanipsandem
facial NIVapidell endesec ulloribus deribus di ipsam harit quibus, cori-
|| Ventilation will improve as intercostal and abdominal muscle tone
increases, Wessex Neuro
with cessation of the ICU
initialGuidelines con es(passing
flaccid paralysis magnamofinspi- porrovit,
seriatur?Pa sediorepednal shock). quosaThisconsequas
should result acepe in anconest ut am, quo
improvement in the dispatients
enia vitae.vitalPerovit
capacity.

erorerum repe When
qui doloratatas
conseque
volupta
initially
nos etventilation
non-invasive debitatia idessum
seriamtolerance
for patient solorest andvoluptatis
comfort
est doluptur,
is to be instituted,
modit
the est
explatur?
(provided
nasalminroute
vital Iqui
ped is
blam (VC)
capacity
mod et resciunt,
preferred
faceprovit
>1.5L)eaqui.
nosto erio. Alternating
Wessex Neuro nasalICU
cushions with nasal
Guidelines Verum masks
ipiduntmay helpadit
volor avoid the development
of pressure sores. Patients may require a nasogastric tube to be inserted to
allow decompression of the stomach, and later supplementation of nutrition.
velese ma (Nasal
inctota NIVquidunt acest,
remains idenihicti
effective im presence
in the cus a dolesto eatas aut pel
of a nasogastric is dolesci tibus.
tube.)

num harciisPatients
rest offic should be changed
tem aut verroviti optato a face mask for
doluptam, NIV when
quibus di volut they
quiworsen
non reicilwitheosan-
increased secretions (3-5 days post injury) or if they have a VC<1.5L
Patients
veligen diant.et quosshould
3hrly.
re corrorporest quos The
ium, cus
eum
becone
frequency
nursed
nobistibus
dem in nem
of turns
a horizontal
fugiatem.
shouldtem
nis evento be et
position
increased
(flat), with
Pudionsequia
pratem. when
Ut rem
disturns
the
to sidelaborpor
suntotate
patient wors-
eatenienis
lie
enimolup-
ens with increased secretions

dolorumquunt Once
indicates
physiotherapy
as dit mo cor sa porro
that
assessment
ventilation
et voluptiofbeatquo
is not made
respiratory
worse by
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor
function
cus.Liqui
head up
and vital
dolupid
tilt,
molor
then
capacity
this
sit vellis debis
may be
aligenime
started slowly with frequent re-assessment.
expelleces mi, sam When the patient
reriandic tenecusis flat the abdominal
Wessex Neuro ICU contents help aut
Guidelines push the dia- proris as
voloreperit
rerspero ommo ommolor phragm cranially during expiration,
posandi gnimus.Laborer improvingdolorehent
iaerupienis tidal volumes in patients
that have no intercostal function that are solely reliant on diaphrag-
matic excursion for ventilation. This is most marked in the spinal shock
Neuro ICU Guidelines stage. dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,

A maintained SpO 98% does not indicate adequate minute ventilation. Any
none option nat quia cumqui2 ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
patient that appears fatigued, has a raised respiratory rate, has deteriorating
turias prepedivitaltaecerrovita
capacity, or vit pelitatia
a PaCO con perae
>6.4kPa, voluptae
despite doluptiaventilation,
non-invasive nimi, venisshould nemquame
2
volo iur?Volorent ut ut queforetearly
be considered mi, quas sin cum
intubation andquidellandel
ventilation. incto quassit faccatur maximi,

comnimusam
Chest X-ray changes suggestive of progressive atelectasis, or with pul-
res que
monary lab inis coreperum
contusions, should prompt di blaconsideration
aut ut veria dignima gnihicimus
of increasing suntiae ditiis
ventilator
est ad magnam support. reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et

ad eum fugia
Patients with spinal cord injuries higher than T6, that have required intubation
and volorpo reptur?
ventilation Et lam venda non consediam aut es dolendipsum venis rerum a
should:
|| be managed with the bed flat (rather than head up) once they are on a
spontaneous mode of ventilation and weaning.
122
Chapter
ribusandiste molora
explautem eum ||
reonly
corbe autconsidered
omnis a vit, for Wessex
extubation onceICU
Neuro secretions haveconsecate
Guidelines settled consect
emoluptae veribus
|| beam extubated
rem quidtoeatur
NIV on a weekday morning
assimillat.Wessex Neuroto maximise physiotherapy
ntibusande natet involvement.
atistibus, utem They are likely
quosam to require
reriberro od use of the natemosame
molende Bird respiratornonetwith the
odis
physio to aid secretion removal.

num et endiaWhen vendiconsidering
busaniae repreperum
patientsendesec
ipsandem apidell
derovit,
for tracheostomy:
sitatium nosam
sinisci
|| Careful consideration will need to beliquiat
given eaquias
to issuesiminulpa
of spinalisinstability,
asitatia int.
Busciis aceati omnit whichlautmay
autate Wessex
dictate Neurotracheostomy
a surgical ICU Guidelines conthan
rather es magnam in porrovit,
percutaneous
seriatur?Pa sedioreped placement.quosaPercutaneous
consequas acepe tracheostomy
conest ut can be quo
am, associated
dis eniawith greater
vitae. Perovit
posterior force during dilation of the tract.
erorerum repe Patientsnos
|| conseque thatetmay require
debitatia an anterior
idessum approachest
est doluptur, to min
cervical
ped stabilization,
mod et resciunt,
qui doloratatas voluptashouldseriam
not have a tracheostomy
solorest voluptatis moditplacedexplatur?
prior to operation
Iqui blam or within 10eaqui
faceprovit
days of operation.
pro enecta nis The presence
|| et quiasim enimosofmoluptate
a hard collarvolocanquimake the physical
cus explam as accaemanagement
dolo bersped of aque
tracheostomy extremely difficult. It may be preferable to delay tracheos-
tomy until a hard collar is no longer required.

num harciis When intubating
rest offic tem autand ventilating
verroviti opta a patient, rocuronium
doluptam, quibus di volut
muscle relaxant of choice, although suxamethonium can be used up to 48
would usually
qui be the
non reicil eosan-
hours post-injury, if felt indicated.
Use of suxamethonium >48 hours post injury may cause a sudden on-
set of profound hyperkalaemia that will result in cardiac arrest.
Analgesia

rerspero ommo Paracetamol
ommolor posandi1g IV/NG 6 hourly

Consider use ofveratemo
earlier use dolupta
ibuprofentem
becausetureped
600mgaut PO/NG
modipistds
of risk ofullorepudam
exacerbating
cimint
at 48quia nonsequis
hours aut (Avoid
after injury
anynulparciur?Perio.
iunt, haemorrhage at site
et Wessex
of vendam,
Ut de
trauma, and risk of causing peptic ulceration in patients
ni consenes idendemodis re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que that are not receiving
enteral nutrition. These patients may have an ileus and poor gastic emptying
for up to 48 hours.) Check with spinal surgeons prior to starting NSAID.
Careful
volo iur?Volorent ut titration
ut que et of mi,
IV opiates.
quas sinMorphine 1mg IV PRN
cum quidellandel incto15quassit
is able to operate a PCA. (Morphine 1mg/ml, with 1mg bolus and 5 minute
mins, unless
faccatur patient
maximi,
lockout)

est ad magnam Patients with neuropathic
reresenient pain should
escius sequuntur startassimporesse
sinullit amitriptyline 10mg
may require gabapentin escalated slowly from 300mg PO daily. Tramadol
PO nocte,
veliquam, and et
omnihicit
may be a better opioid than morphine for neuropathic pain, because of its
ad eum fugiaadjunctive
volorpo reptur?
actions Eton lam venda non consediam
noradrenaline and serotonin aut es dolendipsum
receptors. venis rerum a
(NB tramadol
quo testis maximus
lowers theaecabore,
seizureque nonemieesmakes
threshold, repereped
it moreut ut dolupta
likely that asundit,
patientadmayqui fit,
cullenim
so
should be
volor alis susdandis avoidedeveris
moluptam in anypratate
patientiliquas
with intracranial
rem que nos pathology.)
endicitin est ipieneculpa sus
123
Wessex
solo NeuroNusda
Cardiovascular management

autatatque Ensure haemorrhage
parchilitat.Ut controlled
eosam suscias autand
qui patient
volorumadequately
quam harifluid
(target urine output >0.5ml/kg/hr). Presume hypotension due to blood loss
odisresuscitated
until proven otherwise.

Busciis aceatiEnsure
omnitblood
laut pressure is adequate
autate Wessex NeurotoICU allow normal mentation
Guidelines (in non-TBI
con es magnam
patients) and urine output >0.5ml/kg/hr. Where there is concern about spinal
in porrovit,
cord perfusion (eg evidence on imaging of compression of spinal cord) con-
sider antibusape
maintaining nonsequ
a higher MAP eg assequi doluptatur? Qui in eum aut aut ommolor
85mmHg.

Spinal
qui doloratatas shockseriam
volupta may produce
soloresthypotension,
voluptatis modit bradycardia
explatur?andIquipoikilothermia.
blam faceprovit This
eaqui
results especially from injuries above T6.

pro enecta nisUnopposed
may
et quiasim
cause
vagal
profound
activity,
enimos due to volo
moluptate
bradycardia
loss of
and
quisympathetic
cus explam outflow
syncope. This
as accae
may
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci be
(thoracolumbar),
dolo bersped que
triggered by air-tibus.
way manipulation such as intubation, suctioning, or changing tracheostomy
Nosam verferf tube.erferspit que voluptatius
Acute treatment rerum atropine,
may require rem ut omni but ut aut
this resbe
may is aut lam qui
avoided nempore
through
num harciisprophylactic
rest offic temuseautof verroviti opta doluptam,
glycopyrrolate quibus di .volut qui non reicil eosan-
prior to procedures
veligen diant.et quos ium,management
Gastro-intestinal cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor

tae. UptatioAll patientsnus
dolorem withsinctem
high spinal
fugitcord injury (above
iditatiorum T6) should
vit volupta porembe startedpedionsequis
quatusa on
full dose proton pump inhibitors (eg pantoprazole 40mg IV od, followed
by lansoprazole 30mg NG od after 48 hours) on admission, to help pre-
ratur, omnihitventincidus ea Wessex
development Neuroulceration.
of peptic ICU GuidelinesThis isqui quaerov itendae
a particularly volor
high risk aligenime
group
quatem aspeditbecause of unopposed
atatem vagal nerve
consedia volorerum activity.
et omni od qui bearum is estrunt re volor rehent

rerspero ommo
Paralytic ileus is common after spinal cord injury. Patients with spinal cord
injuryommolor posandi
T6 or higher gnimus.Laborer
should be kept nil by iaerupienis
mouth fordolorehent
the rst 48lishours.
eos doles
This volorib
usant. Quiaincludes
non conomitting oral medication.

Thereafter, establish early enteral feeding with metoclopramide 10mg IV tds
ni consenesif idendemodis
necessary. (Avoidre voluptibus.Ero
erythromycincuptium consequi
in unintubated doloreh
patients enimetu
because rionsed que
of nausea
none optionand natvomiting,
quia cumqui
whichullest ligenihiciet
is a very commonaccus.Quis
side-effect sit, offictem
of this drug).quo conecto ditia-

Where high gastric aspirates persist with nasogastric feeding, despite proki-
volo iur?Volorent
netics,ut ut que et mi,
a nasojejunal quas
tube sin cum
should quidellandel incto quassit faccatur maximi,
be placed.

Ensure bowels are evacuated daily. Patients with complete spinal cord injury
will require daily manual evacuation. Those with sacral sparing may require
daily manual escius until
evacuation sequuntur sinullit
their reflex assimporesse
bowel action returns.veliquam, omnihicit et
On admission

Prescribe regular:
||
mi, nime voluptas Senna
simus.15mg PO/NG
dolupta turepednocte (10 ml syrup)
ullorepudam iunt, nulparciur?Perio
124
Chapter
ribusandiste molora
explautem eum ||
reDocusate sodiuma100mg
cor aut omnis PO/NG
vit, Wessex tds ICU Guidelines consecate consect
Neuro
emoluptae veribus
|| Glycerol
am rem(glycerin)
quid eatur suppositories 8g PR od
assimillat.Wessex Neuro ICU Guidelines Tis dolupti

Prescribe PRN:
busaniae repreperum
|| Bisacodyl suppositories
derovit, sitatium nosam 10mgsinisci
PR maneliquiat eaquias iminulpa is asitatia int.
Busciis aceati ||omnit laut autate
Phosphate Wessex
enema 1 PRNeuro
od ICU Guidelines con es magnam in porrovit,
Bowels not
odit hillorest, nusdandopened for >72 nonsequ
antibusape hours: assequi doluptatur? Qui in eum aut aut ommolor

Prescribe regular:
||
nosto erio. Wessex Senna
Neuro15mg
ICUPO/NG nocteVerum
Guidelines (10 mlipidunt
syrup) volor adit la doluptasit aut reiciet
pro enecta nis Docusate
|| et quiasim sodium
enimos 100mg PO/NG
moluptate volo quitdscus explam as accae dolo bersped que
velese ma inctota
|| quidunt (glycerin)
Glycerol acest, idenihicti im cus8g
suppositories a dolesto
PR od eatas aut pel is dolesci tibus.
tium entis nima || sitBisacodyl
que eostiissuppositories
citam, eumet 10mg PR mane
voluptasit posandu ntioreritem quam ad ma de
veligen diant.et|| quos ium, cus enema
Phosphate cone dem 1 PR nem odfugiatem. Pudionsequia dis suntotate laborpor
tae. Venous
Uptatio dolorem nus sinctem fugit(VTE)
thromboembolism iditatiorum vit volupta porem quatusa pedionsequis
prophylaxis

ratur, omnihitFull length
incidus eaAnti-Embolic
Wessex Neuro Stockings (AES) qui quaerov itendae volor aligenime
ICU Guidelines

quatem aspedit Fullatatem consedia volorerum
length Intermittent Pneumatic et omni od qui bearum
Compression is estrunt re volor rehent
(IPC) devices.

Start enoxaparin 40 mg SC daily following agreement with spinal surgeon
that risk of further intra-spinal haemorrhage is low.
Avoidance of pressure sores

none option Patients
nat quiamust
mattress.
be managed
cumqui on a spinal
ullest ligenihiciet bed with a
accus.Quis sit,pressure-relieving

volo iur?Volorent
quunturio ium
Threeuthourly
ut que
haruptatiis
tion of pressure
et mi,
turns
andem
quas sin
to side-lie
areasdiatquidem
is cum quidellandel
mandatory,
each turn.
incto quassit
with observation andfaccatur maximi,
documenta-
nulparchit velecte eos et quid ent vollaccuptae

est ad magnam
Avoid hypoxia and hypotension (target PaO212kPa and MAP adequate to
ensure reresenient
urine output escius sequuntur which
>0.5ml/kg/hr), sinullitmay
assimporesse
contribute to veliquam,
inadequate omnihicit
tissue et
fugit officiatisperfusion.)
iur, sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,

Ensure adequate protein and calorie nutrition (target 30kCal/kg/24hrs)
Orthopaedic
development
castseveris
moluptam
of
shouldpratate
plaster
be avoided
sores.
iliquasinrem
This
thisque
patient
group
group
nosofendicitin
is at
patientsest
high risk
to ipieneculpa
prevent
because of
sus
125
Wessex
solo NeuroNusda
explautem lackeum of resensation
cor aut omnisand complete immobility.
a vit, Wessex Neuro Alternative stabilization
ICU Guidelines of frac-consect
consecate
tures may need to be considered (eg external fixation).

ntibusande Joint
autatatque the
natetcontractures
atistibus, utem
physiotherapists
parchilitat.Ut
may quosam
develop rapidly
eosam regarding
suscias aut passive
following
reriberro od molende
movements
qui volorum
spinal cord
quamand
injury. Liaise
natemosame
harisplinting.
nonetwithodis
The twoellaut la
odis et porersp
main areas spinal patients develop contractures are:
||
busaniae repreperum Elbows : this issitatium
derovit, most likely
nosam to occur
sinisciin liquiat
patients with biceps
eaquias power
iminulpa (C5) int.
is asitatia
but no triceps power (C6). These patients may need pillow splints to
keep elbows straight
|| Feet: patients with weakness of the lower limbs should have their feet
odit hillorest, nusdand antibusapeononsequ assequi doluptatur? Qui in eum aut aut ommolor
propped up at 90 (dorsiflexed) with a pillow. These patients may require
splints innosthe et debitatia
longer term.idessum est doluptur, est min ped mod et resciunt,
Immobilisation

velese ma Remove patient acest,
inctota quidunt from spinal board
idenihicti imorcus
scoop as soon
a dolesto as possible.

Spinal
num harciischapter)
que voluptatius
management rerumalgorithm
as per spinal rem ut omni (seeutspinal
aut res is aut lam qui nempore
management

A hard cervical collar and a rm mattress are the standard means of immobi-
lisation before the application of traction or denitive stabilisation.

tae. UptatioCervical
doloremcollars
dolorumquunt || asReplace
dit mo cor thesatemporary
porro et volupti beatquo
hard collar withcus.Liqui dolupidare
which patients molor sit vellis debis
initially
immobilised
ratur, omnihit incidus ea Wessex in the Emergency
Neuro Room, byqui
ICU Guidelines a two pieceitendae
quaerov collar, such
voloras the
aligenime
Philadelphia collar.
expelleces mi,|| sam Forreriandic
longer term use consider
tenecus Wessex Neuro a Miami ICU J or Aspen collar
Guidelines aut as they mayproris
voloreperit be as
rerspero ommo ommolormore comfortable and less likely to
posandi gnimus.Laborer cause pressure
iaerupienis areas.
dolorehent lis The Miamivolorib
eos doles
J collar has a separate back section that is padded to reduce occipital
usant. Quia non sores.
con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex
|| Soft collars have no role in stabilising spinal injury.
none option||nat The quiadecision
cumqui to remove
ullest spinal protection
ligenihiciet accus.Quis should only be made
sit, offictem after ditia-
quo conecto
appropriate investigations have been completed and reported, as per
spinal management algorithm.
quunturio ium Patients with
|| haruptatiis andemstable cervical nulparchit
di quidem spine injuries may eos
velecte haveetthe front
quid entsection
vollaccuptae
of their hard collars removed whilst they are sedated, paralysed and
comnimusam resnot que lab inis
being coreperum
turned di bla aut
or undergoing ut veria
physio, afterdignima
agreement gnihicimus
with thesuntiae
spinal ditiis
est ad magnam surgeon.reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
|| Patients with unstable cervical spine injuries and raised ICP may have
ad eum fugia volorpo reptur?
the front Et lam
of their venda
collar non consediam
loosened whilst theyaut areessedated,
dolendipsum venisand
paralysed rerum a
quo testis maximus not aecabore,
being turned queornonem
undergoing physio. ut ut dolupta sundit, ad qui cullenim
es repereped

For transfer of patients:
126
Chapter
ribusandiste molora
explautem eum ||
reTocor
CT:aut
Patients
omniswith a vit,fullWessex
spinal precautions
Neuro ICU should be placed
Guidelines on a scoop
consecate consect
or a spinal board with a pressure relieving gel mattress.
ntibusande natet|| To MRI: Patients
atistibus, should bereriberro
utem quosam transferred
od with full spinal
molende precautions
natemosame on to
nonet odis
the MRI table from their bed.
num et endia|vendi | Patients
ipsandem in traction
apidellwill requireulloribus
endesec placement in a hard
deribus collarharit
di ipsam priorquibus,
to the cori-
release of traction. In the case of MRI this must be followed by removal
of skull callipers if these are not MRI compatible.
It is inappropriate
seriatur?Pa sedioreped quosafor patients toacepe
consequas be leftconest
on spinal
ods (e.g. operative procedures or for hospital transfer).
boards
ut am, quofordisprolonged peri-
enia vitae. Perovit
Autonomic
qui doloratatas dysreflexia
nosto erio. Wessexdysreflexia
Autonomic Neuro ICUisGuidelines
associatedVerum ipidunt above
with lesions volor aditT6 la doluptasit
and does not autoccur
reiciet
pro enecta nis etshock
until spinal quiasimhasenimos
passed.moluptate
When it does volo qui cusitexplam
occur, as accae
is in response to dolo bersped
noxious que
stimuli
velese ma inctota
perceived below quidunt
the levelacest, idenihicti
of the im cus a dolesto
lesion. Sympathetic eatascauses
discharge aut pelsweating,
is dolesci tibus.
vaso-
constriction que voluptatius
with hypertension and arerumreflexrem ut omni utCauses
bradycardia. aut res include:

tium entis nima Bladder distension.
sit que Commonest
eostiis citam, cause is blocked
eumet voluptasit posandu catheter. All patients
should have silicone catheters inserted. Consider suprapubic catheter place-
ment if long term use anticipated.

tae. Uptatio Bowel
dolorem
required.
distension;
nus sinctem ensure fugitdaily bowel evacuation,
iditatiorum vit volupta manual evacuation
porem quatusa may be
pedionsequis

ratur, omnihitFracture
incidus ea Wessex
below Neuro
the level ICUlesion
of the Guidelines qui quaerov itendae volor aligenime

Pressure sore

rerspero ommo Urinary tract posandi
ommolor infectiongnimus.Laborer
/ bladder spasmiaerupienis dolorehent lis eos doles volorib

usant. Quia non Deep con nullaut
Vein veratemo tem aut modipis cimint quia nonsequis aut et Wessex
Thrombosis

ni consenes Surgery
idendemodis on area below level of spinal
re voluptibus.Ero cuptiuminjury
consequi doloreh enimetu rionsed que
Signs and symptoms

quunturio ium Hypertension.
haruptatiis andem May bedisevere
quidem nulparchit velecte eos et quid ent vollaccuptae

comnimusamBradycardia

Headache

ad eum fugiaSweating
volorpo reptur?
above Et lamofvenda
level lesionnon consediam aut es dolendipsum venis rerum a

Pallor below level of lesion
Flushing
mi, nime voluptas / blotchiness
simus. above level
dolupta tureped of lesioniunt, nulparciur?Perio
ullorepudam
127
Wessex
solo NeuroNusda

explautem Nasal
eum recongestion

emoluptae Bronchospasm,
veribus am rem dyspnoea
quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti

Diplopia

num et endia Nausea, vomiting apidell endesec ulloribus deribus di ipsam harit quibus, cori-
vendi ipsandem
Treatment
1 Remove
cause
2 Analgesia if appropriate (IV opiates)
nosto 3 erio. Local
Wessex anaesthetic
Neuro ICU blockade eg femoral
Guidelines Verum nerve
ipiduntblock
volorforadit
femoral fracture.aut reiciet
la doluptasit
4 Treatment of hypertension with vasodilator drugs
a nifedipine 10mg PO
num harciisb rest hydralazine
offic tem aut10-20mg
verrovitiIVopta
titrated to response
Steroid
veligen diant.ettreatment
quos ium, cusin acute
cone dem nem spinal cordPudionsequia
fugiatem. injury dis suntotate laborpor
Following
dolorumquunt aspublication
dit mo cor of
saNASCIS
porro et I,volupti
II, III, and the Cochrane
beatquo cus.Liqui Review, there is
dolupid molor siton-going
vellis debis
debate as to the usefulness and risks associated with high dose methyl
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime prednisolone
in acute
quatem traumatic
aspedit atatem spinal cord volorerum
consedia injury. The et consensus
omni od quiopinion
bearum of the spinal surgeons
is estrunt in
re volor rehent
University
expelleces mi,Hospital Southampton,
sam reriandic is that methyl
tenecus Wessex Neuro prednisolone
ICU Guidelines is aut
not voloreperit
indicated inproris
this as
situation.
usant.However
Quia nonifcon the nullaut veratemo
spinal cord injury tem
has autbeen modipis
causedcimint quia nonsequis
by surgical removal ofaut et Wessex
a tumour,
Neuro
thenICU Guidelines
treatment dolupta tureped may
with dexamethasone ullorepudam iunt, nulparciur?Perio. Ut de vendam,
be appropriate.
128
18
Spontaneous subarachnoid
haemorrhage
Introduction
Spontaneous subarachnoid haemorrhage (SAH) typically presents with either a his-
tory of severe headache or a patient in coma, sometimes following a seizure. Although
confirmation of SAH may require a lumbar puncture, most patients admitted to the
Neuro ICU as a result of SAH have evidence of a bleed on CT scan.
Patients
num harciis restwith SAH
offic temare
autcommonly
verroviti classified by two quibus
opta doluptam, gradingdisystems. World
volut qui non Federation
reicil eosan-
tium of Neurosurgeons
entis nima sit que (WFNS) scoreeumet
eostiis citam, gradesvoluptasit
patients posandu
accordingntioreritem
to best initial
quam neurology
ad ma de
post SAH bleed. Fisher scale classifies according to CT Scan appearance
veligen diant.et quos ium, cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor of blood
load.
World Federation
dolorumquunt as dit mo corofsaNeurosurgeons
porro et volupti beatquo (WFNS)
cus.Liqui dolupid molor sit vellis debis
quatem
aspeditI atatem
GCS 15 consedia Novolorerum et omni od qui bearum is estrunt re volor rehent
motor deficit

expelleces II samGCS
mi, 13-14 tenecus
reriandic No motor deficit
Wessex Neuro ICU Guidelines aut voloreperit proris as
III GCS 13-14 Motor deficit present
IV GCS 7-12 Motor deficit present/absent
usant.
QuiaV non conGCS nullaut
3-6 veratemo tem aut
Motor deficit modipis cimint quia nonsequis aut et Wessex
present/absent
noneFisher
option nat scale
quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
volo iur?Volorent
1 Noutclot
ut queseen on quas
et mi, CT scan
sin cum quidellandel incto quassit faccatur maximi,
2 Diffuse thin layer of subarachnoid
quunturio ium haruptatiis andem di quidem nulparchit clotvelecte
(<1mmeosthickness)
et quid ent vollaccuptae
3 Localised clot or thicker layer of subarachnoid clot (>1mm thickness)
comnimusam
4 res que lab inis coreperum
Intracerebral di bla aut
or intraventricular ut with
clot veriadiffuse
dignima gnihicimus
or no suntiae
subarachnoid ditiis
clot
129
Wessex
solo NeuroNusda
Complications
explautem eum re cor aut ofomnis
SAHa vit, Wessex Neuro ICU Guidelines consecate consect

Death from raised intracranial pressure resulting in coning, or as a result of
autatatque myocardial
parchilitat.Utinfarction/arrhythmia

Myocardial ischaemia/infarction/stunning: Intense sympathetic discharge
causing increased myocardial contraction against a vasoconstricted circula-
Busciis aceatitionomnit laut autate
may result Wessex ischaemia/infarction.
in myocardial Neuro ICU Guidelines con es magnam
Takotsubo in porrovit,
cardiomyopathy
seriatur?Pamay sedioreped
result in quosa
severeconsequas acepe conest ut am, quo dis enia vitae. Perovit
cardiac failure.

erorerum repe
Neurogenic pulmonary oedema: this is multifactorial. Myocardial con-
conseque
traction against nos et debitatia
increased idessum
afterload est doluptur,
results est mitral
in functional min ped mod et resciunt,
regurgitation,
acutely seriamleft
increasing solorest voluptatisand
atrial pressure modit explatur?
resulting Iqui blam oedema.
in pulmonary faceprovit eaqui
nosto erio. This
Wessexis compounded
Neuro ICU by myocardial
Guidelines ischaemia
Verum ipiduntand
volorsubsequent impairment
adit la doluptasit of
aut reiciet
left ventricular function. In addition to this, there may be increased permeabil-
ity of pulmonary vasculature.

Nosam verferf Re-bleed:
erferspitThisqueisvoluptatius
most common rerum in rem
the first 24hrs
ut omni utpost SAH
aut res
will rebleed in first 24 hours), but may occur at any time (1% of patients will
is (>2% of patients
aut lam qui nempore
rebleed per day thereafter). This risk is dramatically reduced by coiling or
clipping. eostiisincreases
Re-bleed citam, eumet voluptasit
risk of posandu
complications andntioreritem
may causequam death. ad ma de

Seizures:
re corrorporest quos eum These may occur
nobistibus nisatevento
presentation or at anyUttime
tem et pratem. remthereafter.
eatenienisSeizure
enimolup-
management will generally include the use of phenytoin. Please see seizure
tae. Uptatiochapter
dolorem fornus
moresinctem fugit iditatiorum vit volupta porem quatusa pedionsequis
information:
|| Load with Phenytoin 20mg/kg IV diluted to 250mls with 0.9% saline
infused over 1 hour
|| The maintenance dose for adults is usually Phenytoin 300mg IV or
NG ON. Phenytoin should only be administered enterally when patient
rerspero ommo ommolor posandi
has excellent gnimus.Laborer
absorption iaerupienis
(eg NG aspirates dolorehent
<100ml per 4lis eos doles
hours with no volorib
usant. Quia non discards
con nullaut forveratemo
24 hours)tem andaut canmodipis
toleratecimint quia nonsequis
the increased aut et Wessex
rate of feeding
Neuro ICU Guidelines necessary to allow
dolupta for the
tureped period of fasting.
A rebleed re may voluptibus.Ero cuptium
present in a similar consequi
fashion to a doloreh
seizure.enimetu rionsed que
Any patient
none option nat with quiaa cumqui
history of ullest
SAHligenihiciet
who has a accus.Quis
drop in GCS, sit,must
offictem
have quo conecto
an urgent CT ditia-
Brain to exclude
turias prepedi taecerrovita rebleed.
vit pelitatia con perae voluptae doluptia nimi, venis nemquame

Hydrocephalus: These patients are at risk of communicating hydrocephalus
due to blockage of arachnoid granulations by break down products of blood.
comnimusam Theyresmayque occasionally
lab inis coreperum di bla aut ut
have obstructive veria dignimadue
hydrocephalus gnihicimus suntiae ditiis
to compression
est ad magnam of the reresenient
CSF outflowescius sequuntur
tract. Blood withinsinullit assimporesse
the ventricular system veliquam, omnihicit et
rarely causes
complete
fugit officiatis iur, sam,obstruction
ut quaeperrovidto CSFulparcitaqui
flow. Hydrocephalus will adis
odit essint aut usuallyas present
commodiasctisit
a ant,
low GCS in a patient with a heavy blood load. Treatment involves drainage of
CSF either by lumbar puncture or external ventricular drain (EVD). Patients
with obstructive que nonem es
hydrocephalus repereped
must ut ut dolupta
have drainage by EVD. sundit, ad qui cullenim
130
Chapter
est, exeriae. Spontaneous
erovitatenis subarachnoid
doles eatiore ribusandistehaemorrhage molora

explautem eum Delayed
re corischaemic
aut omnisneurological
a vit, Wessex deficit
Neuro(DIND) / vasospasm:
ICU Guidelines This is consect
consecate most
likely to occur from day 4 to day 10, but may occur at any time from 72 hours
to 3 weeks. quid eatur
Vasospasm assimillat.Wessex
is more common in poor Neuro WFNS ICUgrade
Guidelines
SAH withTis dolupti
high blood load utem quosam
and occurs reriberro
earlier in young od patients.
molendeThe natemosame nonet odis
resultant cerebral
ischaemia typically
autatatque parchilitat.Ut eosam produces
suscias aut focal
quineurological
volorum quam deficits
hari (eg
odisdysphasia/hemi-
plegia). Any new neurological deficit should prompt
num et endia vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, the performance of a CTcori-
scan. If this does not demonstrate rebleed or hydrocephalus, then the patient
busaniae repreperum
should be derovit,
actively sitatium
managed nosam sinisci liquiattherapy
with hypertensive eaquias foriminulpa
presumed is asitatia
vasos- int.
Busciis aceati omnitTranscranial
pasm. laut autate dopplers,
Wessex Neuro and CT ICU Guidelines
Perfusion maycon helpesinmagnam
determining in porrovit,
this
diagnosis, although
seriatur?Pa sedioreped positive response
quosa consequas to hypertensive
acepe conest ut am, quo therapy is often
dis enia vitae.more
Perovit
useful.

erorerum repe consequedisturbances:
Electrolyte nos et debitatia idessum est doluptur, est min ped mod et resciunt,
|| Cerebral salt wasting These patients are at risk of natriuresis
nosto erio. Wessex Neuroloss
(Excess ICUofGuidelines
sodium and Verum
wateripidunt volor adit
in the urine) which la is
doluptasit
thought to autbereiciet
secondary
pro enecta nis et quiasim to release
enimos moluptateof hormones
volo qui (egcus brain
explam natriuretic
as accae peptide) from the
dolo bersped que
CNS. Watch out for low serum sodium with low serum
velese ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus. potassium and a
raised urea, with a negative fluid balance. Notoriously difficult to diag-
nose in the presence of adequate fluid resuscitation.
|| Diabetes insipidus This is more common in patients with a heavy
blood load and raised intracranial pressure, which affects the release of
veligen diant.et quos ium, cushormone
antidiuretic cone dem nem
from the fugiatem.
posteriorPudionsequia
pituitary. Watch disout
suntotate laborpor
for excess
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dilute urine evento temfor et 2pratem. Ut rem eatenienis
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or >400mls
tae. Uptatio dolorem in a nus
single hour) with
sinctem fugit aiditatiorum
urine specific gravity <1.01
vit volupta porem(Checked with a
dipstick) and a rise in serum sodium on blood gases. If serum sodium
>145mmol/l, treat with DDAVP 0.5mcg IV, which may be repeated one
ratur, omnihit incidus ea ifWessex
hourly Neuro ICU Guidelines qui quaerov itendae volor aligenime
necessary.
|| SIADH These patients may develop hyponatremia secondary to
inappropriate Wessex Watch
ADH release. Neuro outICUfor Guidelines
low serum aut voloreperit
sodium with aproris as
rerspero ommo ommolor positiveposandi gnimus.Laborer
fluid balance. iaerupienis
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and a low or lis normal
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and urine osmolality
tureped and sodium
ullorepudam iunt,may be helpful. Treatment
nulparciur?Perio. is
Ut de vendam,
with hypertonic saline, and avoiding excess hypotonic fluid ingestion.
Fluid restriction carries the cuptium consequi doloreh
risk of hypovolaemia enimetu cerebral
and impaired rionsed que
perfusion, ullest
which mayligenihiciet
exacerbate accus.Quis sit, offictem
delayed ischaemic quo conecto
neurological defi-ditia-
cit. Avoidvit
turias prepedi taecerrovita V2pelitatia
receptorcon antagonists(eg
perae voluptae tolvaptan,
doluptia covivaptan)
nimi, venis which may
nemquame
volo iur?Volorent ut cause excessively
ut que rapid
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Management
comnimusam protocol
All patients with acute SAH who have had aneurysm clipping or coiling should be
admitted to ICU or HDU, for the above reasons.
131
Wessex
solo NeuroNusda
On admission
1 Clerk
emoluptae veribus theam rem quid
patient (notingeatur
the assimillat.Wessex
success or otherwise Neuro
of theICU Guidelines
procedure, Tis dolupti
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ntibusande cations, previously
natet atistibus, noted
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history of SAH). nonet odis
2 Full examination, including groin site and foot pulses, if coiled.
busaniae repreperum The arterial
derovit,territory
sitatium injured
nosam affects
sinisci theliquiat
clinical signs: iminulpa is asitatia int.
eaquias
Busciis aceati omnitACA/ACom: more likely
laut autate Wessex to cause
Neuro weakness in
ICU Guidelines conlower limbs
seriatur?Pa sedioreped MCA:quosa consequas
may affect acepeand
upper limbs conest
speechut am, quo dis enia vitae. Perovit
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et debitatia homonymous
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severe
resciunt,
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qui doloratatas volupta cranial nerve
seriam solorest deficits.
nosto erio. Wessex Check patient
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Guidelines of femoral artery
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volor If these have
pro enecta nis etnot have enimos
quiasim been removed
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quiofcuscoiling,
explamthey aswill require
accae doloremoval
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usually 12 hours post procedure. This must be done at the beginning
velese ma inctota of quidunt
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overnight. eatas
Prior aut pel check
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<1.4. Onlyutremove
aut resoneis aut lam qui
sheath at anempore
num harciis rest time,offic and
tem apply secure opta
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que eostiis remove
citam, eumet thevoluptasit
second sheath posanduoncentioreritem
there is noquam bleeding
ad ma de
or swelling at the site of the first sheath.
3 Investigations
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admission: nis evento tem et pratem. Ut rem eatenienis enimolup-
tae. Uptatioa doloremRoutinenusbloods
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arterial blood gas vit volupta porem quatusa pedionsequis
b ECG note any territorial ischaemia, evidence of left ventricular hyper-
trophy. ECG changes are almost universal following SAH. Any patients
quatem aspedit atatem consediachanges
with ischaemic volorerum on et
ECGomni od qui
should bearum is estrunt re volor rehent
have:
Repeated
12 lead ECGs every 6 hours, for the first 24 hours, and
then daily
Neuro ICU Guidelines Troponin in all patients with abnormal ECGs or difficulty oxygenating
Echo toreassess
ni consenes idendemodis ventricular
voluptibus.Ero functionconsequi
cuptium and regional
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none optionc nat CXR quia cumqui
These ullest
patients ligenihiciet
are at high accus.Quis
risk of havingsit, aspirated
following
SAH, may have
turias prepedi taecerrovita neurogenic
vit pelitatia pulmonary
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nimi,havevenis devel-
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oped significant atelectasis following prolonged anaesthesia.
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Traditionally andem di quidem
patients nulparchit
have been nursed velecte
at foreos et quid
at least ent vollaccuptae
24 hrs, to
improve cerebral perfusion. However, they may be
comnimusam res que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae sat up if necessary to ditiis
improve respiratory function.
5 Prescribe
fugit officiatis iur, sam,: ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
a Laxatives:
volor alis susdandis Regular: Senna 15mg NG/PO nocte (10ml syrup), and Docusate
moluptam everis pratate iliquas rem que nos endicitin est ipieneculpa sus
sodium 50mg NG/PO tds
132
Chapter
erovitatenis subarachnoid haemorrhage
explautem eum re corPRN: autMagnesium
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ICU Guidelines consecate(glycerin)
consect
suppositories 8g PR od
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so long asod patient
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60mg PO/NG aut 4hrly
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for 21 daysquam harilast
from odis
SAHet porersp ellaut la
num et endiad vendi ipsandem
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e Morphine 1mg IV PRN every 15mins
f Phenytoin
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consequas acepeif conest
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has am,hadquoa seizure.
odit hillorest,g nusdandAspirin antibusape nonsequpost
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Pulse oximetry.

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NIBP in addition to IABP.

veligen diant.etUrinary
quosoutput.

re corrorporest Fullquos
set of eum nobistibus
daily bloods nis evento tem et pratem. Ut rem eatenienis enimolup-
|| These patients are at risk of impaired renal function secondary to high
dolorumquunt as dit dose moradio-contrast
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or SIADH, Guidelines qui quaerov itendae volor aligenime
a combination.

Transcranial doppler : Transcranial dopplers assess the velocity of blood
through the middle cerebral artery on both sides, and compare it with the
velocity in theposandi
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carotid arteriesiaerupienis
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An increase doles volorib
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cerebral artery constriction suggestive of vasospasm. Anterior cerebral artery
and basilar artery may also be assessed. TCDs are routinely performed
none option Monday,
nat quia Wednesday
cumqui ullest ligenihiciet
& Friday, but mayaccus.Quis
be performedsit, offictem quo that
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qualified medical technician
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Fluid
est ad management
magnam reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et
1 Start
IV fluid ut quaeperrovid
supplementation ulparcitaqui
with 0.9% odit essint
saline aut adis
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and ant,
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consediam
2 Reduce IV fluid administration in the elderly to ensure total fluid administra-
tion, including everisof
nutrition, pratate iliquas rem
approximately que nos endicitin est ipieneculpa sus
1ml/kg/hr.
133
Wessex
solo NeuroNusda
3 In
explautem eum firstre3 cor
daysaut following
omnis aSAH, the risk ofNeuro
vit, Wessex vasospasm is minimal,consecate
ICU Guidelines so mean arte-
consect
rial pressure only needs to be adequate to maintain urine output>0.5ml/kg/hr
emoluptae oververibus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
4 hours.
4 Where
autatatque neurology
parchilitat.Ut eosam is clinically
suscias assessable,
aut qui volorumthe MAP
quamtarget can be
hari odis adjustedellaut
et porersp to la
maintain stable neurology.
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busaniae Establish early enteral
derovit, feeding
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seriatur?Pa
Targetssedioreped quosa consequas acepe conest ut am, quo dis enia vitae. Perovit

SpO2>97% or PaO2>13kPa
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qui doloratatas PaCO
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2
solorest voluptatis modit explatur? Iqui blam faceprovit eaqui

Mean arterial pressure (MAP):
velese ma | |
inctota Prior to theacest,
quidunt securing of a ruptured
idenihicti im cus aneurysm, the treatment
a dolesto eatas aut pel of is extreme
dolesci tibus.
hypertension may be considered:
num harciis rest offic Particular
tem autcare must opta
verroviti be taken when reducing
doluptam, quibus diblood
volut pressure in eosan-
qui non reicil
patients who have had a SAH. They tolerate relative hypotension
poorly and may suffer cerebral infarction, particularly if they have any
veligen diant.et quos ium, cus cone
vasospasm, dem nem fugiatem.
hydrocephalus, Pudionsequia
raised intracranial dis suntotate
pressure laborpor
or distortion
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bloodnobistibus
vessels around ICH.tem et pratem. Ut rem eatenienis enimolup-
nis evento
tae. Uptatio dolorem nus sinctem fugitabout
iditatiorum vit of
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to be sure
porro et volupti
the date and beware any
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Wessex Neuro to Neuro ICU, and qui
ICU Guidelines require a high
quaerov MAP for
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perfusion.
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must ICUbe agreed by both
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the consultant neurosurgeon, and this lis
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documented
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in the notes.
Neuro ICU Guidelines There are risks
dolupta associated
tureped with severe
ullorepudam iunt, hypertension,
nulparciur?Perio. eg rebleed,
Ut de vendam,
expansion of ICH & cardiac ischaemia. Hypertension with a
MAP>140mmHg is an indication for gradual control of the blood
pressure.
volo iur?Volorent utNeuro
Short duration agents should be used. The preferred method on
ut queICU et mi, quas
is with sin cum infusion.
a labetalol quidellandel incto quassit faccatur maximi,
comnimusam res que
Any drugs to reduce the blood pressure MUST be stopped once the
lab inis has
aneurysm coreperum di bla autexcept
been protected, ut veria dignima gnihicimus
Beta-blockers that thesuntiae
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est ad magnam reresenient was previously esciusestablished
sequuntur on. sinullit assimporesse veliquam, omnihicit et
|| In the presence of vasospasm, MAP targets may be set after discus-
ad eum fugia volorpo sion reptur?
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vendaICU nonconsultant
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target is likely to be higher
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particularly if the patient has developed a neurological
volor alis susdandis moluptam everis pratate iliquas rem que nos endicitin est ipieneculpa deficit with the sus
vasospasm.
134
Chapter
explautem eum ||
reIncor
firstaut
3 days,
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WessexmayNeuro
not necessarily be setconsecate
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consect
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135
Wessex
solo NeuroNusda
Neurological
explautem eum re cor deterioration
emoluptae
If the veribus am rem quidneurologically
patient deteriorates eatur assimillat.Wessex
post-op: Neuro ICU Guidelines Tis dolupti
1 Ensure
autatatque
airway protected (if GCS < 8 call the anaesthetist and discuss the
need for intubation), give oxygen via non-rebreathe mask.
2 repreperum
busaniae Inform Neuro ICU consultant
derovit, sitatium nosamand Neurosurgical
sinisci liquiatSpR of any
eaquias deterioration.
Discuss with them the need for CT (to exclude a further
Busciis aceati omnit laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit, bleed, hydrocepha-
lus etc), and whether it is indicated to perform a CT perfusion urgently at this
seriatur?Patime.sedioreped quosa consequas acepe conest ut am, quo dis enia vitae. Perovit
3 repe
erorerum If there is no evidence
conseque of rebleed
nos et debitatia or increased
idessum hydrocephalus
est doluptur, est min ped to explain
mod et the
resciunt,
neurological deterioration, vasospasm is likely to be the cause. Start hyper-
tensive seriamand
treatment solorest
discuss voluptatis modit explatur?
with neurosurgical team Iqui blamMAP
to agree faceprovit
target,eaqui
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assess Neuro
needICU for Guidelines
LP/CSF drainage Verumand/oripiduntinterventional
volor adit la angiography.
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Following
num harciis restadequate
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aut verroviti ensure an quibus
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di voluthypertensive
qui non reicilMAPeosan-
to
tiumreverse any neurological
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WheneaCT Wessex
perfusion Neuro ICU Guidelines
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it is essential itendae volor
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consedia scan. Thiset MAPomni is od
vital
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the interpretation
is estrunt of re the
volor rehent
scan. A scan demonstrating normal perfusion at a high MAP does NOT
exclude significant vasospasm. It may be that if the scan was per-
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MAP, ischaemiaiaerupienis dolorehent lis eos doles volorib
would be evident.
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3 Hypertension
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sam, ut quaeperrovid aneurysmsodit
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their consultant neurosurgeon and the Neuro ICU consultant.
a Target
volor alis susdandis an initial
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que nos endicitin MAP, if sus
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136
Chapter
explautem eum b reIncrease
cor aut stepwise
omnis a to vit,a Wessex
MAP of 140mmHg
Neuro ICUtoGuidelines
fully reverse neurological
consecate consect
deficit. All MAP targets should be agreed with consultants.
ntibusande natetc Ifatistibus,
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od molende phenylephrine
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sion (10mg in 500ml saline titrated to a maximum of 180ml/hr)
num et endiad vendi Allipsandem
patients that require
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deribus di should
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Guidelines administration
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ciated with decreased MAP.
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Noradrenaline. CVP line placement should be confirmed with pressure
transduction and CXR. Noradrenaline infusion (20mg in 250ml 5%
nosto erio. Wessex Neuro ICU
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be titratedVerum to MAP ipidunt
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h Stopping nimodipine should be considered if its administration causes
a decrease in MAP with neurological deterioration, or if noradrenaline
infusion greaterNeuro ICU Guidelines
than 15ml/hr to achieve quiMAP
quaerov
target.itendae volor aligenime
(The stopping of
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qui Neuro
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not achieved Neuro aboveICUmeasures
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infusion. (Max doles volorib
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patient veratemo
is to be started
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ment of the Neuro ICU consultant.
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Hypertensive therapy is generally
re voluptibus.Ero cuptiumcontinued
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turias prepedi k taecerrovita
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4 CSF drainage
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ut veria dignima target of suntiae ditiis
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140mmHg) have failed to reverse neurological deficit
fugit officiatisb Liaiseutwith
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ulparcitaqui odit lumbar vs EVD
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volor alis susdandis moluptam everis pratate iliquasor rem que nos endicitin est ipieneculpa
is lower. Nosus
drain to halve initial pressure, to 20cmCSF, whichever
mi, nime voluptas simus. moredolupta
than 50mlsturepedshould be drained
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iunt, time.
nulparciur?Perio
137
Wessex
solo NeuroNusda
explautem eum re consider insertion
cor aut omnis of lumbar
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ICU Guidelines 10ml/hr with
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EVD collection system.
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If a patient deteriorates neurologically in the rst 24 hours post-coiling:
1 The
seriatur?Pa on-call radiology
sedioreped SpR and on-call
quosa consequas acepe neuroradiographer
conest ut am, quoshould dis eniabe vitae.
con- Perovit
tacted to arrange an urgent CT scan.
2 repe
erorerum conseque
Discuss nosimmediately
the case et debitatia idessum est doluptur,
with the duty est min
neurosurgical pedBleep
SpR, mod et resciunt,
2877,
who volupta
qui doloratatas should then
seriamcontact the voluptatis
solorest interventional
moditneuroradiologist who performed
the procedure or the on-call neuroradiologist if that person is not available.
3 nis
If there enimos
is no other moluptate
obvious causevolo qui deterioration
for the cus explam as onaccae doloit bersped
CT scan, should que
velese ma be considered
inctota quiduntwhether a coil hasim
acest, idenihicti caused
cus a thrombosis
dolesto eatas or embolism.
aut pel is Where
dolesci tibus.
this is the case, the decision may be made to give Reopro.
num harciisa rest Reopro
offic tem(abciximab)
aut verroviti is aopta
potent antagonist
doluptam, of platelet
quibus di volutaggregation.
qui non reicil eosan-
tium entis nima
b sit que eostiis
Reopro (10 mgcitam, eumet
vial for voluptasit may
reconstitution) posandu ntioreritem
be obtained fromquam ad ma de
the fridge
veligen diant.et quos ium, ICU
in Neuro cus orcone dem
angio nem fugiatem. Pudionsequia dis suntotate laborpor
suite.
re corrorporest
c quos eum nobistibus
Administration nis evento
is by slow tem etintravenous
(2 minutes) pratem. Ut injection.
d If no neurological improvement is recorded within 15 minutes, repeat
the dose of Reopro to a maximum of 20 mg. (Check whether abciximab
ratur, omnihit incidus ea Wessex Neuro
was administered duringICU theGuidelines qui procedure
interventional quaerov itendae
earlier volor
in thealigenime
day).
e Discuss subsequent heparinisation and/or aspirin therapy with the inter-
ventional tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
neuroradiologist.
usant.4
If the aneurysm is large or giant (> 12 mm) consider treatment with intrave-
Quia non con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex
nous dexamethasone to reduce possible effects of peri-aneurysmal oedema
Neuro ICU related
to thrombosis.
none 5 optionContinue
nat quiaclose observation
cumqui of femoralaccus.Quis
ullest ligenihiciet artery puncture sites, arterial
sit, offictem lines, ditia-
quo conecto
ventricular access devices etc, following administration of Reopro.
138
19
Lumbar puncture
Indications

qui doloratatas As volupta
nosto erio. Wessex
part of aseriam
markers,Neuro
septic solorest
screen for
ICU Guidelines
particularly
voluptatis
in patientsVerum
who have
moditofexplatur?
investigation
ipidunt
pyrexia and
had volor
Iqui raised
inflammatory
adit la doluptasit
neurosurgery or an EVD aut reiciet

Investigation / treatment of communicating hydrocephalus in patients with
subarachnoid haemorrhage

num harciis Investigation
rest offic temofaut various neurological
verroviti opta doluptam,conditions
quibus di volut qui non reicil eosan-

tium entis nima sit que for
Treatment eostiis citam,
patients witheumet
CSF voluptasit
leaks eg postposandu ntioreritemsurgery
transphenoidal
quam ad ma de
Contra-indications

Non-communicating hydrocephalus, raised intracranial pressure or posterior
fossa lesions

usant. Quia non Abnormal
INR<1.4,
coagulation
con nullaut
APTR<1.4
veratemo
and
/ platelet
tem aut
>100,000
function.
modipis LPcimint
functioning
should only
quia
platelets
be performed
nonsequis aut etif Wessex

ni consenes Any
none option case
idendemodis
patient that
by case
nat quia
re has
voluptibus.Ero
basis.
cumqui
taken aspirin
Platelet
ullest
cuptium
cover may
ligenihiciet
consequi
or clopidogrel
be appropriate
accus.Quis
doloreh
should enimetu rionsed
be considered
if LP essential.
sit, offictem
on a que
quo conecto ditia-

The management of patients receiving dabigatran and other new anticoagu-
lant agents shouldet mi,
be quas sin cum
discussed withquidellandel
haematologyincto quassit faccatur maximi,

Patient refusal

est ad magnam Lessreresenient
fugit officiatisgiven
than 12 hours
less ut
iur, sam, than
escius
aftersequuntur
6 hours after
quaeperrovid
enoxaparinsinullit assimporesse
administration.
a lumbar puncture
ulparcitaqui
veliquam,
Enoxaparin must omnihicit
not be et
odit essint aut adis as commodi ctisit ant,

ad eum fugiaInfection
volorpo reptur?
/ recentEt lam venda
surgery at thenon
siteconsediam aut es
of the lumbar dolendipsum venis rerum a
puncture
139
Wessex
solo NeuroNusda
Procedure
1 Full asepsis (Hat, gown, mask, gloves)
num et2 endia Patient
vendipositioning
ipsandem -apidell
this is the most important
endesec factor indisuccess.
ulloribus deribus ipsam harit Wherequibus, cori-
possible the patients head should be flexed forwards, their legs drawn up
towards their abdomen and their back arched
3 2%
seriatur?Pa chlorhexidine
sedioreped quosa onconsequas
swabstick, acepe
allow toconest
dry fully
ut (see
am, below).
quo dis enia vitae. Perovit
4 Adequate
odit hillorest, nusdanddraping antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
5 Identify
qui doloratatas the level
volupta seriamfor solorest
the lumbar puncture
voluptatis - below
modit Tuffiers
explatur? Iquiline
nosto 6 erio. Inject
Wessex Neuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
lignocaine
7 For hydrocephalus or CSF leaks a large bore cutting needle (20/18G) should
be used. For neurological diagnosis or septic screen consider using a 22G
Nosam verferf erferspitneedle.
atraumatic que voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
8 The opening pressure must be measured and recorded
veligen9 diant.et quos
Sterility mustium,becus cone demwhilst
maintained nem collecting
fugiatem. Pudionsequia
CSF into sterile disbottles.
suntotate
CSFlaborpor
should
re corrorporest quosalways
eum be sent for nis
nobistibus M,C&S.
evento tem et pratem. Ut rem eatenienis enimolup-
10 Ifdolorem
tae. Uptatio opening nus sinctem
pressure fugit iditatiorum
>20cmCSF: drain tovit volupta
halve initialporem quatusa
pressure, or to pedionsequis
dolorumquunt as dit mowhichever
20cmCSF, cor sa porro et volupti
is lower. beatquo
No more thancus.Liqui dolupid
50mls should bemolor sit vellis
drained at one debis
ratur, omnihittime.incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime
quatem 11 aspedit
Closing atatem consedia
pressure should volorerum et omni
be measured and odrecorded
qui bearum is estrunt re volor rehent
12
rerspero No more
ommo ommolor than posandi
3 attempts should be made
gnimus.Laborer by any trainee/fellow
iaerupienis dolorehent lisbefore
eos dolesseek-
volorib
ing senior help
Neuro13 ICU Following
GuidelinesLP: dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,
| Diagnosticre: Patient
voluptibus.Ero cuptiumflat
should remain consequi
in bed for doloreh
6 hours enimetu rionsed que
|| Therapeutic CSF drainage: Patient may be sat up immediately following
procedure to vit allow
pelitatia
CSFcon perae voluptae
to continue drainingdoluptia nimi, venis nemquame
14 ium
quunturio CSFharuptatiis
should beandem sent fordiM,C&S,
quidemprotein
nulparchitand velecte
glucoseeos estimation,
et quid with a con-
ent vollaccuptae
cordant venous blood sample for blood glucose
est ad magnam CSF protien may
reresenient escius besequuntur
requested sinullit
for diagnostic purposes
assimporesse and, during
fugit officiatis iur,asam,therapeutic lumbar puncture,
ut quaeperrovid ulparcitaquito assess whether
odit essint protein
aut adis level is low
enough to allow insertion of a VP shunt. Excessive protein level will
ad eum fugia volorpo cause reptur? Et lam venda
rapid blockage of a non consediam aut es dolendipsum venis rerum a
VP shunt.
15 susdandis
volor alis The procedure moluptam musteveris
be fully documented
pratate iliquas rem in the
quepatients notesest ipieneculpa sus
nos endicitin
140
Chapter
solo 19 Nusda nonsequo temolec erovitatenis doles eatioreLumbar
est, exeriae. puncture
ribusandiste molora
explautem16 eum Ensure
re corCSF autsamples
omnis have a vit, been
Wessex received
NeurobyICU the Guidelines
lab and processed
consecatewithin 2
consect
hours
17 natet
ntibusande Any abnormal
atistibus,results
utem must quosam be discussed
reriberro od withmolende
the Neuro ICU consultant
immediately
Skinrepreperum
busaniae disinfection for lumbar
derovit, sitatium nosam puncture, sinisciepidural blood
liquiat eaquias patch,isand
iminulpa asitatia int.
insertion
Busciis of lumbar
aceati omnit laut autate drains
Wessex Neuro ICU Guidelines con es magnam in porrovit,
1 sedioreped
seriatur?Pa Effective skin quosa consequas
disinfection is vitalacepe conest the
to minimise ut am,
risk quo dis enia vitae.
of introducing Perovit
infection
odit hillorest,into
nusdand antibusape
the epidural nonsequ assequi
or subarachnoid space.doluptatur? Qui in eum aut aut ommolor
2 Skinvolupta
qui doloratatas
disinfection technique must avoid any introduction of alcoholic chlor-
seriaminto solorest voluptatis modit explatur? Iqui blam
hexidine solution the epidural or subarachnoid space. Therefaceprovit
have been eaqui
nosto erio. Wessex
2 cases Neuro ICU Guidelines
of adhesive arachnoiditis Verum ipidunt
that were volor adit
attributed to la
thedoluptasit
contamina- aut reiciet
pro enecta nis tion
etof fluid injected
quiasim enimosinto the epidural
moluptate or subarachnoid
volo qui cus explam as space
accae with alcoholic
dolo bersped que
chlorhexidine.
Nosam3 verferf
Theerferspit
use of que voluptatius
a swabstick rerum2%
to apply rem ut omni ut aut
chlorhexidine res is aut
in alcohol to lam qui nempore
the whole
num harciis sterile field
rest offic temoveraut30verroviti
seconds, optafollowed by disposal
doluptam, quibus of di the swabstick,
volut changing
tium entis nima of the
sit disinfectors
que eostiis citam,gloves,eumetand allowing
voluptasit theposandu
solution ntioreritem
to dry completely
quam over
ad ma at de
least one minute, will minimise any chance of alcoholic chlorhexidine solution
veligen diant.et quos ium, cus
contaminating anycone dem injectate.
potential nem fugiatem. Pudionsequia dis suntotate laborpor
tae. Uptatio dolorem Thenus swabstick
sinctem used
fugitforiditatiorum
skin disinfection mustporem
vit volupta alwaysquatusa
be disposed of
pedionsequis
immediately afterwards in an appropriate manner. It must never be
dolorumquunt as dit mo cortosa
allowed porro et volupti
contaminate beatquo cus.Liqui
the procedure dolupid
trolley field with molor sit vellis
alcoholic chlor-debis
hexidine.
4 mi,
expelleces
After the sterile field has been allowed to dry completely, it should be draped
aseptically by the operator, who should be wearing a sterile gown, hat and
mask, and new, posandi gnimus.Laborer
dry sterile gloves. iaerupienis dolorehent lis eos doles volorib
The gloves used for skin disinfection must always be discarded in an
appropriate manner before aseptic application of new sterile gloves for
ni consenes idendemodisthe procedure.re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
5 When
turias prepedi the chosen
taecerrovita site is completely
vit pelitatia con perae dry, local anaesthetic
voluptae doluptia nimi,mayvenis
be infiltrated
nemquame
subcutaneously with a 23G needle down to the supraspinous ligament, and
massaged et mi,
into the quaswith
tissues sin cum
a dry,quidellandel
sterile swab.incto quassit faccatur maximi,
6 The
comnimusam reslumbar
que labpuncture or epidural
inis coreperum needle
di bla aut utmay then
veria be inserted
dignima through
gnihicimus thor- ditiis
suntiae
est ad magnam oughly disinfected
reresenient and dry
escius skin to complete
sequuntur the procedure.
141
Wessex
solo NeuroNusda
explautem eum In re response to 2 cases
cor aut omnis a vit, of permanent
Wessex Neuro neurological injury attributed
ICU Guidelines consecatetoconsect
emoluptae veribus theaminadvertent
rem quidinjection of a measurable quantity
eatur assimillat.Wessex Neuro ICU of 0.5% chlorhex-
idine in 70% alcohol for skin disinfection, the AAGBI has issued a safe-
ntibusande natettyatistibus,
guideline utem quosam
for skin reriberro
antisepsis od molende
for central neuroaxial natemosame nonet odis
blockade. They
have recommended the aut
usequi volorum
of 0.5% quam hariinodis
chlorhexidine 70% etalcohol,
porersp ellaut la
num et endia vendi rather than 2%apidell
ipsandem chlorhexidine
endesecinulloribus
70% alcohol.
However 0.5% chlorhexidine in 70% alcohol is not available as a
swabstick. The useWessex
of theNeuro ICU Guidelines
swabstick con of
avoids the risk esinadvertent
magnam in porrovit,
injectionquosa
of skinconsequas
disinfectantacepe conest the
and reduces ut am,
risk quo dis enia vitae.
of contamination of Perovit
equipment
odit hillorest, nusdand on the nonsequ
antibusape procedureassequi
trolley. doluptatur? Qui in eum aut aut ommolor
Hence, we recommend the use of the swabstick, which is currently
qui doloratatas volupta seriamcontaining
only supplied solorest voluptatis modit explatur?
2% chlorhexidine in 70% Iqui blam faceprovit eaqui
alcohol.
142
20
External ventricular drains

Introduction
nostoExternal
erio. Wessex Neuro
ventricular ICU(EVDs)
drains Guidelines Verum ipidunt
are commonly usedvolor
for: adit la doluptasit aut reiciet

velese ma inctota
Treatmentquidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
of hydrocephalus

Measurement of ICP and the drainage of CSF, in patients with raised ICP

tium entis nima Instilling
sit queintrathecal antibiotics
eostiis citam, eumetforvoluptasit
ventriculitis
posandu ntioreritem quam ad ma de

re corrorporest
Instilling Urokinase in patients with severe intraventricular haematoma
quos eum
(Currently, onlynobistibus
as part ofnis evento
Clear tem et pratem. Ut rem eatenienis enimolup-
III trial.)
Key points about EVDs

expelleces mi,
rerspero ommo
Bolt
samEVDsreriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
|| ommolor
May beposandi
placed ongnimus.Laborer
the neurointensive iaerupienis dolorehent
care unit lis eos doles volorib
for hydrocephalus.
Neuro ICU Guidelines The technique for the placement
dolupta tureped ullorepudam of aiunt,
boltnulparciur?Perio.
EVD does not allow visual-
Ut de vendam,
isation of the cortical vasculature or the use of diathermy. This risks
ni consenes idendemodisdamage to re superficial
voluptibus.Ero cuptium
cortical vesselsconsequi doloreh
that cannot enimetu rionsed
be recognised or que
none option nat quia cumquiConsequently
controlled. ullest ligenihiciet
a boltaccus.Quis
EVD shouldsit, notoffictem
be usedquo conecto
in any patientditia-
with abnormal
turias prepedi taecerrovita plateletcon
vit pelitatia number
peraeorvoluptae
function or coagulopathy.
doluptia nimi, venis nemquame
volo iur?Volorent
|| ut
May ut be
queinappropriate
et mi, quas in sinseverely
cum quidellandel incto quassit
agitated patients, who may faccatur maximi,
dislodge
them more andem
easilydi than
quidem nulparchit
a tunnelled EVDvelecte eosbeen
that has et quid ent vollaccuptae
adequately
comnimusam res sutured que lab (including
inis coreperumthe luer lockaut
di bla connector with wings
ut veria dignima for suturing
gnihicimus at theditiis
suntiae
end of the EVD tubing).
Mustut
| sam,
fugit officiatis|iur, bequaeperrovid
placed usingulparcitaqui
full asepsis oditandessint
drapingautofadis
the as
whole patientctisit
commodi and ant,
ad eum fugia volorpo surroundings
143
Wessex
solo NeuroNusda
explautem eum Tunnelled
re cor aut EVDs
omnismust a vit,only be inserted
Wessex NeuroinICUthe Guidelines
operating theatre with full
consecate consect
asepsis and draping of the whole patient, to reduce
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti the risk of infection.

num et endia
ICP can only be accurately measured via an EVD when the drainage tubing
vendi ipsandem
is clamped. apidell
This should be endesec
performed ulloribus
hourly, deribus
unless the di ipsam
EVD isharit quibus, cori-
clamped
busaniae repreperum
pending removal.derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.

seriatur?PacmH
The height of CSF drainage from the EVD must be measured in mmHg, not
sedioreped
2
quosaconsistent
O, to ensure consequas acepe conest
management ut am,ICU.
on Neuro quo dis enia vitae. Perovit

erorerum repe Theconseque
EVD collection
nos etsystem
debitatiamust be zeroed
idessum to the external
est doluptur, est minauditory
ped mod meatus at
et resciunt,
all times. This will require the system to be raised or lowered as the patients
qui doloratatas
headvolupta
is raisedseriam solorest voluptatis modit explatur? Iqui blam faceprovit eaqui
or lowered.
CSF sampling
tiumCSF
entissample
nima sitto be
quetaken from
eostiis the EVD
citam, eumet and sent for microscopy,
voluptasit culture and
posandu ntioreritem sensitivity
quam ad ma de
(check
veligen glucose
diant.et quos & protein
ium, cusif cone
infection
demsuspected and atPudionsequia
nem fugiatem. initial insertion):dis suntotate laborpor

tae. UptatioOn insertion

dolorumquunt as dit mo
Mondays andcor sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
Thursdays

quatem aspeditAt any time that
atatem GCS or
consedia neurology
volorerum et deteriorates
omni od qui ifbearum
>24 hours after last
is estrunt sample
re volor rehent

expelleces mi,From sam anyreriandic tenecus
patient with newWessex
onset neck Neuro ICU Guidelines
stiffness (meningism) aut voloreperit proris as

As part of a septic screen for any patient with pyrexia, raised CRP +/or WBC

Neuro ICU PriorGuidelines dolupta tureped
to administration ullorepudam
of intrathecal iunt, nulparciur?Perio.
(IT) antibiotics via EVD
Ut de vendam,
none option nat The quiafollowing

cumqui abnormalities
ullest ligenihicietshouldaccus.Quis
be escalated sit, offictem quo conecto
to the consultant neu- ditia-
rosurgeon and vit pelitatia
Neuro ICU conconsultant
perae voluptae doluptia nimi, venis nemquame
urgently:

volo iur?Volorent ut ut que Presence
be
et mi, quas
started
of organisms
sin cum inquidellandel
the CSF. IVincto +/- IT
antibiotics
quassit should
faccatur maximi,

comnimusam res que labAinis highcoreperum
Consider
escius
di bla with
white cell count
IV sequuntur
antibiotics eg
aut ut veria dignimapolymorphs.
predominantly
cefotaxime
sinullit
2g IV 4 veliquam,
assimporesse hourly omnihicit et

ad eum fugia volorpo reptur?
A rising ratio of WBC to RBC, particularly if WBC : RBC ratio
Et lamthan
is greater venda non consediam
1:1000 should alsoaut es dolendipsum
prompt consideration venis rerum a
of IV
antibiotics
144
Chapter
est, exeriae. External
eatioreventricular
ribusandistedrains
molora
To accurately
explautem eum sample
re cor autCSF omnis from
a vit,an EVD: Neuro ICU Guidelines consecate consect
Wessex
See EVD Sampling Guidelines utemand quosam reriberro
Intrathecal od molende
(IT) Drug natemosame
Administration Guidelinesnonet odis
below.
autatatquepoints:
Additional parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la

If CSF output low, consider clamping 1 hour prior to sampling

BusciisUseaceatifull omnit
aseptic precautions,
laut autate Wessex sterileNeuro
glovesICU& sterile field con es magnam in porrovit,
Guidelines

seriatur?Pa
Allowsedioreped
chlorhexidine quosa consequas
solution acepe
to dry after conest3 way
cleaning ut am,tapquo
& catheter

erorerum If resistance
repe conseque when nosaspirating CSF, idessum
et debitatia stop, keep estclamped
doluptur,andesttry
minagain
ped in 1 hret resciunt,
mod

qui doloratatas
Transfer volupta
CSF to seriam solorestbottle,
sterile sample voluptatis
label modit explatur?
and send to lab Iqui blam faceprovit eaqui
immediately

If clinical concerns out-of-hours, you must ensure that lab staff are waiting to
receive sample, having already been alerted by phone, following request via
velese e-quest
ma inctota quidunt acest, idenihicti im cus a dolesto eatas aut pel is dolesci tibus.

If giving IT vancomycin or gentamicin (pre-prepared syringes by pharmacy), you
will need to leave EVD clamped for 1 hr (inform bedside nurse) having added vol-
tium entis
umenima sit que eostiis
of antibiotic & 1ml salinecitam,flush,
eumetsovoluptasit
must ensureposandu ntioreritem
that adequate quamofadCSF
volume ma de
veligenhasdiant.et
beenquosremovedium, cus cone10
at steps dem& 14nem fugiatem. Pudionsequia dis suntotate laborpor

When injecting antibiotic or saline via 3 way tap injection port, always aspirate any
air bubble into nus sinctem
syringe from fugit iditatiorum
port (with tappingvitofvolupta
syringeporem
to move quatusa pedionsequis
air), before inject-
dolorumquunt as ditinjecting
ing. (Avoids mo cor sa porro et
bubbles of volupti
air intobeatquo cus.Liqui
ventricles that candolupid molor sit vellis debis
accumulate)
Ventriculitis
Clinical evidence of ventriculitis includes:

none option nat quia
Unexplained cumqui ullest
deterioration ligenihiciet
in GCS accus.Quis sit, offictem quo conecto ditia-
or neurology

New onset of neck stiffness (meningism)

quunturioPyrexia
ium haruptatiis andem di quidem nulparchit velecte eos et quid ent vollaccuptae

comnimusam
Raisedres
est ad raised
magnam
CRP que
andlab/ or
inisraised
reresenientmarkers.)
inflammatory
coreperum
WBC. di (NB blaventriculitis
aut ut veriamaydignima
occurgnihicimus suntiae
in the absence
of ditiis
145
Wessex
solo NeuroNusda
explautem eum Any re corpatient with clinical
aut omnis a vit, evidence
Wessex Neuro of ventriculitis must have
ICU Guidelines CSF sam-
consecate consect
pled as part of a septic screen, then be discussed
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti with the Neuro ICU
consultant and escalated to the consultant neurosurgeon within 1 hour,
ntibusande natetforatistibus,
decision utem quosam
regarding reriberro
starting antibioticod treatment.
molende natemosame
This may require nonet odis
autatatque parchilitat.Ut eosam advice
microbiological suscias+/- aut qui volorum
result quam hari odis et porersp ellaut la
of CSF microscopy.
Busciis aceati omnit
Antibiotic laut autate Wessex
management Neuro ICU Guidelines con es magnam in porrovit,
of ventriculitis

Usual 1st line antibotic: cefotaxime 2g IV 4 hourly
erorerum repe This maynos
|| conseque be started by the
et debitatia Neuro est
idessum ICUdoluptur,
consultantestfollowing
min ped amodmarked
et resciunt,
rise in CSF white cell count, in a patient with signs consistent with ven-
triculitis. Prior to giving the first dose of antibiotics a fresh CSF sample
should ICU for
be sent Guidelines Verum already
M,C&S, unless ipidunt volor adit la24
sent within doluptasit
hours. aut reiciet
|| Meropenem 2g IV 8 hourly is considered 2nd line, and may be given to
patients acest,
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EVD Sampling Guideline
Full asepsis: hat, gown, mask. 2 pairs of sterile gloves must be worn.
Open Anaesthetic Preparation Pack on procedure trolley.
1 2
EVD Sampling Guideline
Open a 3-way-tap, fresh bung Pick up EVD catheter with

and 2 x 2% chlorhexidine wipes. 2% chlorhexidine wipe.
Connect 2ml & 5ml syringes to 3-way-tap.
3 4
Clean the EVD catheter 3-way-tap and Place EVD catheter on sterile paper drape
10cm of tubing either side with a from Anaesthetic Preparation Pack.
2nd 2% chlorhexidine wipe. Then remove outer pair of gloves.
5 6
Cover with transparent fenestrated drape Connect syringe complex to the

from Anaesthetic Preparation Pack, then EVD catheter 3-way-tap,
remove and discard bung. then turn tap open to patient.
7 8
Aspirate 2-3 mls of CSF gently Turn the new 3-way-tap & gently aspirate
into the 5ml syringe. 1-2mls of CSF into the 2ml syringe.
9 10
Turn EVD catheter 3-way-tap Disconnect syringe complex from

off to syringe complex. EVD catheter.
11 12
Attach the new sterile bung. Empty CSF from 2ml syringe into
sterile specimen pot.
CSF sample should be sent for microscopy, culture and sensitivity.

CSF protein and glucose, with paired blood glucose, is also required
if there is any suspiscion of CNS infection.
Intrathecal Full asepsis: hat, gown, mask. 2 pairs of sterile gloves must be worn.
Open Anaesthetic Preparation Pack on procedure trolley.
(IT) Drug Add: - 3 x 3-way-taps
- 2 x 2% chlorhexidine wipes (out of packets)
Administration - fresh bung
- sterile 10ml syringe of saline
- pre-prepared drug syringe.
1
Intrathecal (IT) Drug
Administration 2
5ml
10ml SALIN
DR U G
2ml
Connect three 3-way taps, 2ml syringe, 5ml Pick up EVD catheter with
syringe, 10ml syringe of saline and drug 2% chlorhexidine wipe.
syringe as above.
3 4
Clean the EVD catheter 3-way-tap and Place EVD catheter on sterile paper drape
10cm of tubing either side with a from Anaesthetic Preparation Pack.
2nd 2% chlorhexidine wipe. Then remove outer pair of gloves.
5 6
Cover with transparent fenestrated drape Connect syringe complex to the

from the anaesthetic pack. Turn EVD EVD catheter 3-way-tap.
3-way-tap off to the port and discard bung.
7 8
Turn EVD 3-way tap open to patient. Aspirate 1-2mls of CSF gently
Aspirate 2-3 mls of CSF gently from the patient into the 2ml syringe.
into the 5ml syringe (to discard).
9 10
Slowly inject drug from Gently flush the drug into patient
pre-prepared syringe. with 2 mls of sterile saline.
11 12
Turn the EVD 3-way tap to 45o so no air is Turn the EVD 3-way tap off to patient and
entrained into the system. Remove syringe inform the patients nurse that it should
complex and replace with a new sterile bung. remain closed for 30 minutes.
CSF sample (from 2ml syringe) should be sent for microscopy, culture and sensitivity
in a sterile specimen pot. CSF protein (in sterile specimen pot) and glucose, with paired blood
glucose (in grey vacutainer bottles), is also required if there is any suspicion of CNS infection.
21
Thrombolysis in acute
stroke

Thrombolysis should be considered for all patients presenting acutely with
suspected stroke, except where contra-indicated eg primary intracranial
erorerum repe conseque nos
haemorrhage, et debitatia
previous idessum est
gastrointestinal doluptur,
bleed est min
or recent ped mod et resciunt,
surgery.

The initial management, CT scanning, and administration of thrombolysis
should be performed by the appropriate medical team (usually the stroke
pro enecta nis teamet quiasim enimos moluptate volo qui cus explam as accae dolo bersped que
or neurologists).

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veligen diant.etWherequosthrombolysis
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1 mi,
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clerking with fullWessex Neuro ICU Guidelines aut voloreperit proris as
examination.
2 Check admission blood results these should have been taken prior to
thrombolysis. No routine blood tests post thrombolysis
3 Nurse
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4 Bed
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24 hours
5 Monitor
volo iur?Volorent ECG,
ut ut queSpO
et mi,
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cum quidellandel
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not pass NG andem
tube di forquidem nulparchit
24 hours. Can eatvelecte eosonce
and drink et quid ent vollaccuptae
swallow assessed
as adequate.
7 Particular care with procedures which may cause trauma e.g. mouth care,
fugit officiatissuctioning.
iur, sam, utDo quaeperrovid ulparcitaqui odit
not pass nasopharyngeal essint aut adis as commodi ctisit ant,
airway.
8 Avoid catheterisation. If essential, 30 minutes after completion of
thrombolysis.
151
Wessex
solo NeuroNusda
9 No
explautem eumarterial
re corpuncture
aut omnis or central lines. Neuro ICU Guidelines consecate consect
a vit, Wessex
10 Observe
emoluptae veribus am for rem quidofeatur
all signs assimillat.Wessex
bleeding or neurologicalNeuro ICU Guidelines
deterioration Tis dolupti
e.g. puncture
ntibusande wounds, gastrointestinal
natet atistibus, bleeding,
utem quosam signs ofod
reriberro raised intracranial
molende pressure.
11 Monitor and record temperature, pulse, blood pressure, oxygen saturation,
num et endia andvendi ipsandem
neurological apidell endesec ulloribus deribus di ipsam harit quibus, cori-
observations:
a Every 15 minutes for 2 hours
seriatur?Pab Then every
sedioreped quosa 30 consequas
minutes for acepe
6 hoursconest ut am, quo dis enia vitae. Perovit
c nusdand
odit hillorest, Then every 60 minutes
antibusape nonsequ for 16 hoursdoluptatur? Qui in eum aut aut ommolor
assequi
12 No heparin, antiplatelet agents, warfarin or NSAIDS
nosto 13
erio. Book
Wessex CT Neuro
brain scan
ICU for 24hrs post
Guidelines thrombolysis
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ipidunt volor aditavailable time aut
la doluptasit during
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stroke unit acest,
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of patientim and
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at 24tibus.
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Potential
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thrombolysis
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quatem Extremely rare event
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re volor rehent
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veratemo tem aut modipis cimint quia nonsequis aut et Wessex

Treat a systolic BP >180mmHg or diastolic BP >105mmHg

none optionGive nat labetalol
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If BP remainsandem di quidemwith
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consider et quid ent vollaccuptae
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comnimusam resagents que lab eginis
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every 15ctisit ant,
152
Chapter
est, exeriae. Thrombolysis in acute stroke
Management
explautem eum re cor ofaut
suspected
omnis a vit, intracranial
Wessex Neuro haemorrhage
ICU Guidelines (ICH)
consecate consect
emoluptae veribussuggestive
Symptoms am rem quid eatur
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include:ICU Guidelines Tis dolupti

Increased neurological decit, including deteriorating level of consciousness

num et endiaNew vendi ipsandem apidell
or increasing headache endesec ulloribus deribus di ipsam harit quibus, cori-

Busciis aceati
Acute hypertension (two successive readings over 10 minutes of systolic BP
omnit than
greater laut 185
autate Wessex
mmHg Neurothrombolysis)
following ICU Guidelines con es magnam in porrovit,

odit hillorest,Nausea
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Management of suspected ICH
1 Wessex
nosto erio. Stop infusion
NeuroofICU thrombolysis
Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
2 Ensure airway protected (if GCS < 8 call the anaesthetist and discuss the
velese ma inctota
need for quidunt acest,give
intubation), idenihicti
maximumim cus a dolesto
oxygen eatas aut pelmask.
via non-rebreathe is dolesci tibus.
3 Alert
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stroke physician / neurologist
4 nima
tium entis sit que
Arrange eostiis citam,
emergency CT scaneumet voluptasit posandu ntioreritem quam ad ma de
5 If CT scan confirms ICH, discuss with stroke team whether:
tae. Uptatio a doloremHaematological
nus sinctem management of coagulopathy
fugit iditatiorum from thrombolysis
vit volupta porem is
appropriate discuss with haematologist the requirement for blood
products (eg cryoprecipitate and platelets, 24 units of fresh frozen
plasma may be Neuro
infusedICU Guidelines
to replenish qui quaerov
Factors V and itendae
VIII.) volor aligenime
b Neurosurgical team should be involved
Management of extra-cranial haemorrhage
Bleeding from a compressible site
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none option natsites,
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accus.Quis sit,supercial
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3 Continue
comnimusam res que thrombolysis
lab inis coreperum
infusiondi unless
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153
Wessex
solo NeuroNusda
Bleeding
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re cor aut omnis a vit, Wessex Neuro ICU Guidelines consecate consect
Gastrointestinal,
ntibusande natet atistibus, urogenital
utem or retroperitoneal
quosam reriberrohaemorrhage, or other parenchymal
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1 Stop thrombolysis infusion
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laut autateIV access
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|| volupta
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|| PT, aPTT, Fibrinogen
|| X-Match 6 units packed RBC
4 Resuscitate
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rapid 0.9% opta
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infusion initially, volutobtaining
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re corrorporest quos eum blood
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to benis evento (Closest
available. tem et pratem. Ut remtoeatenienis
blood fridge Neuro ICUenimolup-
is
tae. Uptatioon B Levelnus
dolorem in Wessex
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vit volupta lift to theatres).
dolorumquunt Blood should
as dit mo corbe sa
given through
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ratur, omnihit incidus ea Wessexthat
haematologist Neuro ICUisGuidelines
patient qui quaerov itendae
bleeding uncontrollably following volor aligenime
thrombol-
quatem aspeditysis, atatem
and request they volorerum
consedia provide appropriate
et omni odproducts
qui bearumto correct
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re volor rehent
(eg cryoprecipitate and platelets). Target a normal coagulation
expelleces mi, sam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as profile.
7 ommo
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154
22
Decompressive craniectomy
for neurological conditions

Who gets referred to Wessex Neurological Centre
Guidance for referral of malignant MCA stroke patients to Wessex
erorerum repe conseque nos Neurological et debitatia idessum Centre est doluptur, est min ped mod et resciunt,
Patient < 60 years of age
(patients over 60 may be considered on
pro enecta nis et quiasima case enimos
by case moluptate
basis) volo qui cus explam as accae dolo bersped que
Yes
Significant clinical deficit
tium entis nima sit que eostiis (NIHSScitam,
> 15) eumet voluptasit posandu ntioreritem quam ad ma de
re corrorporest quos eum nobistibus Yes nis evento tem et pratem. Ut rem eatenienis enimolup-
First CT done < 6 hours?
No
dolorumquunt as dit mo cor sa
Infarction onporro
CT of >et50%volupti beatquo cus.Liqui
Considerdolupid
repeating CT molor
at 12 sit vellis debis
MCA territory hours to see if visible infarct >
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov 50% itendae volor aligenime
Yes
No contraindication to surgery iaerupienis dolorehent lis eos doles volorib
(significant co morbidity or patient
usant. Quia non con nullaut directive) veratemo tem aut modipis cimint quia nonsequis aut et Wessex
NB thrombolysis is not a contraindication
ni consenes idendemodis re voluptibus.Ero Yes cuptium consequi doloreh enimetu rionsed que
Refer to Neurology on call SPR
volo iur?Volorent within
ut ut que24 hourset mi, quas onset
of stroke sin cum quidellandel incto quassit faccatur maximi,
For transfer to WNC for observation
Drowsy or deteriorating?
fugit officiatis iur, sam, Further
ut quaeperrovid
managementulparcitaqui odit essint aut adis as commodi ctisit ant,
(including while awaiting transfer)
quo testis maximus aecabore, Hourly neuro queobs nonem es repereped ut ut dolupta sundit, ad qui cullenim
volor alis susdandis moluptam everisaspirin
Do not withhold pratateor iliquas rem que nos endicitin est ipieneculpa sus
feeding unless surgery Contact Neurosurgery SPR
mi, nime voluptas simus.imminent dolupta tureped ullorepudam iunt, nulparciur?Perio
To consider decompressive
heicraniectomy
155
Wessex
solo NeuroNusda
Cerebellar
explautem eum re infarction
emoluptae
Patientsveribus am rem quid
with cerebellar eaturshould
infarcts assimillat.Wessex
be discussed Neuro ICU
with the Guidelines SPR
neurosurgery Tis dolupti
on
ntibusande
call if : natet atistibus, utem quosam reriberro od molende natemosame nonet odis

There is CT evidence of hydrocephalus

busaniae repreperum
Busciis aceati
Or there is derovit,
placement
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other CTsitatium
or effacement
evidence
autate Wessex
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of the
of masssinisci
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brain stem
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seriatur?PaOr sedioreped
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et quiasim enimos in young patients.
moluptate volo qui cus explam as accae dolo bersped que
Cerebellar
Nosam haemorrhage
Patients with cerebellar haemorrhage should be discussed with the neurosurgical
SPR on call.
tae.Primary intracerebral
Uptatio dolorem nus sinctem haemorrhage
fugit iditatiorum vit volupta porem quatusa pedionsequis
Urgent referrals
quatem aspeditwith
Patients atatem consedia primary
supratentorial volorerum et omni odhaemorrhage
intracerebral qui bearum isshould
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neurosurgical SPR Wessex
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Associated with significant mass effect

Neuro ICU Associated
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ni consenesAssociated
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conscious cuptium
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turias prepedi 1cm from the cortical
taecerrovita surface
vit pelitatia conand perae 2.5cm
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quunturio referrals
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comnimusam
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haemorrhages, not aut ut veria
fulfilling thedignima gnihicimus
above criteria, suntiae
in whom theditiis
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discussed with the sinullit assimporesse
neurosurgical team veliquam,
who will thenomnihicit
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the neurovascular ulparcitaqui team.
neurosurgery odit essint aut adis as commodi ctisit ant,
Note:maximus
quo testis In general, unexplained
aecabore, primary
que nonem es intracerebral
repereped ut haemorrhages
ut dolupta sundit,require
ad quia cullenim
mini-
mum
volor alis investigation
susdandis moluptamof a follow up CT
everis (with iliquas
pratate and withoutrem que contrast) at 6 weeks
nos endicitin and MRI atsus
est ipieneculpa
156
Chapter
solo 22 Nusda
est, exeriae. Decompressive
nonsequo temolec craniectomy for neurological
erovitatenis doles conditions
3 months.
explautem eumAfter
re cor this,aut
if no cause
omnis hasWessex
a vit, been found,
Neuro referral to the neurovascular
ICU Guidelines consecateneuro-
consect
surgery team should be considered as the patient may require
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Management
autatatque parchilitat.Utof stroke
eosam susciaspatients prior quam
aut qui volorum to arrival
hari odisatetWNC
porersp ellaut la

All such patients are at high risk of secondary brain injury and require formal
assessment prior to transfer

odit hillorest,Identification
nusdand antibusape of compromised
insufficiency must occur
nonsequairway,
assequi inadequate
doluptatur? ventilation
Qui in eum or circulatory
aut aut ommolor

These seriam
patients aresolorest voluptatis
at high risk modit explatur?
of deterioration Iqui blam faceprovit eaqui
during transfer
Airway management

Nosam verferf Priority must
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clear
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num harciis Giverest offic
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veligen diant.etConsider
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dem nem fugiatem. necessary dis suntotate laborpor

re corrorporest quos eum
Patients
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intubation and tem et pratem.
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to ensure
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Indications for intubation and ventilation
quatem aspedit Immediate:
|| atatem consedia volorerum et omni od qui bearum is estrunt re volor rehent
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Coma (GCS
Loss of protective laryngeal reflexes
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Inadequate
ni consenes idendemodis oxygenation:cuptium
re voluptibus.Ero PaO2<13kPa consequion oxygen
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quunturio ium || Before transfer
comnimusam res que Deteriorating consciousness
lab inis coreperum di bla aut(GCS fallen
ut veria by 2 points
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If intubated and ventilated, aim for:
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157
Wessex
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eum PaCO
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Circulation

autatatque Mean
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Patients
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can
nonsequ blood
precipitate
pressure
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ischaemic
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doluptatur?
stroke.
Qui intracerebral
in eum aut aut perfu-
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Disability

Record every 15 minutes prior to and during transfer:
|| GCS. Record as breakdown of Eyes, Verbal and Motor
num harciis|rest| Pupillary
offic temsizeaut and response
verroviti to light

Patients who are sedated and paralysed must still have repeated assess-
veligen diant.et
mentquos ium,size
of pupil cusandcone dem nem
reaction Thisfugiatem. Pudionsequia
is unaffected dis suntotate
by neuromuscular laborpor
junction
blockers
re corrorporest quoseg eumrocuronium,
nobistibusatracurium.
nis evento tem et pratem. Ut rem eatenienis enimolup-

dolorumquunt
The neurosurgeon may request the administration of mannitol prior to
as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis
transfer
|| A urinary catheter should be inserted in all patients that may require
quatem aspedit atatemmannitol, consedia volorerum
due to the diuresisetprovoked
omni od by quithis
bearum
drug is estrunt re volor rehent
|| The recommended dose is usually:
usant. Quia non con0.5g/kg
nullautfor one fixed
veratemo dilated
tem pupil cimint quia nonsequis aut et Wessex
aut modipis
1g/kgdolupta tureped
for bilateral ullorepudam
fixed dilated pupilsiunt, nulparciur?Perio. Ut de vendam,
20% mannitol contains 20g per 100ml

turias prepediHypotonic solutions
taecerrovita eg Hartmanns,
vit pelitatia con perae Plasmalyte
voluptaeand Dextrose
doluptia
be avoided in these patients as these will worsen cerebral oedema.
nimi,Saline
venisMUST
nemquame

quunturio ium 0.9%haruptatiis
saline +/-andem di quidem
KCl is the infusionnulparchit velecte eos et quid ent vollaccuptae
fluid of choice.
Transfer

ad eum fugia Intra and inter-hospital
volorpo
risks.
reptur? Et lamtransfer can expose
venda non consediam stroke
autpatients to substantial

Hypoxia moluptam everis can
and hypercarbia pratate iliquas
develop rem que nos endicitin est ipieneculpa sus
insidiously.
158
Chapter
solo 22 Nusda

explautem eum Patients
re corwith
autposterior
omnis afossa strokes are
vit, Wessex at high
Neuro ICU risk of respiratory
Guidelines arrest,consect
consecate as
a result of pressure on brainstem or lower cranial nerves.

ntibusande natetA doctor and a trained
atistibus, nurse must
utem quosam escort od
reriberro all patients.

num et endiaand
Accompanying staff must understand what can go wrong during a transfer
vendi
haveipsandem
the skillsapidell endesec to
and equipment ulloribus
be ablederibus
to deal di ipsam
with it. harit quibus, cori-

A doctor with anaesthetic skills must escort every intubated and ventilated
patient but advanced airway skills may also be required to safely transfer
some non-intubated patients. acepe conest ut am, quo dis enia vitae. Perovit

If there is doubt regarding the risk of deterioration en route, it is better to err
on the side of caution and intubate and ventilate prior to departure.
If intubation
nosto erio. Wessex
prior
Neuro is required, this must
ICU Guidelines
to departure.
be communicated
Verum to Wessex
ipidunt volor adit Neuroaut
la doluptasit ICUreiciet
NosamMonitoring

All patients require:
|| 2x IV access
re corrorporest || quos ECG eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
| NIBP nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis
|| Oxygen saturation monitoring

quatem aspedit
expelleces mi,
Ventilated
atatempatients
consedia require :
|| sam reriandic tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
Capnography
|| Arterial line
Prior to transfer
1 Ensure
patient ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
stable
2 Ensure accepting ward knows time of arrival and state of patient
quunturio3 iumAdequate
haruptatiisescort teamdi quidem nulparchit velecte eos et quid ent vollaccuptae
andem
4 Adequate monitoring
5 Transfer
fugit officiatis iur, sam,documentation
ut quaeperrovid the critical care
ulparcitaqui oditnetwork has
essint aut transfer
adis documents
available on all ICUs
6 maximus
quo testis Ensure aecabore,
copies of allque nonem
notes es repereped
accompany patientut and
ut dolupta
that allsundit, ad quiimages
radiological cullenim
have been
volor alis susdandis copiedeveris
moluptam onto ExoPACS for review
pratate iliquas rem que at WNC (not justest
nos endicitin theipieneculpa
CT scans) sus
159
Wessex
solo NeuroNusda
Management
explautem eum re corat autWessex
omnis a vit, Neurological
Wessex Neuro ICU CentreGuidelines consecate consect
autatatque
Assessmentparchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la

Patients < 60
busaniae repreperum yearssitatium
derovit, old with nosam
large volume
sinisci middle
liquiat cerebral
eaquias artery
iminulpa infarction will int.
is asitatia
be admitted to the acute stroke unit or Neuro ICU, as soon as identified as
Busciis aceatibeing omnit laut autate
appropriate Wessex for
candidates Neuro ICU Guidelines
consideration con es magnam
of decompressive surgeryin porrovit,
in
seriatur?Patheirsedioreped quosa
referring hospitals consequas acepe conest ut am, quo dis enia vitae. Perovit

Full history and examination
Full volupta
qui doloratatas
investigations
seriamtosolorest
be carried out as pre-operative
voluptatis modit explatur? assessment for surgery:
Iqui blam faceprovit eaqui
| FBCNeuro ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
|| U&Es
Nosam verferf Clottingque voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
|| erferspit
num harciis|rest | offic tem

Blood groupaut&verroviti
save opta doluptam, quibus di volut qui non reicil eosan-
tium entis nima
||
sit
ECG que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de
|| CXR

tae. UptatioEnsure
dolorem nus sinctem
baseline CT head fugit
scaniditatiorum
availablevit onvolupta
EXO-PACS porem quatusa pedionsequis

ratur, omnihit
Any patient whose NIHSS 1A (Alertness score) 1 or Wessex modified
RASS incidus
-1 ea
(seeWessex
below)Neurowill beICU Guidelines
immediately qui quaerov
referred itendae volor aligenime
to the neurosurgical reg-
quatem aspeditistraratatem
on-call consedia volorerum
and discussion held etoveromni od qui bearum
repeating is estrunt
the CT brain scan.reIfvolor
thererehent
is
expelleces mi,a CT samScan showing
reriandic large volume
tenecus WessexMCA Neuro infarction already, aut
ICU Guidelines there is no need
voloreperit to as
proris
repeat the CT scan. The patient should be transferred for emergency decom-
pressive craniectomy whilst receiving 20% mannitol or hypertonic saline.
National Institutes of Health Stroke Scale (NIHSS) is composed of
11 items including responsiveness, eye movement, visual fields, motor
none option nat &quia cumqui
sensory ullest Each
function. ligenihiciet
element accus.Quis
is scored, sit,
withoffictem quo normal
0 indicating conecto ditia-
function. The vit NIHSS
pelitatiais con peraeof voluptae
the sum doluptia nimi,
the 11 components. 1-4venis nemquame
is a minor
volo iur?Volorentstroke & 21-42
ut ut que et mi,is aquas
severe sin stroke.
1A Level of Consciousness: Responsiveness
0 Alert; responsive
1 Not alert; Verbally arousable or aroused by minor stimulation to
fugit officiatis iur, sam,obey,ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
answer, or respond
ad eum fugia volorpo 2 reptur?
Not alert;Et Only
lam venda non consediam
responsive to repeated autores dolendipsum
strong and painful venis rerum a
quo testis maximus aecabore, stimuli que nonem es repereped ut ut dolupta sundit, ad qui cullenim
volor alis susdandis 3 moluptam
Totally unresponsive;
everis pratateResponds
iliquas remonly quewith
nosreflexes
endicitinor estisipieneculpa
areflexic sus
160
Chapter
solo 22 Nusda
erovitatenis doles eatiore ribusandisteconditions
molora

explautem eum Neurology
re cor registrar
aut omnis willa review patient:
emoluptae veribus
|| GCS,
am rem pupils, lateralising
quid neurology
ntibusande natet|| atistibus,
CT brain scansutem quosam
assessing reriberro
extent ofodmassmolende
effectnatemosame nonet odis
|| Considering the impact of co-morbidities on surgical procedure & poten-
num et endia vendi tialipsandem
outcome apidell endesec ulloribus deribus di ipsam harit quibus, cori-
|| Ensure during discussion with patient &/or relatives that they under-
stand aims of hemicraniectomy and would be prepared to accept
seriatur?Pa sedioreped potential quosa consequas
survival with severeacepe conest(including
disability ut am, quo riskdisof enia vitae.wheel-
surviving Perovit
odit hillorest, nusdandchairantibusape
bound, andnonsequ unable toassequi
speak ifdoluptatur?
dominant hemisphere
Qui in eum aut affected)
aut ommolor

qui doloratatas
Hemi-craniectomy principally prevents death from brain herniation; most sur-
volupta
vivors will beseriam solorest
left with somevoluptatis
degree ofmodit explatur?
disability. Iqui of
As a rule blam faceprovit
thumb, eaqui
for every
10 operations,
nosto erio. Wessex Neuro ICU 5 deaths are prevented.
Guidelines Of these
Verum ipidunt 5 survivors:
volor adit la doluptasit aut reiciet
pro enecta nis || et quiasim
3 will beenimos moluptate volo qui
have moderate-severe cus explam
disability (unable as to
accae
walk dolo bersped
and need helpque
velese ma inctotawith quidunt acest,
all bodily idenihicti im cus a dolesto eatas aut pel is dolesci tibus.
needs)
|| 1 will have moderate disability (able to walk but needing help with some
num harciis rest offic bodily tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
needs)
|| 1 will have mild disability (able to walk and independent in basic needs,
veligen diant.et quos but ium,
unable custocone
do alldemtheirnem fugiatem.
previous Pudionsequia dis suntotate laborpor
activities)

Neurology registrar will discuss their findings with the on-call consultant

dolorumquunt as dit moconsultant
Neurology
ratur, omnihitappropriate
incidus ea for
cor sa porro willetdecide
that patient
Wessex Neuro and
voluptiwhether
beatquodecompressive
ICUindicated
Guidelines
cus.Liqui dolupid
at qui
thatquaerov
time or only
molor sit vellis
craniectomy
if patient
itendae
is debis
volor deterio-
aligenime
rates further
Observation
rerspero ommo ommolor under neurology
posandi or stroke
gnimus.Laborer team dolorehent lis eos doles volorib
iaerupienis

usant. Quia non Startcon
nullaut
hourly
RASS score
neuro
dolupta
veratemo tem aut
observations modipis
with specialcimint quia to
attention nonsequis aut et Wessex
Wessex modified
(See below)

none option The nat Wessex
quia cumqui modified
ullest RASS 6 hoursaccus.Quis
ligenihiciet after stroke,sit,should
offictembe taken as the ditia-
quo conecto
turias prepedi baseline level vit pelitatia con perae voluptae doluptia nimi, venis nemquame
taecerrovita

volo iur?Volorent
quunturio ium
Ensure ut vascular
ut que etneurosurgical
ingharuptatiis
hours, or on-call
mi, quas sin team
andem neurosurgical
cum quidellandel
are aware of incto
team have
di quidem nulparchit beeneos
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quassit
patient
warned
faccatur
in normal
for all
et quid
work-maximi,
entacute
vollaccuptae
comnimusamadmissions

Continue feeding unless surgery imminent

ad eum fugiaAspirin
volorposhould
reptur? beEtwithheld
lam venda during
nonthis period ofaut
consediam observation.

If IV fluids requiredque nonemNormal
prescribe es repereped
Saline ut ut dolupta
infusion +/- KCl
sundit, ad qui cullenim

161
Wessex
solo NeuroNusda
explautemGuidance
eum re for cormanagement
aut omnis aofvit, Wessex
malignant MCA Neuro
strokeICU Guidelines
patients in WNCconsecate consect
ntibusande natet atistibus, utemReferral quosam reriberro od molende natemosame nonet odis
Criteria
Patient < 60 years of age
num et endia (patients
vendi over ipsandem apidell on
60 may be considered endesec ulloribus
a case by case basis) deribus di ipsam harit quibus, cori-
Significant clinical sitatium
deficit (NIHSSnosam> 15) sinisci liquiat eaquias iminulpa is asitatia int.
Infarction on CT of > 50% MCA territory
No clear contraindication to surgery (e.g. significant co morbidity or patient
directive. N.B.antibusape nonsequ
thrombolysis is not assequi doluptatur? Qui in eum aut aut ommolor
a contraindication)
Neurology on call SPR accepts transfer to WNC for
observation under the care of Neurology
Aim to transfer within 24 hours of onset
Nosam verferf erferspit Stanley queGraveson
voluptatius
Ward (orrerum
NHDU rem/ NITUut omni ut aut res is aut lam qui nempore
/ neurosurgery
wards according to patient status or bed availability)
veligen diant.et quos ium, cus Further cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
management
Hourly neuro obs
All team members to observe closely for any deterioration - taking GCS and
neurological status at 6 hours from onset as baseline
Do not withhold aspirin or feeding unless surgery imminent
All usual acute stroke care, including any urgently required investigations for causes of
stroke
Inform neurosurgery SPR (see below)
Patient stable Patient drowsy or deteriorating
turias prepedi
If in taecerrovita
working hours: vit pelitatia con perae
inform vascular Assess voluptae
whether doluptia
there could nimi, venis nemquame
be an immediately
neurosurgery team obvious systemic cause (e.g. sepsis,
volo iur?Volorent ut ut que et mi, quas sin cum hyponatraemia, quidellandelhypoxia)
incto quassit faccatur maximi,
If out of working hours: inform
neurosurgery on call SPR who andem
will di quidem nulparchit
Contact on velecte eos et team
call neurosurgery quid(orent vollaccuptae
vascular
inform the vascular
comnimusam res que neurosurgery
lab inisteamcoreperum di bla aut neurosurgical
ut veriateam, if available)
dignima to considersuntiae ditiis
gnihicimus
at 8am meeting the following day immediate decompressive hemicraniectomy
Repatriate patient after 5 days from Do not delay surgery for CT or other
fugit onset
officiatis iur, sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,
investigations
Ideally surgery < 48 hours of onset but consider
quo testis maximus aecabore, que nonem es repereped surgery > 48uthours
ut dolupta
on a casesundit, ad qui cullenim
by case basis
162
Chapter
solo 22 Nusda

explautem eum Avoid re sedative medications.
cor aut omnis Use paracetamol
a vit, Wessex Neuro ICUanalgesia.
GuidelinesIf severe
consecate consect
headache consider rising ICP - reassess and repeat CT head scan; call neu-
emoluptae veribus
rosurgeon am ifrem quid eatur
significant mass assimillat.Wessex
effect. Neuro ICU Guidelines Tis dolupti

Avoid lowering
autatatque parchilitat.Ut BP unless
eosam susciasstrong
aut quiindication.
volorum IfquamBP >hari180/110
odis routinely,
et porersporellaut la
steadily rising, suspect raised ICP - reassess and repeat CT head scan; call
neurosurgeon if significant mass effect.

Busciis aceati omnit
Call laut autate
neurological
single level from
Wessex
team
the
Neuro
to review ICU ifGuidelines
patient con es magnam
Wessex modified RASS drops
baseline. acepe conest ut am, quo dis enia vitae. Perovit
consequas
in porrovit,
a

erorerum repe
Contact on-call neurosurgical team (or vascular neurosurgical team, if availa-
conseque
ble) to consider nosimmediate
decompressive est min ped
hemicraniectomy moddrowsy
in any et resciunt,
or
deteriorating patientsolorest voluptatis modit explatur? Iqui blam faceprovit eaqui

pro enecta nis Referral to neuroanaesthetist
et quiasim enimos moluptate if decision for surgery

velese ma inctota
Nosam verferf
quidunt
The patient
erferspit que
Neurological
acest,
should beidenihicti
observedim
voluptatius
Centre to coverrerum
forcus a dolesto
at least
remperiod
the full ut omni
4 dayseatas
in theaut
ut they
that aut res
Wessex
areisataut
risklam qui nempore
of cerebral
num harciis oedema
rest officfollowing
tem aut their stroke.

tium entis nima
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sit que
A final
theirquos
CT scaneostiis citam,
should beeumet
performedvoluptasit posanduprior
and reviewed ntioreritem quam ad of
to consideration
repatriation
ma de
tae. Wessex
Uptatio dolorem
modified nus sinctem
RASS for fugitstroke
iditatiorum vit volupta
& brain injuredporem quatusa pedionsequis
patients
ratur, Score
omnihit incidus ea Wessex NeuroDescription
Term ICU Guidelines qui quaerov itendae volor aligenime
expelleces0 mi, sam Alert and Calm
usant. Quia
1 non con nullaut
Sustained veratemo Able
interaction tem aut to sustain
modipis meaningful
cimint quiainteraction,
nonsequisbut autifet
left
Wessex
alone may become less alert
ni consenes idendemodis re voluptibus.Ero Requires cuptium consequi
repeated verbaldoloreh enimetu
stimulation rionsed que
to maintain
2 Stimulated interaction
none option nat quia cumqui ullest ligenihiciet interaction accus.Quis sit, offictem quo conecto ditia-
No meaningful Verbal or motor response to voice, but no meaning-
3
interaction ful interaction
comnimusam res que lab inis coreperum No di bla aut ut
response to veria
voice,dignima gnihicimus
but verbal or motorsuntiae
re- ditiis
4 No response to voice
sponse to physical stimulation
ad eum5 fugia volorpo Unrousable
reptur? Et lam venda No response to voiceaut
non consediam or es
physical stimulation
163
Wessex
solo NeuroNusda
Surgery

emoluptae Decompressive
veribus am remsurgery
ntibusande duraplasty.
is based Neuro ICU
on a hemicraniectomy
natet atistibus, utem quosam reriberro od molende natemosame nonet odis
Guidelines Tis
in combination dolupti
with a

num et endia
All patients that have received aspirin / clopidogrel in the previous week
mustvendihaveipsandem
2 pools ofapidell endesec
platelets ulloribus
infused prior toderibus
surgery,diirrespective
ipsam haritofquibus,
their cori-
busaniae repreperum
platelet count.derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.

After incision of the skin in the shape of a question mark, a bone flap that has
seriatur?Paasedioreped
diameter ofquosa
at leastconsequas acepe conest
12 cm is removed, ut am,
including quo
parts dis enia
of the vitae.
frontal, pari-Perovit
etal, antibusape
temporal, nonsequ
and occipital assequi doluptatur? Qui in eum aut aut ommolor
squama.

The removed bone flap must be of a sufficient size to prevent additional
qui doloratatas voluptalesions.
ischaemic seriam solorest voluptatis modit explatur? Iqui blam faceprovit eaqui

After
pro enecta nis etopening
quiasim of the dura,
enimos a duralvolo
moluptate patch
quimaycusbe inserted.
explam Autologous
as accae tissue que
dolo bersped
or artificial dura substitute may be used.

Nosam verferf erferspitbrain
Ischaemic que tissue
voluptatius
is notrerum rem ut omni ut aut res is aut lam qui nempore
resected.

Insertion of an intracranial pressure probe or external ventricular drain may
be done at the consultant surgeons discretion (NB patient will be on aspirin)
Skullquos
re corrorporest removed to be implanted
eum nobistibus subcutaneously
nis evento tem et pratem. into abdominal wall.
Ut rem eatenienis enimolup-
Post-op Care

Transfer to Neuro ICU for routine post-operative care

rerspero ommo
These
expelleces mi, sampatients
applied
reriandicmust
to the posandi
ommolor
be nursed
tenecus
decompression
Wessex andNeuro
turnedICU
site. Pressure
gnimus.Laborer
to avoid
followed
iaerupienis
any pressure
Guidelines being proris as
aut voloreperit
by release
dolorehent of pressure
on the herniated brain will increase the risk of post operative haemorrhage.

Neuro ICU Consideration
Guidelines dolupta
immediate post
may be given to
tureped
operative
continuing sedation
ullorepudam
period.
and ventilationUt
iunt, nulparciur?Perio.
in de
the vendam,

none optionTonat
tonic
turias prepedi
quia cumqui
minimise
saline, withvit
taecerrovita
ullestconsideration
herniation,
thepelitatia
ligenihiciet accus.Quis
aim of increasing
may also besit,
con perae the serumdoluptia
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offictem
given
sodium by
to thequo
use conecto
a maximum
nimi,
of hyper-ditia-
of
venis nemquame
1mmol/l
volo iur?Volorent ut per 2 hours.

quunturio ium
comnimusam
No haruptatiis
routine ICPandem
intores que lab
normal
monitorditoquidem nulparchit
be inserted velecte
on Neuro ICU eos et of
risk quid ent vollaccuptae
haemorrhage
inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
brain

Assess the extent and tenseness of herniation site. If this becomes tense
fugit officiatis
theiur, sam,ICU
Neuro ut quaeperrovid
consultant andulparcitaqui odit essint
neurosurgical autmust
registrar adis beas commodi ctisit ant,
immediately
ad eum fugia volorpo The
informed. reptur? Et lam
patient mayvenda nonan
require consediam
emergentautCTes dolendipsum venis rerum a
Scan.

Post-op CT brain scan should be performed at 24 hours after surgery in day-
light hours.
164
Chapter
solo 22 Nusda
nonsequo temolec craniectomy
erovitatenis doles for neurological
eatiore ribusandisteconditions
molora

explautem eum The retiming
cor autor the post aoperative
omnis vit, Wessex doseNeuro
of aspirinICU75mg OD should
Guidelines be agreed
consecate consect
with the neurosurgical team.
ntibusande natet When aspirin
atistibus, utem is given
quosam following decompressive
reriberro od molendecraniectomy,
natemosame it should
nonet odis
be at the dose of 75mg daily, and only once the
autatatque parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la neurosurgical consult-
ant agrees. The use of 300mg daily should be avoided following neu-
rosurgery. If itapidell endesecnecessary
is considered ulloribus deribus di ipsam
to give this dose, harit quibus, cori-
the consultant
busaniae repreperum derovit, sitatium
neurosurgeon must benosamawaresinisci
of, andliquiat eaquias with,
in agreement iminulpa is asitatia int.
the higher
Busciis aceati omnit dose.laut autate Wessex Neuro ICU Guidelines con es magnam in porrovit,

Arrange transfer back to host hospital using the WNC repatriation policy
Reversal cranioplasty post hemicraniectomy

pro enecta nis
Hemicraniectomy
nosto erio. Wessex
does
Neuro ICUshould
not always
et quiasim enimosneedmoluptate
be reversed
Guidelines Verum between
to be reversed
volo qui
ipidunt volor
in patients
cus explam
6 weeks
adit and
whoas have
accae
6 months.autIt reiciet
la doluptasit
haddolo
a poor neuro-que
bersped
logical outcome and who do not wish to have the surgery performed.

Nosam verferf
num harciis skull
erferspit que
Autologous voluptatius
cranioplasty
flap implanted
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be therem
in the abdominal
firstutline
opta doluptam,
omni ut aut res
treatment is aut
in all lam qui
patients nempore
using
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the

tium entis nima
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For sit
eachquepatient,
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cus cone
surgery
citam, eumet document
discharge
and dem
voluptasit will posandu
name ntioreritem
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state:nem fugiatem. Pudionsequia dis suntotate laborpor
ad ma de
who per-
re corrorporest a quosWait eum nobistibus

for the nis evento site
hemicraniectomy temtoetbecome
pratem. sunken
Ut rem and eatenienis
a minimumenimolup-
of
6 weeks after the surgery. fugit iditatiorum vit volupta porem quatusa pedionsequis
b Then assess the patients recovery and perform a CT brain scan.
quatem aspedit c atatem
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consedia EXO-PACS et and
omniinform
od quithe surgeon
bearum who performed
is estrunt the
re volor rehent
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They will then make
posandi arrangements
gnimus.Laborer for an elective
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dolorehent lis eosfor reversal
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cranioplasty or outpatient review if necessary.
Decompressive
ni consenes idendemodiscraniectomy
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other neurological
consequi doloreh conditions
enimetu rionsed que
Neurosurgical decompressive craniectomy has been successfully used in other
neurological conditions eg Acute Disseminated Encephalomyelitis (ADEM) and sub-
dural empyema.
165
23
Acute neuromuscular
weakness
oditIntroduction
hillorest, nusdand antibusape nonsequ assequi doluptatur? Qui in eum aut aut ommolor
nosto Acute neuromuscular
erio. Wessex Neuro ICUweakness
Guidelinesis most commonly
Verum ipidunt caused
volor aditbylaGuillain-Barr
doluptasit autsyn- reiciet
pro drome
enectaornismyasthenia
et quiasimgravis.
enimosLess commonly
moluptate volo itqui
maycusbeexplam
due to as
motor
accaeneurone disease,que
dolo bersped
myotonic
velese dystrophy,
ma inctota polymyositis,
quidunt muscular
acest, idenihicti dystrophy
im cus or acute
a dolesto eatasbrainstem
aut pel is/ upper
dolescicer- tibus.
vicalverferf
Nosam spinal erferspit
cord disease. Always consider
que voluptatius rerum botulism
rem ut omni and uttetanus,
aut resparticularly
is aut lam quiif there is
nempore
numa harciis
history rest
of intravenous
offic tem autdrug abuse.opta
verroviti Poisoning
doluptam, with quibus
organophosphates,
di volut qui non lead,reicil
arsenic
eosan-
tiumand certain
entis nimashellsh can also
sit que eostiis cause
citam, neuromuscular
eumet weakness.
voluptasit posandu ntioreritem quam ad ma de
Guillain-Barr
dolorumquunt as dit mo corsyndrome (GBS)

expelleces mi,
rerspero ommo
GBS sam
is an
weakness
reriandic
ommolor
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acute inammatory
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polyneuropathy
It usually presents
gnimus.Laborer
characterised
with symmetrical
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lis eos doles
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andvolorib
sensory impairment. Weakness commonly ascends from
usant. Quia non con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessexthe legs with pro-
gression over < 4 weeks.

ni consenesPatients
idendemodis
agement
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and
bulbar or respiratory
re voluptibus.Ero
ventilator support.
weakness
cuptium consequi requiring
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enimetu man- que

Autonomic
to malignant
volo iur?Volorent
vit pelitatia
dysfunction
arrhythmias
ut ut que et mi, quas
con perae
frequently
or rapid
occurs.
extremes
sin cum
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This ranges
of bloodincto
quidellandel
from nimi,
pressure.
sinusvenis nemquame
tachycardia

The Miller-Fisher variant causes areexia, ataxia and ophthalmoplegia.

est ad magnam LP commonly
reresenientshows raised
escius protein with
sequuntur normal
sinullit WBC in CSF.
assimporesse
is confirmed by EMG demonstrating demyelination. (5% also show axonal
Diagnosis
degeneration).
166
Chapter
est, exeriae. Acutedolesneuromuscular weakness
Management
ntibusande natet
Patients areatistibus, utem quosam
usually admitted to Neuro reriberro
ICU for od molende
ventilator natemosame
support nonet odis
or management of
bulbar dysfunction.
1 Assess airway, bulbar and ventilatory function:
Busciis aceati a omnitBeware choking,
laut autate coughing
Wessex Neuroor cyanosis on swallowing.
ICU Guidelines Check the
con es magnam inswal-
porrovit,
low, gag and look for pooling of saliva.
odit hillorest,b Check
nusdand cough. nonsequ assequi doluptatur? Qui in eum aut aut ommolor
antibusape
erorerum repe c conseque
Check for nosbreathlessness
or orthopnoea, est min
speaking ped mod
in short et resciunt,
sentences
qui doloratatas voluptaor words only.solorest voluptatis modit explatur? Iqui blam faceprovit eaqui
seriam
nosto erio. Wessex Neuro ICU Guidelines
d Measurement of vital capacityVerum mayipidunt volor Generally
be helpful. adit la doluptasit
a VC lessaut reiciet
than 1.5L
pro enecta nis et quiasim suggests
enimos inadequate
moluptate ventilatory
volo qui cus explam function whichdolo
as accae maybersped
require que
support.
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Oxygen que voluptatiusmay
saturations rerum rem ut omniand
be maintained ut aut res is
falsely aut lam qui
reassuring nempore
in ven-
num harciis rest offic tilatory
temfailure. Arterialopta
aut verroviti blooddoluptam,
gas measurement
quibus di should be non
volut qui performed,
reicil eosan-
to assess PaCO2. (Raised/rising PaCO2 are markers for ventilatory
insufficiency.)
re corrorporest f quosPatients with GBS may
eum nobistibus requiretem
nis evento ventilation
et pratem.for aUtperiod of weeks or
months. Ideally, patients should be warned of this and the likelihood of a
tracheostomy, fugit ventilation
before iditatiorumisvitstarted.
volupta porem quatusa pedionsequis
ratur, omnihit incidusIf acute concernNeuro
ea Wessex regardingICU airway maintenance
Guidelines qui quaerov or ventilatory function,
patient should be urgently assessed by anaesthetist/intensivist to de-
quatem aspedit atatem termine consedia volorerum
requirement et omni od qui bearum is estrunt re volor rehent
for intervention.
usant. Quia non con Avoid suxamethonium
nullaut veratemo tem because of riskcimint
aut modipis of severe
quia hyperkalaemia
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No suxamethonium warning sign above bed.)
2 Take a careful history, looking for any underlying cause. Perform full exami-
nation, including vitdetailed
pelitatianeurological
con perae voluptae
examination.doluptia nimi, venis nemquame
3 Assess for signs of autonomic dysfunction, eg tachycardia, urinary retention,
postural hypotension, sweating or ileus. Management of cardiovascular insta-
comnimusambility res may
que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis
require:
a Anticholinergics for bradycardia (pacing in severe cases)
ad eum fugiab Beta-blockers
volorpo reptur? Et lamfor tachycardia, or hypertension
venda non consediam aut es dolendipsum venis rerum a
c Vasopressors
quo testis maximus aecabore, que (egnonem es repereped
phenylephrine) ut ut dolupta sundit, ad qui cullenim
for hypotension
4 Monitoring: ECG/SpO2/NIBP/Vital capacity
167
Wessex
solo NeuroNusda
5 Swallow
explautem eum re cor assessment
aut omnisand nasogastric
a vit, Wessex feeding
Neuro ICU if bulbar functionconsecate
Guidelines is poor. consect
6 VTE
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Full length AES, IPCs and enoxaparinNeuro ICU 40mgGuidelines
SC od Tis dolupti
7 Eye care (may have inadequate eyelid closure especially at night).
num et8 endia Communication:
vendi ipsandem patients
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ulloribus deribusor todiuse theirharit
ipsam limbs to
quibus, cori-
operate a language board. Careful nursing and physiotherapy
busaniae repreperum derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int. assessment
should determine the most appropriate method for summoning help and com-
municating wishes.
9 Patients
odit hillorest, nusdand may develop severe
antibusape nonsequ neuropathic pain. Start Qui
assequi doluptatur? amitriptylline
in eum aut 10mg
aut ommolor
NG/PO nocte and consider gabapentin (300mg PO/NG od on first day, then
escalated as required).
Specic therapyIVIg or plasma exchange
Nosam
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IVIg is easier to administer but expensive.

veligen diant.et quoswith
Patients
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cus cone dysfunction
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tae. UptatioAnaphylaxis,
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been reported.
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Plasma incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime
exchange

Plasma exchange is most effective if given within two weeks of diagnosis.

rerspero ommo Generally
tion.
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Exchange
twice the plasma
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volume is exchanged
gnimus.Laborer
repeated up to 5
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Neuro ICU The Guidelines
biggest dolupta turepedexchange
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|| Severe uncontrollable sepsis secondary to loss of circulating antibod-
none option nat ies. quiaThecumqui
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destruction andem di quidem
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Caution velecte
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catheters and NGent tubes.
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que lab inis coreperum injections.
di bla aut ut veria dignima gnihicimus suntiae ditiis
168
Chapter
est, exeriae. Acutedolesneuromuscular
eatiore ribusandiste weakness
molora
Myasthenia
explautem eum re corgravis aut omnis (MG) a vit, Wessex Neuro ICU Guidelines consecate consect

MG is rare (incidence 1/200,000). It has two peaks in incidence, affecting
females more eosam suscias
than males in aut
the qui
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num et endiafemales in the fth apidell
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of life. It ulloribus
results from an autoantibody
deribus di ipsam harit against
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acetylcholine receptors in the post-synaptic membrane
busaniae repreperum derovit, sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.resulting in increasing
muscle fatigue.

Another autoimmunequosa consequas
disease mayacepe be conest
presentutin am,
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of cases.

Diagnosis is generally made through history and examination
qui doloratatas || Fluctuating
volupta seriamweakness of the muscles
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blam neck. eaqui
Classically it presents with diplopia and ptosis but may cause dysar-
thria, ICU Guidelines
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or respiratory ipidunt volor adit la doluptasit aut reiciet
insufficiency.
|| Fatigue is increased by exercise and improved by rest.

Nosam verferf
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Confirmation
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temacetylcholine
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nonpositive).
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|| Among patients who are seronegative for acetylcholine receptor anti-
bodies, a subgroup with antibodies to muscle-specic tyrosine kinase
re corrorporest quos haseum beennobistibus
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|| Decreasing response on repetitive nerve stimulation. Fade on tetanic
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perienced. volorerum et omni
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improvement aut voloreperit
in strength proris as
within 1 minute
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posandi cholinergic crisisiaerupienis
will get a worsening
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1 Assess airway, bulbar and ventilatory function.
est ad magnam a reresenient
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sinullit assimporesse Check the
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169
Wessex
solo NeuroNusda
explautem d eum re Measurement
cor aut omnis of vital capacity
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Neuro a VC less consect
Generally consecate
ICU Guidelines
than 1.5L suggests inadequate ventilatory function which may require
support.
e Oxygen saturations may be maintained and falsely reassuring in ven-
tilatory failure. Arterial blood gas measurement should be performed,
to assess PaCOapidell endesec ulloribus
. (Raised/rising PaCO2deribus di ipsam
are markers harit quibus, cori-
for ventilatory
2
busaniae repreperum insufficiency.)
If acute concern regarding airway maintenance or ventilatory function,
seriatur?Pa sedioreped quosa be
patient should consequas acepe conest
urgently assessed ut am, quo dis enia vitae.
by anaesthetist/intensivist to de-Perovit
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to smallVerum
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num harciis rest should
offic tembe aut verroviti
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the likelihood of aditracheostomy,
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re corrorporest
tion quos eum function.
in muscle nobistibus nisexamination,
Full evento tem including
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quatem 5 aspedit
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consedia and nasogastric
volorerum feeding
et omni od quiif bearum
bulbar function is poor.
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6 mi,
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prophylaxis. Full length Wessex Neuroand
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operate a language board. Careful nursing and physiotherapy assessment
Neuro ICU should
Guidelines dolupta
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8 Certain drugs can exacerbate symptoms
a Antibiotics:
volo iur?Volorent ut ut que et neomycin,
mi, quasstreptomycin, gentamicin,
sin cum quidellandel inctotetracyclines, erythro-
mycin, polymixin, ampicillin, kanamycin
comnimusam b resCardiovascular: -blockers,
que lab inis coreperum quinidine,
di bla procainamide,
aut ut veria verapamilsuntiae ditiis
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est ad magnam c CNS reresenient escius sequunturlithium,
drugs: chlorpromazine, sinullitmorphine
assimporesse veliquam, omnihicit et
d Drugs for RA: penicillamine, chloroquine, quinine
e Others:
quo testis maximus lignocaine,
aecabore, steroids,
que nonem es procaine,
reperepedgadolininium
170
Chapter
est, exeriae. Acutedolesneuromuscular weakness
explautem eum reIt cor is usually considered
aut omnis safe to give
a vit, Wessex Neuro a single dose of gentamicin
ICU Guidelines consecate 120mg
consect
IV to patients with myasthenia gravis, while on the Neuro
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti ICU. Any
exacerbation of symptoms will generally be mild and short lived.
Specic therapy
Anticholinesterases
seriatur?Pa sedioreped (pyridostygmine)

Immunosuppression (steroids, azathioprine, cyclosprin)

qui doloratatas Thymectomy for patients
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nosto erio. Wessex
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Plasmaquidunt
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from urinary tract or lines used for exchange.
|| Haemorrhage secondary to washing out of coagulation factors and
destruction of platelets. Caution with urinary catheters and NG tubes.
tae. Uptatio dolorem Avoidnus sinctem fugitinjections.
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Myasthenic crisis
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none option pyridostigmine.
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(muscle
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sis, abdominal colic etc).

est ad magnam Management
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linergic (eg atropine) and providing respiratory support if necessary.
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171
Wessex
solo NeuroNusda
Motoreum
explautem neurone
re cor aut disease
omnis a vit, (MND)
MND is a group of disorders characterised by progressive deterioration in motor
function (sensory and higher functions remain normal). Males are affected more fre-
quently than females. Treatment is supportive with death occurring within 35 years
from diagnosis.
Diagnosis
seriatur?Pa is generally
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clinicalutfeatures:
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1 Assess bulbar ventilatory function.
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none optionc nat Check for breathlessness
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tilatory failure. Arterial blood gas measurement should be performed,
to assess PaCO2. (Raised/rising PaCO2 are markers for ventilatory
insufficiency.)
172
Chapter
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omnis regarding
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ICU Guidelines function,
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patient should be urgently assessed by anaesthetist/intensivist
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termine requirement for intervention.
num et 2 endiaTake
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ICU Guidelines con es magnam in porrovit,
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posandu
respiratory
there isntioreritem
Pudionsequia
a reversible quam ad ma de
condition
dis suntotateThe
function to deteriorate. laborpor
re corrorporestdecision
quos eumto ventilate
nobistibusa patient for an tem
nis evento acute
et deterioration
pratem. Ut rem must be discussed
with an ICU consultant and patients consultant neurologist

dolorumquunt
ratur, omnihitmay
as dit mo
Patients withcor sa porro
MND
needeasupportive
incidus
that is
Wessex Neuro
etprogressing
volupti beatquo
(non-invasive)
ICU Guidelines
withcus.Liqui
deteriorating
ventilation
dolupid
qui especially
molor sitfunction
ventilatory
quaerov itendaeovernight.
vellis debis
volorThis
aligenime
quatem aspedit atatem consedia volorerum et omni od qui bearum is estrunt re volorof
should be assessed and managed whilst the patient is in a stable phase rehent
their illness. Long-term invasive ventilation is possible, but will require tra-
cheostomy, PEGtenecus Wessex support.
and community Neuro ICU ThisGuidelines
will require autinvolvement
voloreperit proris
of the as
rerspero ommo ommolorconsultants
respiratory posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
that run this service.

Respiratory deterioration is the most common mode of death for patients with
MND and this dolupta
may tureped ullorepudam
be a terminal episode.iunt, nulparciur?Perio.
It is important to avoid Ut de vendam,
instigating
ni consenes invasive
idendemodis re voluptibus.Ero
ventilation inappropriately cuptium consequi
in patients dolorehnot
that would enimetu rionsed
be suitable for que
none option longterm
nat quia community
cumqui ullest ventilation.
ligenihiciet accus.Quis sit, offictem quo conecto ditia-

Most of these patient will have advanced directives, which should be readily
volo iur?Volorent ut utand
available queconsidered
et mi, quas sin cum
when quidellandel
deciding management. incto quassit faccaturofmaximi,
In the absence an
quunturio ium advanced
haruptatiis directive,
andemthe MND care
di quidem co-ordinator
nulparchit velecte/ neurologist
eos et quid mayentbevollaccuptae
con-
comnimusamtacted res quefor lab
further
inis guidance.
est ad DNACPR
magnam reresenient
decisions. Allescius sequuntur
patients should besinullit
offered assimporesse
the chance toveliquam, omnihicit
discuss their wishes et
fugit regarding
officiatis iur, sam, ut quaeperrovid
end-of-life decisions. Theseulparcitaqui
should beodit essint documented
formally aut adis as commodi ctisit ant,
in the notes.
173
24
Therapeutic plasma
exchange
Therapeutic antibusape
plasma exchange nonsequ
allowsassequi
removaldoluptatur?
of plasmaQui in eum autassociated
constituents aut ommolor
with disease nos etantigens,
eg antibodies, debitatiaimmune
idessumcomplexes
est doluptur, est minToped
or drugs. be mod et resciunt,
effective, the
qui rate
doloratatas
of removalvolupta seriam
of these solorest voluptatis
substances must exceed modit explatur?
their Iqui blam faceprovit eaqui
rate of production.
It differs from renal replacement haemofiltration in that the pore size is set to allow
removal of substances with a high molecular weight (eg antibodies) rather than low
molecular weight molecules (eg urea, creatinine, electrolytes). Therefore, plasma
exchange requires replacement of plasma proteins (eg albumin, clotting factors) rather
than just crystalloid.
veligen It diant.et quosplasmapheresis
differs from ium, cus cone dem in thenem fugiatem.
volume Pudionsequia
of plasma dis suntotate laborpor
that is removed.

Plasmapheresis is rarely used, and involves the removal of up to 600ml of
tae. Uptatioplasma,
doloremwhich nus sinctem
may not fugit iditatiorum
require vit volupta
replacement with IV porem
fluids. quatusa pedionsequis

ratur, omnihit Plasma
incidus exchange
ea Wessex will Neuro
alwaysICU require replacement
Guidelines of human
qui quaerov albumin
itendae and
volor aligenime
may also require fresh frozen plasma to control the anticoagulant effect of
removing consedia
clotting volorerum et omni od qui bearum is estrunt re volor rehent
factors.
rersperoPlasma
ommoexchange
ommolor requires a vascath attached
posandi gnimus.Laborer to a haemofiltration
iaerupienis dolorehent lispump that has
eos doles volorib
a large pore filter to allow separation of cellular components of
usant. Quia non con nullaut veratemo tem aut modipis cimint quia nonsequis aut et Wessex blood from plasma.
Plasma
Neuro ICU is removed dolupta
Guidelines in exchange
turepedfor 4.5% human iunt,
ullorepudam albumin solution. The Ut
nulparciur?Perio. patient and
de vendam,
lter are anticoagulated
ni consenes idendemodis re with heparin during
voluptibus.Ero the procedure.
cuptium consequi doloreh enimetu rionsed que
turias prepedi
Plasma taecerrovita
exchange vitcommonly
is most pelitatia conused perae voluptae
on Neuro ICU doluptia nimi, venis
for the treatment of: nemquame

quunturio ium Myasthenia
haruptatiis gravis

Guillain-Barr
Neuromyelitis
fugit officiatis optica (NMO)ulparcitaqui odit essint aut adis as commodi ctisit ant,
iur, sam, ut quaeperrovid

ad eum fugia volorpoinammatory
Chronic reptur? Et lam venda non consediam
demyelinating aut es(CIDP)
polyneuropathy dolendipsum venis rerum a

Paraneoplastic neurological deterioration

mi, nime voluptas
Antibody simus. dolupta
mediated tureped ullorepudam
encephalitis eg anti-NMDA iunt, nulparciur?Perio
174
Chapter
est, exeriae. Therapeutic
doles eatioreplasma exchange
ribusandiste molora

explautem eum It mayre also
cor autbe considered
omnis a vit,inWessexmultiple Neuro
sclerosis
ICUthat is rapidly consecate
Guidelines progressiveconsect
and
unresponsive to immunotherapy.
Patients
autatatque may be transferred
parchilitat.Ut eosam suscias from autthe ward on a regular
qui volorum quambasis for exchange,
hari odis et porersporellaut
may la
num require
et endia admission to the unit.
vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-
Management
1 Careful assessment to exclude contra-indications:
a Sepsis
nosto erio. Wessex Neuro plasma exchangeVerum
ICU Guidelines will result in worsening
ipidunt volor adit of la sepsis dueaut
doluptasit to the
reiciet
removal of circulating antibodies.
b Cardiovascular
velese ma inctota quidunt acest, instability
idenihicti imcare cusrequired
a dolesto in patients
eatas aut onpel
vasopressor
is dolesci tibus.
support.
num harciis c Recent
rest offic temACE inhibitor administration
aut verroviti opta doluptam,(withinquibus24hrs)
di volut qui non reicil eosan-
2 nima
tium entis sit que
Vascular eostiiswith
access, citam, eumet voluptasit
a vascath, should beposandu
obtainedntioreritem
immediately quam
priorad
to ma de
veligen diant.etthe quos ium, cus cone
first exchange. This dem nemthe
will limit fugiatem.
durationPudionsequia
of time that largedis suntotate
bore venouslaborpor
re corrorporest access
quosiseum present, limiting
nobistibus nisrisk of systemic
evento tem et infection.
3 dolorem nusofsinctem
tae. Uptatio Prescription fugit volume
appropriate iditatiorum vit volupta porem
of replacement fluid quatusa pedionsequis
a Calculate patient plasma volume: Estimated plasma volume (l) =0.07 x
weight (kg) x (1-haematocrit)
This is usually about 3 litres
rerspero ommo b ommolor
The volumeposandi of replacement
gnimus.Laborer fluidiaerupienis
may be reduced by uplistoeos
dolorehent 500ml pervolorib
doles
usant. Quia non con exchange
nullaut ifveratemo
the patient temisautfluidmodipis
overloaded.
cimint quia nonsequis aut et Wessex
c For Guillain-Barr:
ni consenes idendemodis re voluptibus.Ero cuptiumagainst
consequi doloreh
humanenimetu
albuminrionsed que
2 plasma volumes exchanged 4.5%
Plasmavitexchange
4 times in one week
d ut
volo iur?Volorent Forutmyasthenia
que et mi, gravis:
quas sin cum quidellandel incto quassit faccatur maximi,
1.5 plasma
quunturio ium haruptatiis andemvolumes
di quidem nulparchit
exchanged velecte
against eoshuman
4.5% et quidalbumin
ent vollaccuptae
Plasma exchange 5 times in 10 days
4 Patients
fugit officiatis iur, sam,require daily bloods
ut quaeperrovid taken on the
ulparcitaqui oditmorning
essint aut prior toas
adis exchange.
commodi ctisit ant,
ad eum fugiaa volorpoU&Es reptur? Et lam
: monitor venda non
potassium andconsediam aut es
calcium, and dolendipsum
replace venis rerum a
as necessary.
quo testis maximus Initially add Kque
aecabore,
+
at nonem
4 mmol/l esand Ca at 2.0
2+
repereped ut utmmol/l,
doluptaadjust asad
sundit, required for
qui cullenim
later sessions.
175
Wessex
solo NeuroNusda
explautem b eum re FBC:corwatch platelets
aut omnis and
a vit, white cell
Wessex count
Neuro (consider
ICU withholding
exchange or platelet transfusion)
ntibusande c natetClotting: abnormal
atistibus, coagulation
utem quosam may prompt
reriberro infusion
od molende of FFP as part
natemosame of odis
nonet
exchange
Complications

Hypotension:
erorerum repe || Usually vaso-vagal
conseque or hypovolaemia.
qui doloratatas Treatment
|| volupta withsolorest
seriam anticholinergic or IV
voluptatis fluids
modit as required.

Respiratory distress:
|| Fluid overload or bronchospasm.
Nosam verferf Occasionally
|| erferspit anaphylactoid
que voluptatius rerumwith
remFFP.
ut omni ut aut res is aut lam qui nempore

Hypocalcaemia:
|| Tetany relatively common
re corrorporest
|| quosGiveeum
prophylactic calcium
nobistibus chloride
nis evento tem10etml 10% Ut rem eatenienis enimolup-
pratem.

tae. UptatioCoagulopathy:
|| Clotting factors are removed
quatem aspedit Daily treatments
|| atatem may need FFP
consedia volorerum at last
et omni exchange

Sepsis
|| Immunosuppression as a result of antibody removal
Neuro ICU | | Rapid antimicrobial
Guidelines dolupta turepedtreatment

ni consenesHypokalaemia:
|| May be caused by dilution.
||
volo iur?Volorent Replace
ut ut queaset
requiredbest
mi, quas sin cum4 mmol KCl per litre
quidellandel of uid
incto quassit faccatur maximi,

quunturio ium Drugharuptatiis
removal:andem di quidem nulparchit velecte eos et quid ent vollaccuptae
|| Protein-bound drugs are removed.
|| iur,Best
fugit officiatis sam,given after rather ulparcitaqui
ut quaeperrovid than before odit
plasma exchange
176
25
Pre-operative care
Ensure that the patient has:

2 UHS patientnos et debitatia
labels, one on idessum est doluptur,
the arm and one on theestleg
min ped mod et resciunt,

A consent form

pro enecta nis A completed
et quiasim theatre
enimos checklist
moluptatewith appropriate
volo additional
qui cus explam formsdolo
as accae (eg bersped
CJD) que

Nosam verferf
Current group and save. The antibody status must be checked and, if anti-
erferspit
bodies que voluptatius
are present, rerum be
blood should remordered
ut omniif ut aut res is aut lam qui nempore
appropriate

Their name on an operating list that day

veligen diant.et
re corrorporest
Hadquos
been
enteral
quos
ium,feed
cusstopped
aspirated.
cone dem 6 hours
It is not necessary
eum nobistibus
before surgery
nem fugiatem.
nis evento to stop
tem et enteral
and the gastric
Pudionsequia
pratem.feed if the
Ut rem
tube has
patient isenimolup-
eatenienis being
fed via a jejunal tube, but the gastric tube should still be aspirated

dolorumquunt as dit mosedation
Adequate
syringes
cor sa porro
available
et volupti beatquo
and vasopressor cus.Liqui
infusions dolupid
via syringe molor sit
drivers,
vellis
with sparedebis
Drugs
expelleces mi,onsamday of surgery
When a patient is admitted for surgery, all their normal medication should be pre-
scribed. However, some medication should be omitted on the day of surgery. If you are
unsure as to the class of a medication, look in the current edition of the BNF. Drugs
may be taken with a small amount of water at any time during the Nil By Mouth period.
Give:

fugit officiatisAll
iur,cardiac
sam, ut or
receptor
blood pressure
quaeperrovid
antagonists and
drugs except
ulparcitaqui
diuretics
ACEaut
odit essint inhibitors,
adis asangiotensin-II
commodi ctisit ant,

All antibiotics que nonem
(including oral) es repereped ut ut dolupta sundit, ad qui cullenim

All epilepsy or Parkinsons drugs
177
Wessex
solo NeuroNusda

explautem All eum asthma
re cordrugs or inhalers

emoluptae All veribus
tablets
ntibusande ranitidine)
amwhichrem reduce
gastric Neuro ICU
acid (e.g. omeprazole,
natet atistibus, utem quosam reriberro od molende natemosame nonet odis
lansoprazole,

All thyroid drugs
All hypnotics,
busaniae repreperum anxiolytics,
derovit, sitatium
medications taken regularly at home
barbiturates,
nosam sinisci antipsychotic and antidepressant

seriatur?PaAll drugs used
sedioreped in substance
quosa consequas dependence
acepe conest e.g. nicotine
ut am, quoreplacement
dis enia patches
vitae. Perovit

All steroids taken regularly, including inhalers
All immunosuppressants
qui doloratatas volupta seriam solorest andvoluptatis
cancer drugsmodit(eg. azathioprine,
explatur? Iqui blamtamoxifen)
faceprovit eaqui

nosto erio. All
pro enecta nis
Wessex Neurocan
analgesics
toryetdrugs
quiasim
ICU beGuidelines
given before Verum ipidunt
surgery volor
except adit la doluptasit
non-steroidal
(NSAIDS)
aut reiciet
anti-inflama-
tiumDo NOT
entis nimagive:

veligen diant.et
ACEquos
re corrorporest
dropquos
ium, and
inhibitors cus cone
eum nobistibus
the blood
dem nemreceptor
angiotensin-II
pressure duringnis evento
fugiatem.
an anaesthetic.
Pudionsequia
antagonists.
tem et pratem.
Thesedis drugs
SomeUtanaesthetists
suntotate
rem eatenienis
maylaborpor
may enimolup-
tae. Uptatiorequest
dolorem thatnusthese drugsfugit
sinctem are iditatiorum
given before vitsurgery
voluptabut this will
porem be requested
dolorumquunt on as
an dit
individual
mo cor basis.

ratur, omnihit
quatem aspedit
Allincidus
diuretics.
on anatatem
ea The
individual
Wessex Neuro ICU
anaesthetist mayGuidelines
request that quithese
quaerovare itendae volor
given, this
basis.volorerum et omni od qui bearum is estrunt re volor rehent
consedia
willaligenime
be

rerspero ommo
Diabetic treatment. The patient must be written up for alternative diabetic
ommolor
treatment by theposandi gnimus.Laborer
surgical team. iaerupienis dolorehent lis eos doles volorib

Aspirin, clopidogrel, dipyridamole or warfarin
Any patient retaking
voluptibus.Ero cuptium consequi
aspirin, clopidogrel, doloreh
dipyridamole warfarin must
or enimetu rionsed que
none option nat be brought
quia cumqui to the attention
ullest of both
ligenihiciet the consultant
accus.Quis neurosurgeon
sit, offictem and ditia-
quo conecto
consultant anaesthetist. Further discussion may also be required with
a cardiologist, as stopping these drugs in patients with coronary stents
volo iur?Volorentrisks ut utstent
que thrombosis.

comnimusam Drugs which
res que labare
inisnot essential di
coreperum in the short
bla aut utterm
veriaeg vitamins,
dignima iron, laxatives,
osteoporosis treatment, liquid antacid medicines (eg gaviscon), HRT, antihis-
est ad magnam tamines,reresenient escius sequuntur
herbal remedies or homeopathicsinullitmedicines.

ad eum fugia Lithium
volorpo should
reptur? notEtbelam
given
vendafor non
24 hours beforeaut
consediam surgery.

quo testis maximus
indometacin,
aecabore,
Non-steroidal que nonem es
anti-inammatory
naproxen),
moluptam everisunless
repereped
drugs
pratateprescribed
iliquas rembyque
ut ut dolupta
(eg. diclofenac
annos
anaesthetist
sundit,ibuprofen,
(Voltarol),
endicitin estas a
ad qui cullenim
pre-med. sus
ipieneculpa
178
Chapter
est, exeriae. Pre-operative care
ribusandiste molora
explautem eum reAny corpatient takinga NSAIDs
aut omnis vit, Wessex Neuro ICUmust
preoperatively be brought
Guidelines to the consect
consecate
emoluptae veribusattention
am remofquidbotheatur
the consultant neurosurgeon
assimillat.Wessex Neuroand ICUconsultant anaes-
thetist. For intracranial or intradural / multi-level spinal procedures the
ntibusande natet NSAIDsatistibus,may
utem quosam
provide reriberro od risk
an unacceptable molende natemosame
of perioperative nonet odis
bleeding.
179
26
Epidural blood patch for

intracranial hypotension
The patient mustantibusape
have beennonsequ reviewedassequi doluptatur?
by a consultant Qui in eum
neurologist andautitaut ommolor
must be
documented in the notesnosthat
et debitatia idessumisest
the neurologist doluptur,that
convinced est the
minpatient
ped mod hasetintrac-
resciunt,
qui ranial
doloratatas voluptafrom
hypotension seriam solorest
a spinal CSFvoluptatis modit explatur?
leak confirmed on imaging,Iquithat
blam hasfaceprovit eaqui
not settled
nosto
witherio. Wessex Neuro
conservative ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
management.
In the absence of a history of dural puncture from previous recent
velese ma inctota quidunt acest,
intervention, idenihicti
a recent im cus
audit has a dolesto eatas
demonstrated aut pel blood
that epidural is dolesci tibus.
patch isqueonlyvoluptatius
successfulrerum rem utpatients
in relieving omni ut symptoms
aut res is aut lam qui
if there nempore
is clear
num harciis rest evidence
offic tem ofautintracranial hypotension
verroviti opta doluptam, onquibus
cranialdiimaging.
volut qui Egnon bilateral
reicil eosan-
subdural collections, pachymeningeal enhancement,
tium entis nima sit que eostiis citam, eumet voluptasit posandu ntioreritem quam ad ma de tonsillar descent
through the foramen magnum.
A doctor from that team should speak to the anaesthetist running the CEPOD thea-
tre and the theatre coordinator to plan the best time to perform the epidural blood patch
and on which list.
quatem aspedit atatemAny spinal imaging
consedia that haset
volorerum been performed
omni must be
od qui bearum broughtretovolor
is estrunt the rehent
expelleces mi, sam attention of the
reriandic anaesthetic
tenecus Wessex team performing
Neuro the procedure.
ICU Guidelines If the site
of CSF leak is obvious, this may allow a targeted blood patch with bet-
rerspero ommo ommolorter chance posandi gnimus.Laborer
of success. There mayiaerupienis
also be CSF dolorehent
present in listhe
eosepidural
doles volorib
usant. Quia non space,con nullaut
which veratemo
would make tem identification
aut modipis cimint
of thisquia
spacenonsequis
difficult. aut Thisetmay
Wessex
Neuro ICU Guidelines indicatedolupta
that intra-procedural
tureped ullorepudamimagingiunt,
will be necessary.
Patient
turias prepedi preparation
taecerrovita vit pelitatia con perae voluptae doluptia nimi, venis nemquame
quunturio ium
1 Theharuptatiis
patient canandem
eat and di drink
quidem andnulparchit
should notvelecte eos et
be starved quid the
before ent vollaccuptae
procedure.
2 They
fugit officiatis iur,
should have an up to date (not more than a day old) full blood count,
sam,a ut quaeperrovid ulparcitaqui
CRP and coagulation profile and haveodit essint test
a dipstick aut adis
of a as
urine commodi
sample.ctisit ant,
3 maximus
quo testis They should have their
aecabore, que vital
nonem signses recorded
reperepedregularly up to sundit,
ut ut dolupta the timeadofqui thecullenim
procedure i.e. temperature, pulse, blood pressure and oxygen saturation on
air.
180
Chapter
solo 26 Nusda nonsequo
est, exeriae. Epiduraltemolec blood patch for
erovitatenis intracranial
doles hypotension
explautem4 eum Bloodre culture
cor autbottles
omnisand request
a vit, Wessex should be provided
Neuro by the admitting
ICU Guidelines consecateward.
consect
emoluptae5 veribus am rem quid
The anaesthetist eatur assimillat.Wessex
performing the procedure must Neuro ICUwritten
obtain Guidelines
consentTisfrom
dolupti
ntibusande natetthe patient. Consent
atistibus, utemmustquosam include:
a The expected eosam benefits:
busaniae repreperum Relief of headache
Busciis aceati omnit Prevention
laut autate of development/expansion
Wessex Neuro ICU Guidelines of intracranial subduralin porrovit,
con es magnam
collections
odit hillorest,b The following
nusdand antibusape complications:
Failure nostoetlocate
debitatia idessumspace
the epidural est doluptur, est min ped mod et resciunt,
Risk of a dural puncture and the consequences
pro enecta nis et
Risk of nerve damage
velese ma inctota quiduntRisk ofacest,
infection leadingim
idenihicti to cus
epidural abscess
a dolesto andaut
eatas thepel
consequences,
is dolesci tibus.
including paralysis
num harciis rest offic Potential
tem auttoverroviti
cause aopta radiculopathy
doluptam, with persistent
quibus di volutneuropathic pain
Risk of arachnoiditis
re corrorporest quos Risk of epidural haematoma/ subdural haematoma
tae. Uptatio dolorem Risk
nus of paralysis
ratur,Contraindications
omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime

Fever

usant. Quia non conwhite
Raised nullaut cellveratemo
count and temCRPaut modipis cimint quia nonsequis aut et Wessex

Any possibility of ongoing infection in CNS & especially CSF

none option Evidence
nat quia of urinaryullest
cumqui tract ligenihiciet
infection accus.Quis sit, offictem quo conecto ditia-

Infection at site of epidural injection

quunturio ium Coagulopathy

comnimusamTechnical
difficulty
Procedure
1 susdandis
volor alis moluptam
This procedure everis pratate
requires iliquas rem
an anaesthetist, que
who nos be
must endicitin est ipieneculpa
a consultant or a sen-sus
ior registrar,
mi, nime voluptas simus. and another
dolupta turepeddoctor able to take
ullorepudam blood
iunt, aseptically.
nulparciur?Perio
181
Wessex
solo NeuroNusda
2 Both
explautem eum doctors
re cor aut should
omnis scrub and
a vit, wear gowns,
Wessex Neuro gloves and masks.
3 One
performs thequid eaturand
epidural assimillat.Wessex
the other does the Neuro ICU Guidelines Tis dolupti
venesection.
4 An aseptic technique is used to locate the epidural space in the lower lumbar
spine and in the lateral position with loss of resistance to saline.
5 repreperum
busaniae The antecubital fossa
derovit, of the nosam
sitatium dependant armliquiat
sinisci is cleaned
eaquiaswithiminulpa
2% chlorhexidine
is asitatia int.
and the area is draped. Blood is drawn and handed aseptically to the anaes-
thetist performing the epidural. A further 20 ml of blood is taken and injected
seriatur?Paaseptically
sediorepedinto quosa consequas
the blood cultureacepe
bottles.conest ut am, quo dis enia vitae. Perovit
6 20-30 ml of blood is injected into the epidural space slowly and injection
should be stopped if any of the following occur:
nosto erio. | |
Wessex Neck pain ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
Neuro
pro enecta nis
|| etRadicular
quiasim enimos
pain in moluptate
the leg volo qui cus explam as accae dolo bersped que
|| Worsening headache
num harciis|rest| offic tem aut
Resistance to verroviti
injection opta doluptam, quibus di volut qui non reicil eosan-
|| Complaint of back pain
re corrorporest
There is no quos eum nobistibus
consensus as to thenis eventoamount
optimum tem et of pratem.
blood to Utbe
rem eatenienis
injected enimolup-
but 20-30ml
tae.isUptatio doloremaccepted
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all of thevitblood
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been injected, pedionsequis
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needle should as dit
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of saline beforedolupid
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ducer incidus
replaced, to ea Wessexleakage
minimise Neuro of ICU Guidelines
blood into thequi quaerov itendae
subcutaneous volor aligenime
tissues.
Post epidural blood patch instructions
Neuro1 ICU The patient should
Guidelines doluptaremain
tureped in ullorepudam
the supine position for at least 2 hours
iunt, nulparciur?Perio. Ut after the
de vendam,
ni consenesprocedure.
idendemodis Afterrethis time, they can
voluptibus.Ero gradually
cuptium sit up but
consequi aim to
doloreh keep the
enimetu lum- que
rionsed
bar spine straight or lordotic.
turias 2 All patients
prepedi should
taecerrovita vit be prescribed
pelitatia aperients
con perae to ensure
voluptae easynimi,
doluptia bowel motion
venis and
nemquame
advised
volo iur?Volorent uttoutavoid
que etopiates
mi, quasfor their headache.
sin cum quidellandel incto quassit faccatur maximi,
3 ium
All straining andandem
heavydilifting
quidem nulparchit
should velecte
be avoided eos
for at et quid
least ent vollaccuptae
2 weeks.
4 Patients should be told to seek medical care immediately if they experience
severe back pain, fever or any new neurological symptoms.
182
27
Withdrawal of therapy and
end of life care

Withdrawal
odit hillorest, nusdandof therapy
If the treating team are in agreement that a patient would not recover to a level of
functioning that the patient would consider acceptable, it may be appropriate to with-
draw active therapy. This decision may already have been taken by the patient in the
form of an advanced directive.

num harciis Continuing
rest offic temactive
aut treatment of a doluptam,
verroviti opta patient becomes
quibus futile, or against
di volut qui nontheir
interests if the clinical and radiological features support the diagnosis of an
reicilbest
eosan-
unsurvivable brain injury. These features include:
|| Clinical
tae. Uptatio dolorem Persistent
nus sinctem motor score
fugit of 1 or 2vit(ievolupta
iditatiorum extends at best)
dolorumquunt as dit mo cor sa porro et volupti
of 1 beatquo cus.Liqui dolupid molor sit vellis debis
Persistent Eye score
quatem aspedit atatem Bilaterally fixed pupils in the absence of local injury or blindness
Absencetenecus
of brainstem
Wessex reflexes
rerspero ommo || ommolor
Imagingposandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non con Tnullaut
onsillarveratemo
herniationtem aut modipis cimint quia nonsequis aut et Wessex

Complete
loss of grey white matter differentiation
re voluptibus.Ero cuptium consequi doloreh enimetu rionsed que
none option nat quia Severe
cumqui midline
ullestshift with sub-uncal
ligenihiciet accus.Quisherniation
turias prepedi taecerrovita vit pelitatia conofperae
sulci, voluptae doluptia nimi, venis nemquame
Complete effacement gyri & basal cisterns
Inadequate arterial blood flow on CT angiogram

comnimusamThe resdecision
que lab to
agreement by:
iniswithdraw
coreperum active treatment
di bla on a dignima
aut ut veria patient requires documented
The neurointensive
| sam,
fugit officiatis|iur, ut quaeperrovidcare consultant.
ulparcitaqui oditThis would
essint normally
aut adis be in discus-
sion with colleagues, however this may be unnecessary
ad eum fugia volorpo reptur? Et lam venda non consediam aut es dolendipsum venis rerum depending on a
the clinical context
||
volor alis susdandis The responsible
moluptam neurosciences
everis pratate iliquas consultant
rem que nos(neurosurgeon, neurology orsus
endicitin est ipieneculpa
stroke)
183
Wessex
solo NeuroNusda
explautem | eum| Thecor
re patients
aut omnis next aofvit,
kin Wessex Neuro ICU Guidelines consecate consect

emoluptae The veribus
ntibusande agreement
entire amneurointensive
natet atistibus,
rem quid eatur
prior toutemwithdrawal
assimillat.Wessex
care team involved with
quosamof reriberro
active treatment
NeurothatICU Guidelines
patient should be
Tisindolupti

num et endia
Where the next of kin disagrees with the decision to withdraw active
vendi ipsandem
treatment, even after apidell
detailedendesec ulloribus
explanation deribus di ipsam
of radiological imaging harit
andquibus, cori-
investigations:
Busciis aceati|| omnit Confirm laut brainstem
autate Wessex death,Neuro ICU to
if thought Guidelines
be present, conasesthismagnam
may help in porrovit,
with
seriatur?Pa sedioreped next of kin quosa consequas acepe conest ut am, quo dis enia vitae. Perovit
acceptance
odit hillorest,
||
nusdand
Whilstantibusape
legally it is nonsequ
not necessary assequi doluptatur?
to have next ofQui in eum aut aut
kin agreement ommolor
for with-
erorerum repe conseque drawal ofnos activeet debitatia
treatment, idessum est doluptur,
the hospital legal team est should
min pedbemod et resciunt,
involved if
agreement cannot be reached
Guidelines
velese ma inctotafor withdrawal
quidunt of therapy
1 Ensure
num harciis rest offic full tem aut verrovitiofopta
documentation doluptam,
decision making quibus
process di volut
as above qui non reicil eosan-
2 Ensure the next of kin understands:
a quos
re corrorporest The eum reasons for the decision
nobistibus nis evento made
tae. Uptatiob dolorem That nus sinctemoffugit
withdrawal active iditatiorum
treatmentvit volupta
means thatporem quatusa pedionsequis
the management will
change to palliative care with preservation of comfort
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sit vellis debis and dignity
ratur, omnihitc incidusThat ea theWessex
patient may Neuro notICU
die Guidelines qui quaerov
rapidly following withdrawal itendae volor treat-
of active aligenime
quatem aspedit atatem ment, inconsedia
which case they willetstart
volorerum omnia od
compassionate
qui bearum iscare pathway
3 Where the patient is likely to die rapidly following withdrawal of care, it is
appropriate toposandi
considergnimus.Laborer
organ donation.iaerupienis
(See separate dolorehent
chapter).lis eos doles volorib
In these
usant. Quiacases
non con it isnullaut
vital that the relatives
veratemo tem aut understand that the
modipis cimint quiadecision
nonsequisto withdraw
aut et Wessex
Neuro ICU care is entirely
Guidelines separate
dolupta fromullorepudam
tureped the process of organ
iunt, donation.
4 Where
organ donationre voluptibus.Ero
is considered cuptium consequi
possible, doloreh
the timing andenimetu
processrionsed
of que
none optionwithdrawal
nat quia cumqui of activeullest ligenihiciet
treatment should accus.Quis
be guided by sit,advice
offictemfromquothe conecto
organ ditia-
turias prepedidonation team. These
taecerrovita casescon
vit pelitatia must be discussed
perae voluptae with the coroner
doluptia nimi, venispriornemquame
to
withdrawal of care.
5 ium
quunturio Ensureharuptatiis
adequate andemsymptomdi quidem
control nulparchit
to maintain velecte
comfort eosand et quid entStop
dignity. vollaccuptae
all
non-palliative care medication and minimise monitoring.
comnimusam res que lab inis coreperum di bla aut ut veria dignima gnihicimus suntiae ditiis See Compassionate
Care Pathway (below)
6 Move
fugit officiatis iur, sam, ut quaeperrovid
the patient into a sideulparcitaqui
room, if possible,odit essint aut adis
or a more as commodi
appropriate bedctisit ant,
ad eum fugia space
quo testis maximus
7 Insert NGaecabore, tube, if not que nonem
already es repereped
present, prior tout ut doluptaThis
extubation. sundit,
is toadallow
qui cullenim
feeding /moluptamhydration everis pratate
to continue foriliquas
symptom remrelief
que nos endicitin est ipieneculpa sus
184
Chapter
est, exeriae. Withdrawal
erovitatenisof therapy
doles eatioreandribusandiste
end of lifemolora care
explautem8 eum Withdrawal
re cor aut of respiratory
omnis a vit, support
a Patients
emoluptae veribus am remwho quidhave been
eatur diagnosed as brainstem
assimillat.Wessex Neuro ICU dead, and whoTis dolupti
Guidelines
ntibusande natet are awaiting
atistibus, organ
utem donation,
quosam will remain
reriberro venitlatednatemosame
od molende on Neuro ICU. nonet odis
Ventilation will be withdrawn in theatre.
num et endiab vendi Patients
ipsandem who apidell
are potential
endesecnon-heart
ulloribusbeating
deribus donors,
di ipsamshould
haritbe extu- cori-
quibus,
bated at a time guided by the organ donation process
Busciis aceati c omnit All laut
otherautate
patients shouldNeuro
Wessex be extubated at a timecon
ICU Guidelines thatesis magnam
appropriate for
in porrovit,
seriatur?Pa sedioreped patient,quosa
relatives and Neuro
consequas ICU conest
acepe team ut am, quo dis enia vitae. Perovit
9 The
support antibusape
of religiousnonsequ
and/or assequi doluptatur? Qui
cultural organisations mayin eum aut aut ommolor
be sought
10 Staff may nd terminal care patients with whom they have been closely
associated stressful and distressing. It is important to seek the support
nosto erio. Wessex
and guidanceNeuro of ICU Guidelines
colleagues andVerum ipidunt volor adit
other professionals suchlaasdoluptasit
the Hospitalaut reiciet
pro enecta nis Chaplain
et quiasim enimos moluptate volo qui cus explam as accae dolo bersped que
Nosam verferf erferspit que care
Compassionate voluptatius rerum rem ut omni ut aut res is aut lam qui nempore
pathway
veligen1 Ensure
diant.et quosthatium,the
cus patients
cone dem family
nemare fully informed
fugiatem. that the care
Pudionsequia of the patient
is to become palliative, prioritising dignity and comfort. This discussion must
be documented in the patients notes
2 Move
dolorumquunt as ditthe
mopatient
cor sainto
porroa side room,beatquo
et volupti if possible, or a more
cus.Liqui appropriate
dolupid molor sit bed
vellis debis
space
quatem3 aspedit
Stopatatem consedia volorerum
all non-palliative et omni This
care medication. od qui bearum
includes is estrunt gut
antibiotics, re volor
protec-rehent
expelleces mi, tion andreriandic
sam LMWH injections
rerspero ommo ommolorprescribe:
4 Analgesia
a Morphine 1mg IV PRN every 15 mins
ni consenes b Morphinereinfusion
idendemodis 1-10mg/hr
voluptibus.Ero IV
cuptium consequi doloreh enimetu rionsed que
none option c nat quia cumqui ullest
Diamorphine ligenihiciet
1-5mg/hr S/C (If no accus.Quis
IV cannula) sit, offictem quo conecto ditia-
5 Shortness of breath: opiates as above. Oral / nasal airways should be
avoided, as these can cause bleeding & pressure areas
6 Anxiety
comnimusam res que/ labagitation: prescribedimidazolam
inis coreperum 1mg dignima
bla aut ut veria IV PRN every 15 mins
est ad 7 magnam reresenient
Secretion control escius sequuntur sinullit assimporesse veliquam, omnihicit et
prescribe:
a Hyoscine 200-400mcg IV PRN
b Hyoscine
quo testis maximus aecabore, patch
que(ifnonem
no IV cannula)
es repereped ut ut dolupta sundit, ad qui cullenim
8 susdandis
volor alis Hydration moluptam everiscontinue
& feeding: pratate iliquas
NG feed rem
forque nos endicitin
symptom relief est ipieneculpa sus
185
Wessex
solo NeuroNusda
explautem a eum re Insert
cor aaut
NGomnis
tube prior
a vit,toWessex
extubationNeuroof patient, if not already
ICU Guidelines presentconsect
consecate
emoluptae b veribus Consider
am rem re-inserting
quid eaturNG tube into patientNeuro
assimillat.Wessex if required, to continue Tis
ICU Guidelines hydra-
dolupti
ntibusande natettion & feed utem quosam reriberro od molende natemosame nonet odis
atistibus,
9 Pressure
autatatque parchilitat.Ut eosam
areas: Thesuscias
frequency aut of
quiturns
volorum
should quam hari odis on
be assessed et porersp ellaut la
an individual
num et endia patient
vendibasis, but must
ipsandem be aendesec
apidell minimum of 3 hourly
10 Continue all usual nursing care of eyes, mouth, bladder, bowels etc
11 Stop
seriatur?Pa all monitoring,
sedioreped quosa except
consequasthoseacepe
required to observe
conest ut am, forquosymptom
dis eniacontrol.
vitae. Perovit
Disable all alarms
12 repe
erorerum In theconseque
event ofnos lossetofdebitatia
IV access, idessum
consider est replacing
doluptur, IVestcannula
min pedifmod it is et resciunt,
required
qui doloratatas for symptom
volupta control.voluptatis
seriam solorest However,modit alternative
explatur?methods should
Iqui blam be usedeaqui
faceprovit
nosto erio. where
Wessex possible.
Neuro ICU Eg diamorphine
Guidelines VerumS/C, hyoscine patch adit la doluptasit aut reiciet
ipidunt volor
13 nis
Following enimos
the death of moluptate
the patient,volo qui cus explam as accae dolo bersped que
inform:
a The family
b The patients GP, both by telephone & typed summary
c sit
tium entis nima The primary
que eostiisconsultant
citam, eumet (neurosurgical, neurological
voluptasit posandu or stroke)
re corrorporest
Do not attempt quos eumCPR nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
(DNACPR)

ratur, omnihitPatients
inciduswith severe brain
ea Wessex Neuro injury
ICUmay be successfully
Guidelines qui quaerov resuscitated
dio-respiratory perspective, but be left severely brain damaged with a quality
itendae volorfrom aligenime
a car-
of life they would have considered unacceptable

rerspero ommo On Neuro
ommolor ICU, DNACPR
posandi decisions must
gnimus.Laborer be madedolorehent
iaerupienis with agreementlis eosbetween:
doles volorib
usant. Quia|non | con nullaut
The Neuro ICU veratemo tem aut modipis cimint quia nonsequis aut et Wessex
consultant
|| The neurosurgical / neurological / stroke consultant
|| The Next of Kin

turias prepedi
the
taecerrovita
All active
point
treatment
of CPR
vit pelitatia
should be con perae voluptae
continued despite anydoluptia
DNACPR
nimi, order,
venis nemquame
up to

quunturio ium
comnimusam
haruptatiis
All patients
care respathway,
thatandem
que lab should
surviveditoquidem
inis coreperum
Neuro ICU
have thediDNACPR
nulparchit velecte
discharge,
bla aut utorder
whoeosareetnot
veriareconsidered
quid
on ent vollaccuptae
a palliative
dignima gnihicimus suntiae ditiis
186
Chapter
est, exeriae. Withdrawal of therapy
erovitatenis andribusandiste
doles eatiore end of lifemoloracare
Do not
explautem eumescalate
re cor aut therapy
It may not be in patients best interest to escalate therapy if :
num et 1 endiaThey
vendihave an irreversible
ipsandem neurological
apidell endesec injury,deribus
ulloribus which would prevent
di ipsam harit them from
quibus, cori-
recovering to a quality of life that they would have wished for
Busciis2 aceati omnit
They lauta autate
have Wessex
progressive Neuro ICU
underlying Guidelines
terminal conthat
condition es is
magnam
no longer in porrovit,
responding to
seriatur?Pa sedioreped maximal
quosa therapyacepe conest ut am, quo dis enia vitae. Perovit
consequas
odit hillorest,The
3 nusdand antibusape
new therapy nonsequ
would be likelyassequi doluptatur?
to worsen Qui underlying
the patients in eum aut condition
aut ommolor
Treatments limitations include:

DNACPR

Nosam verferf
Withholding the institution of renal support (haemoltration or dialysis) for
erferspit que voluptatius
hyperkalaemia, acidosis or rerum
volumerem ut omni ut aut res is aut lam qui nempore
overload

Not re-intubating and/or re-ventilating

veligen diant.etNotquos ium, cus
changing cone dem
or restarting nem fugiatem. Pudionsequia dis suntotate laborpor
antibiotics

Not escalating vasoactive therapy (specify agent and dose limits)
187
28
Diagnosis of brain death
and brain stem testing
odit hillorest,
Death is nusdand antibusape
the irreversible lossnonsequ assequi doluptatur?
of the essential characteristicsQui which
in eumare autnecessary
aut ommolor
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to the repe conseque
existence nos ethuman
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person and est
thusdoluptur, est min
the definition ofped mod
death et resciunt,
should be
qui regarded
doloratatas as volupta seriam solorest
the irreversible loss of thevoluptatis
capacitymodit explatur? Iqui blam
for consciousness, faceprovit
combined eaqui
with the
nosto erio. Wessex
irreversible Neuro
capacity ICU Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
to breathe.
The irreversible cessation of brain-stem function whether induced by intracranial
events or the result of extra-cranial phenomena, such as hypoxia, will produce this
clinical state and therefore irreversible cessation of the integrative function of the brain-
stem equates with the death of the individual and allows the medical practitioner to
diagnose death. (Academy of Medical Royal Colleges (2008) A Code of Practice for
the Diagnosis And Confirmation Of Death. http://www.aomrc.org.uk)
In the legal nus insinctem
system the UKfugitthereiditatiorum vit volupta
is no statutory porem
definition quatusa
of death but pedionsequis
the courts
dolorumquunt
have adopted as dit mouse
the cor of
sa neurological
porro et volupti beatquo
testing as cus.Liqui
a criteria dolupid molor sitofvellis
for diagnosis death.debis
ratur, omnihit
This incidus
has been theea Wessex
case since Neuro ICU Guidelines
1976 (Conference qui quaerov
of Medical Royalitendae volor
Colleges andaligenime
their
quatem aspedit
Faculties atatem
in the consedia
UK. BMJ volorerum et omni od qui bearum is estrunt re volor rehent
1976;2:1187)
Preconditions
1 The
ni consenes patients condition
idendemodis is due to irreversible
re voluptibus.Ero brain damage
cuptium consequi dolorehofenimetu
known rionsed que
aetiology.
turias 2 prepedi taecerrovita
Exclusion vit pelitatia
of reversible causesconofperae
coma voluptae
and apnoea. doluptia nimi, venis nemquame
comnimusam
Exclusion res que lab inis coreperum
of reversible causesdi bla aut
of ut veria dignima
coma gnihicimus suntiae ditiis
and apnoea
ad eum The following
fugia volorposhould
reptur?beEtexcluded
lam venda before commencement
non consediam aut esofdolendipsum
testing: venis rerum a
1 maximus
quo testis Coma and aecabore, que nonemtoesdepressant
apnoea secondary reperepeddrugs:
ut ut dolupta sundit,
The patient ad qui
must not cullenim
have hadmoluptam
any drugseveris pratate
that may have iliquas rem que
contributed tonos endicitin est ipieneculpa
unconsciousness, apnoea sus
or loss simus.
mi, nime voluptas of braindolupta
stem reflexes.
tureped ullorepudam iunt, nulparciur?Perio
188
Chapter
est, exeriae. Diagnosis of brain death
temolec erovitatenis doles and brain
eatiore stem testing
ribusandiste molora
explautem eum a reThesecor autinclude
omnisthea following
vit, Wessexdrugs:Neuro ICU Guidelines consecate consect
emoluptae veribus amHypnotics
rem quid / Sedatives/ tranquilisers Neuro ICU Guidelines Tis dolupti
eatur assimillat.Wessex
Narcoticsutem quosam reriberro od molende natemosame nonet odis
Muscle relaxants
b Consideration
busaniae repreperum derovit, sitatium must be taken sinisci
nosam if the patient
liquiat has hepatic
eaquias or renal
iminulpa is failure
asitatia int.
as this may prolong metabolism or excretion of the drugs. Measuring
drug levels for midazolam (recommendation <10mcg/ml) or thiopentone
seriatur?Pa sedioreped (<5mg/ml)quosa canconsequas
be consideredacepe conest this
although ut am, quo
is not dis enia vitae.
widespread Perovit
practice
odit hillorest, nusdandwithinantibusape
the UK. nonsequ assequi doluptatur? Qui in eum aut aut ommolor
erorerum repe c conseque
Consider nos et debitatia
specific idessum
antidotes est doluptur, est(eg
to benzodiazepines min ped mod200mcg
flumazenil et resciunt,
qui doloratatas voluptaIV everyseriam solorest
minute up to voluptatis
max of 1mg) modit explatur?
and/or opiatesIqui
(egblam faceprovit
naloxone 400mcgeaqui
nosto erio. Wessex IV Neuro
every 2ICU minutes up to maximum
Guidelines Verum ipidunt of 10mg)
volorasadit
necessary.
2 nisComa
and apnoeaenimos moluptatetovolo
secondary qui cus explam
temperature, as accae
circulatory dolo bersped
, metabolic or endo-que
crine disturbances
a The following criteria should be achieved before testing:
tium entis nima sit Core temperature
que eostiis > 34C posandu ntioreritem quam ad ma de
citam, eumet voluptasit
veligen diant.et quos Meanium,Arterial
cus conePressure
dem nem >fugiatem.
60mmHgPudionsequia dis suntotate laborpor
re corrorporest quos pHeum nobistibus nis evento 7.35-7.45
tae. Uptatio dolorem PaO nus
2
>10kPa
dolorumquunt as ditPaCO mo cor2 sa porro et volupti >6kPa
ratur, omnihit incidus Serum Na
ea Wessex 115-160mmol/l
quatem aspedit atatem Serum K
consedia volorerum et>2.0mmol/l
omni od qui bearum is estrunt re volor rehent
expelleces mi, samSerum reriandicMgtenecus Wessex 0.5-3.0mmol/l
rerspero ommo ommolor Serumposandi
PO4 gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
0.5-3.0mmol/l
Serum veratemo tem aut3-20mmol/l
glucose modipis cimint quia nonsequis aut et Wessex
ni consenes b It is recognised
idendemodis that some disturbances
re voluptibus.Ero cuptium consequi may be secondary
doloreh to brain-
enimetu rionsed que
stem death and do not preclude determination of brainstem death.
Futhermore it may be detrimental to rapidly correct such abnormalities
c If endocrine disturbance is suggested this should be excluded with the
appropriate assays
189
Wessex
solo NeuroNusda
Clinical
explautem eumassessment
re cor aut omnisof a brain
vit, Wessexstem function
Neuro ICU Guidelines consecate consect
All the following tests must be fulfilled for the diagnosis of Brain Stem Death (BSD)
to be made.
Cranial nerves
BusciisClinical
aceati omnit
test laut autate Wessex Neuro ICU Guidelines
tested con es magnam in porrovit,
Technique
Afferent Efferent
No pupillary re- Fixed pupils that do not respond to sharp
II
odit hillorest, nusdand antibusape III
sponse to light changes in the intensity of light
No corneal reflex V VII No blink response when cornea is touched
nosto erio. Wessex Neuro ICU Guidelines Verum No eyeipidunt
movementvolor whenadit la50mls of ice-wa-
ter is irrigated to each ear over a 1 minute
pro enecta nis et quiasim enimos moluptate volo qui (Head
period. cus explam
tilt at 30aso)accae dolo bersped que
No vestibulo-oc-
velese ma inctota quidunt VIII acest, idenihicti
III, VI im cus aresponse
Normal dolesto eatas aut pel is with
in an individual dolesci
a tibus.
ular reflex
Nosam verferf erferspit que voluptatius rerumfunctioning rem ut omni brainstem
ut aut res is is
foraut
thelam
eyes quitonempore
num harciis rest offic tem aut verroviti opta doluptam, turn towards the side
quibus cold qui
di volut waternonis reicil
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ed, with nystagmus away from that side.
No motor re-
veligen diant.et
sponse quos ium,
to cen- V cus coneVII dem nemNo somaticPudionsequia
fugiatem. or cranial nerve disresponse
suntotatetolaborpor
re corrorporest quos eum nobistibus nis evento pressure
tem etexerted
pratem.on Uttheremsupraorbital
eatenienis ridge
enimolup-
tral stimulation
tae. No gag and
Uptatio dolorem nus IX,sinctem
X IX, X iditatiorum
fugit vit volupta
Visualisation of the porem quatusa
posterior pedionsequis
oropharynx
cough reflexes
dolorumquunt as dit mo cor sa porro et voluptiand beatquo cus.Liqui
stimulation withdolupid
Yankauer molor sit vellis debis
sucker.
Passing of suction
ratur, omnihit incidus ea Wessex Neuro ICU Guidelines qui quaerov itendae volor tubing to carina to aligenime
stim-
ulate response
Apnoea Starting PaCO2 is greater than 6.0 kPa
expelleces mi, sam reriandic tenecus Wessex Neuro ICU Guidelines
(ICS Guidance aut voloreperit proris as
Starting pH is less than 7.4
2013)
rerspero ommo ommolor posandi gnimus.Laborer Allowiaerupienis dolorehent
PaCO2 to increase bylis
at eos
leastdoles volorib
usant. Quia non con nullaut veratemo tem aut 0.5kPa
Neuro ICU Guidelines dolupta tureped ullorepudam Observe iunt,for any respiratory effort
nulparciur?Perio. Utfordeatvendam,
least 5 minutes
Performance
turias prepedi taecerrovitaandvitrepetition
pelitatia con of peraetesting
voluptae doluptia nimi, venis nemquame

The performance of brain stem tests should be done by at least two medical
practitioners who have been fully registered by the General Medical Council
est ad magnam for at reresenient escius
least five years. One sequuntur
of these sinullit
must beassimporesse
a consultant. veliquam,
Both should omnihicit
be et
fugit officiatis iur, sam, in
competent ut the
quaeperrovid ulparcitaqui
eld and neither shouldodit
have essint aut adis
a conflict withasperforming
commodi ctisitthe ant,
ad eum fugia tests.

quo testis maximus
Two setsaecabore,
of tests are
moluptam
two practitioners may
queperformed
nonem esto
everis pratate
do these
repereped
remove the
iliquas rem
together
ut ut
riskdolupta
que nos endicitin
or separately.
sundit,error.
of observer ad qui The
est ipieneculpa
If together,
cullenim
then each sus
practitioner
mi, nime voluptas simus.has to perform
dolupta turepedaullorepudam
full set of tests. One practitioner observing
190
Chapter
est, exeriae. Diagnosis of brain death
temolec erovitatenis doles and
eatiore brain stem testing
ribusandiste molora
explautem eum the other
re corpractitioner
aut omnis doesa vit,not count as
Wessex a second
Neuro set of tests.consecate
ICU Guidelines The time inter-
consect
val between the tests is not stipulated.

ntibusande natetThe legal time ofutem
atistibus, deathquosam
is whenreriberro
the rst setod ofmolende
tests hasnatemosame
been completed. nonet odis

num et endiawhen
Death is confirmed on completion of the second set of tests irrespective of
vendiactive
ipsandem apidell
support endesec ulloribus
is discontinued. deribus
Confirmation of di ipsam
death stillharit
needsquibus,
to be cori-
performedderovit,
busaniae repreperum if there sitatium
is a circulatory
nosamarrest
siniscibetween tests. iminulpa is asitatia int.
liquiat eaquias
Miscellaneous consequas acepe conest ut am, quo dis enia vitae. Perovit
considerations

qui doloratatas Pre-existing
volupta seriam respiratory
solorestdisease
voluptatisPatients with chronic
modit explatur? Iquicarbon
retention should have a starting PaCO of greater than 6.5kPa. The PaCO2
dioxide eaqui
blam faceprovit
nosto erio. Wessex Neuro ICU Guidelines Verum 2ipidunt volor adit la doluptasit aut reiciet
should increase over the duration of testing to>0.5kPa above the starting
value.

Local pathology that precludes clinical testing Facial trauma can cause
difficulties in performing the cranial nerve tests. In this situation ancillary
num harciis testing
rest offic temasaut
such EEGverroviti opta doluptam,
or cerebral angiogramquibus
can bediconsidered
volut qui non reicil not
although eosan-
mandatory.

re corrorporest
Medical conditions that may mimic brain death. Medical conditions such
quos eum
as severe nobistibus nis
Guillain-Barr evento tem
syndrome, et pratem.
rabies Ut rem
encephalitis, eatenienis
brainstem enimolup-
encephali-
tae. Uptatio tis,
dolorem nus sinctem
amitriptyline overdosefugitand
iditatiorum
bretylliumvitoverdose
volupta porem quatusa
could mimic pedionsequis
brain death.
191
29
Organ and tissue
transplantation
This chapter antibusape
considers nonsequ assequi
the management of thedoluptatur?
patient for Qui
organin donation
eum aut aut ommolor
following
either brain stem deathnos et debitatiadeath.
or circulatory idessum est doluptur, est min ped mod et resciunt,
The General Medical Council (GMC) guidance Treatment and care towards the end
of life: good practice in decision making requires that consultant staff who have clinical
responsibility for patients who are potential donors exercise a duty to consider organ
donation as part of end-of life care. The legal framework that allows donation after
death is described in the Human Tissue Act 2004.
Donor
veligen identification
diant.et quos ium, cus cone and dem referral
nem fugiatem. Pudionsequia dis suntotate laborpor
Early identification of patients for donation is advised. NICE have published guid-
ance. University Hospital Southampton is still in the process of developing its own
guidelines. There should be early liaison with the Specialist Nurse in Organ Donation
(SNOD).
rerspero
When ommo ommolor
organ posandi
donation gnimus.Laborer
occurs, it follows eitheriaerupienis
cardiacdolorehent
or brainstem lis eos doles
death of volorib
the
donor:

ni consenesthat
Donor after cardiac death (DCD): When the medical team and family agree
idendemodis
continuing re voluptibus.Ero
medical treatmentcuptium
is not in consequi doloreh enimetu
the best interests rionsed que
of the patient,
none optionegnat poorquia cumqui ullest
neurological ligenihiciet
outcome, then theaccus.Quis sit, offictem
decision may be madequo conecto ditia-
to withdraw
active medical treatment, eg stop invasive ventilation.
turias prepedi taecerrovita vit pelitatia con perae voluptae doluptia nimi, venis If the patient diesnemquame
within a few hours of being extubated, then organ donation may be possible.

quunturio ium
comnimusam
Donor
stem
haruptatiis
restesting
que lab
andem
after brain
has
di quidem
death nulparchit
(DBD): This
inisdemonstrated
coreperum dithat bla the
refersvelecte
to organeos
aut patient
et quidafter
donation
ut veriaisdignima
brainstem
ent brain-
vollaccuptae
dead. suntiae ditiis
gnihicimus
192
Chapter
est, exeriae. Organdoles and eatiore
tissueribusandiste
transplantationmolora
Contraindication
explautem eum re cor aut omnis to organ donation
a vit, Wessex Neuro ICU Guidelines consecate consect
autatatque
Absolute parchilitat.Ut eosam susciastoaut
contraindications qui volorum
organ donation quam hari odis et porersp ellaut la

Age >85 years

Busciis aceati Any
nodes)
cancer
omnit lautwith
within 3
evidence
autate
years
Wessex
of
of Neuro
spreadICU
donation
outside affectedcon
Guidelines
(however, localised
organes (including
magnam inlymph
prostate, thyroid,
porrovit,
in situ
cervical cancer and non-melanotic skin cancer are acceptable)

erorerum repe conseque(except
Melanoma nos et completely
debitatia idessum
excisedest doluptur,
Stage est min ped mod et resciunt,
1 cancers)

Choriocarcinoma

pro enecta nis Active haematological
et quiasim malignancy
enimos moluptate volo(myeloma, lymphoma,
qui cus explam leukaemia)

velese ma inctota
Nosam verferf
quidunt
Definite, acest,
probable
erferspit que voluptatius
encephalopathies,
idenihicticase
or possible
includingrerum
im cus
CJD and
a dolesto
of human
rem vCJD,
eatas aut spongiform
transmissible
ut omniindividuals
ut aut reswhose
is aut lam
bloodquirela-
nempore
num harciis tives havetem
rest offic hadautfamilial CJD,opta
verroviti other neurodegenerative
doluptam, diseases
quibus di volut associated
tium entis nima withsit
infectious agents

veligen diant.et TB:quos
activeium,
andcus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
untreated

HIV disease (but not HIV infection)
ratur,Organ
omnihitspecific
incidus eacontraindications
Wessex Neuro ICU Guidelines qui quaerov itendae volor aligenime
quatemInaspedit
addition atatem
to the consedia volorerum et omni
absolute contraindications od qui bearum
a number of organisspecific
estrunt contraindica-
re volor rehent
expelleces mi, sam
tions have beenreriandic
developed tenecus
by each Wessex
NHSBT Neuro ICUGroup
Advisory Guidelines aut in
to assist voloreperit proris as
the assessment
rerspero
of a ommo
potential ommolor posandi
organ donor; gnimus.Laborer
these iaerupienis
are listed below. dolorehent lis eos
Each contraindication is doles
specificvolorib
to
usant. Quia non con nullaut veratemo tem aut modipis cimint quia nonsequis
the organ listed and does not preclude the donation of any other organ. In some cases, aut et Wessex
individual transplantdolupta tureped
units have ullorepudam
developed furtheriunt, nulparciur?Perio. Ut de vendam,
contra-indications.
noneLoption
iver nat quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-

Acute hepatitis (AST>1000 IU/L)

quunturio ium Cirrhosis

Portal vein thrombosis
fugit Kofficiatis
idney iur, sam, ut quaeperrovid ulparcitaqui odit essint aut adis as commodi ctisit ant,

Chronic kidney disease (CKD stage 3B and below, eGFR<45)

Long term moluptam
dialysiseveris pratate
(that is, iliquas
not acute rem que
relating
nos endicitin
to acute illness)est ipieneculpa sus
193
Wessex
solo NeuroNusda

explautem Renal
eum remalignancy (priorakidney
cor aut omnis tumours
vit, Wessex of lowICU
Neuro grade and previously
Guidelines excised
consecate consect
would not exclude donation)

ntibusande Previous kidney transplant
natet atistibus, utem quosam (> 6 months
reriberro previously)
numPancreas
et endia vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-

busaniae repreperum derovit,diabetes
Insulin dependent sitatium (excluding
nosam sinisciICU liquiat eaquias
associated iminulpa
insulin is asitatia int.
requirement)

Any history of pancreatic malignancy
Heart
Age volupta
qui doloratatas >65 seriam solorest voluptatis modit explatur? Iqui blam faceprovit eaqui

nosto erio. Documented
pro enecta nis
Wessex Neuro ICU Guidelines
coronary
et quiasim stenting)
percutaneous
Verum
artery disease ipidunt
(e.g. volor adit
confirmed la doluptasit
history of MI, CABG
aut or
reiciet

Median sternotomy for cardiac surgery

num harciisLVEF30% on more
rest offic tem than one
aut verroviti occasion

Massive inotropic or pressor support, but only if adequate circulating volume
veligen diant.et quos confirmed
has been ium, cus cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
by monitoring
tae.LUptatio
ungs dolorem nus sinctem fugit iditatiorum vit volupta porem quatusa pedionsequis

DCD donor age >65; DBD donor age>70 years

quatem aspeditPrevious
atatemintra-thoracic malignancy

expelleces mi,
rerspero ommo
sam reriandic
Significant,
ommolor
trolled
chronic
asthmaposandi
tenecus Wessex
destructive Neuro ICU Guidelines
or suppurative
gnimus.Laborer
are suitable donors)
lung disease aut(those
with con-
iaerupienis dolorehent lis eos doles volorib

Chest X-ray evidence of major pulmonary consolidation
noneConsent
option nat quia cumqui ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-

volo iur?Volorent
quunturio ium under
ut ut que
Registration
haruptatiis
the Human
et mi,
on the
andem
Organquas sin cum
Donor
di quidem
Tissue Act 2004.
quidellandel
Register
nulparchit velecte
If a patient
inctoas
is now seen
is noteos
quassit
et quidthe
registered
faccatur
a lawful consent
entnext
maximi,
vollaccuptae
of kin
comnimusam should be approached.

The NICU Consultant and / or SNOD should make the approach for donation.
194
Chapter
est, exeriae. Organdolesand eatiore
tissueribusandiste
transplantation
molora
explautem eum reDiscussioncor aut omniswith the family
a vit, aboutNeuro
Wessex organ ICU
donation must be
Guidelines kept separate
consecate consect
from the initial discussions considering withdrawal
emoluptae veribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti of treatment be-
cause of poor prognosis.
ntibusande natet Ifatistibus,
these twoutem issuesquosam
are notreriberro od molende
kept separate, natemosame
the relatives may end nonet
up withodis
the impression that theaut qui volorum
withdrawal quam hari
of treatment odis et
is being porersp ellaut
considered to la
num et endia vendi facilitate
ipsandemorgan donation.
Organnusdand
odit hillorest, donation following
antibusape nonsequ brainstem deathQui in eum aut aut ommolor
assequi doluptatur?
Management of the patient being considered for organ donation following Brain
Stem Death.
Monitoring

num harciis All
tium entis nima
restpatients:
offic tem aut verroviti opta doluptam, quibus di volut qui non reicil eosan-
sitTemperature
|| (naso-pharyngeal)
|| SpO2
tae. Uptatio | |
dolorem ECGnus (continuous
sinctem fugitand iditatiorum
printed 12-lead)
dolorumquunt ||as dit mo cor
Arterial sa porro
blood et volupti
pressure beatquo
(left radial cus.Liqui dolupid molor sit vellis debis
line)
|| Urine output (urinary catheter)
|| Chest radiograph (CXR)

rerspero ommo Theommolor
followingposandi
may also gnimus.Laborer
be considerediaerupienis
necessary:dolorehent lis eos doles volorib
|| Central venous pressure (right internal jugular triple lumen catheter)
|| Trans-thoracic or trans-oesophageal echocardiography
none option |nat | quiaFibre-optic
cumquibronchoscopy
ullest ligenihiciet accus.Quis sit, offictem quo conecto ditia-
turias prepedi || taecerrovita
Pulmonaryvitartery
pelitatia con perae
catheter (Rarelyvoluptae
required)doluptia nimi, venis nemquame
Basic management

est ad magnam Oncereresenient
declared brainesciusdead the donorsinullit
sequuntur requires active management
assimporesse veliquam,toomnihicit
optimal physiology in preparation for multi-organ retrieval. Regular review by
maintain et
the ITU team (doctors, nurses, physiotherapists and the transplant co-ordina-
ad eum fugiator) volorpo reptur?
is vital, as is Et
thelam venda non consediam
communication aut es dolendipsum
with the transplant venis rerum
centre accepting the a
organs aecabore,
quo testis maximus on offer. que nonem es repereped ut ut dolupta sundit, ad qui cullenim
195
Wessex
solo NeuroNusda

explautem Keep thecor donor
aut warm
omnisata 37 vit,CWessex
with a warming blanket, bair hugger and consect
O
eum re Neuro ICU Guidelines consecate
warmed intra-venous fluids.

ntibusande Maintain
in the form
an optimal
natet atistibus,
of 5%
utemfluidquosam
dextrose
balancereriberro
to avoid
(neutral balance
od molende
hypernatraemia
to +500 ml) with crystalloid
natemosame
(secondary
autatatque parchilitat.Ut eosam suscias aut qui volorum quam hari odis et porersp ellaut la to
nonet odis
diabetes
insipidus) and to maintain hepatic glucose stores. For colloid administration
num et endia usevendi
packed ipsandem
red cellsapidell endesec
to maintain the ulloribus
Hb > 10g/dl.deribus di ipsam harit quibus, cori-

Busciis aceatiHourly
omnit nasogastric
laut autatetube suction
Wessex to minimise
Neuro the risk ofcon
ICU Guidelines aspiration.
es magnam 1-2 hourly
in porrovit,
turning and endo-tracheal/bronchial suctioning using the standard asep-
tic technique. Two hourly chest physiotherapy for secretion clearance and
recruitment manoeuvres. nonsequ assequi doluptatur? Qui in eum aut aut ommolor
qui Drug
doloratatas
therapyvolupta seriam solorest voluptatis modit explatur? Iqui blam faceprovit eaqui

pro enecta nisMethylprednisolone
et quiasim enimos
brain death.
15mg/kg
moluptate bolusvolodosequi immediately
cus explam as after declaration
accae of
dolo bersped que

Nosam verferf Vasopressin
MAP
erferspit que
> 70
2 unit
mmHg
bolus followed
voluptatius
and SVR
rerumby
800
rem
1200
1 to
ut 10
omniunit/hour
dyn.s.cm-5.
num harciis rest offic tem aut verroviti opta doluptam, quibus di volut qui non reicil
infusion
ut aut res
Wean
is auttolam
down/off
maintain
qui nempore
all exist-
eosan-
ing catecholamine infusions after starting vasopressin.

veligen diant.et quos ium, cus4mcg
Tri-iodothyronine cone bolus
dem nem fugiatem.
followed Pudionsequia
by 3mcg/hour dis suntotate laborpor
infusion.

Insulin infusion 1 unit/hour then adjust to maintain glucose of 5-10 mmol/l

dolorumquunt Supplement
as dit mo cor K+ and Mg2+ et volupti beatquo cus.Liqui dolupid molor sit vellis debis
sa porro

Broad ea Wessex
spectrum Neuro(as
antibiotics ICUperGuidelines qui quaerov itendae volor aligenime
local ITU protocol).
Ventilation and airway management

usant. QuiaMinimise
non con FiO to veratemo
nullaut
2
maintain PaO tem2 aut11 modipis
14 kPacimint quia nonsequis aut et Wessex

PEEP 5 10 cmH2O

none optionTidal nat volume
quia cumqui 10 ml/kg butligenihiciet
ullest peak airwayaccus.Quis
pressures sit,
< 35cmH
offictem
2
O quo conecto ditia-

turias prepedi
volo iur?Volorent
taecerrovita
Repeat PaO2 onvit pelitatia
100%
ut ut que etideal
to be considered mi, for
FiO2 con
quas
every perae
sin cum
retrieval.
2 hours voluptae
should
quidellandel
If the
doluptia
gas exchange
be >40 nimi,
kPavenis
for thenemquame
incto deteriorates
quassit faccatur
lungs
acutelymaximi,
quunturio ium to <haruptatiis
40 kPa onandem 100% FiO (despite
di quidem
2
optimal physiotherapy,
nulparchit velecte eos et endobronchial
suctioning and anaesthetic review) inform the transplant centre and retrieval
team. Selective pulmonary venous blood gas analysis is then considered to
est ad magnam identifyreresenient esciuswithin
regional defects sequuntur sinullit assimporesse veliquam, omnihicit et
the lungs.

Overhydration must be avoided because of the risk of precipitating or potenti-
ating pulmonary oedema.
Fibre-optic
volor alis susdandis bronchoscopy
moluptam may beiliquas
everis pratate performed to check
rem que the endobronchial
nos endicitin est ipieneculpa sus
mi, nime voluptas simus. dolupta tureped ullorepudam iunt, nulparciur?Perio Proximal
anatomy and to exclude the presence of aspiration and/or infection.
196
Chapter
est, exeriae. Organdoles and eatiore
tissueribusandiste
transplantation
molora
explautem eum tracheal
re cor secretions
aut omnisarea aspirated
vit, Wessex andNeuro
a bronchoalveolar
ICU Guidelines lavage (BAL) per-
consecate consect
formed. The 3 samples (tracheal aspirate, left lung BAL and right lung BAL)
emoluptae veribus
are sentam to rem quid eatur
microbiology forassimillat.Wessex
M,C+S to help guide Neurothe ICU Guidelines
antibiotic Tis dolupti
treatment
ntibusande natetof the atistibus, utem recipient.
post-transplant quosam reriberro od molende
The discovery natemosame
of abnormal nonet odis
anatomy (e.g.
tracheal RULeosam
autatatque parchilitat.Ut bronchus),
susciasseverely
aut quiinflamed
volorummucosa
quam hariand/or
odiscopious mucopu-
num et endia vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus,becori-
rulent secretions coming from the airways are adverse features and must
reported directly to the transplant surgeon.

Busciis aceati Hourly
omnitturning
hourly chestquosa
and bronchial
laut autate Wessex Neuro
physiotherapy
consequas
suctionICU
for acepe
using
secretion
aseptic technique
Guidelines
clearance
conest ut am,and
and 1 toin2 porrovit,
con es magnam
quorecruitment manoeu-
vres. A CXR is taken at the declaration of brain death and 3-4 hourly
odit hillorest,thereafter
nusdand antibusape
particularly nonsequ
when there assequi
has beendoluptatur?
an acuteQui in eum autinaut
deterioration theommolor
gas
exchange. nos et debitatia idessum est doluptur, est min ped mod et resciunt,
nostoOptimal
erio. Wessexdonor Neuro ICUparameters
target Guidelines Verum ipidunt volor adit la doluptasit aut reiciet
velese maTemperature
inctota quidunt acest, idenihicti 37oC im cus a dolesto eatas aut pel is dolesci tibus.
pH erferspit que voluptatius7.36-7.44
Nosam verferf rerum rem ut omni ut aut res is aut lam qui nempore
PaO
num harciis rest 2
(FiO 1.0)
offic2 tem aut verroviti optakPa
>40 doluptam, quibus di volut qui non reicil eosan-
PaCO2 3.8-6.0 KPa
PEEP 5-10 cmH2O
Tidal volume 10 ml/Kg
Peak airway pressure <35 cmH2O
CXR NAD
Bronchoscopy NAD
HR 60-90 sinus rhythm
MABP 65-85 mmHg
ECG SR. No ST changes or Q waves. No LVH
Fluid balance posandi gnimus.Laborer
0 to +500 ml iaerupienis dolorehent lis eos doles volorib
Maintenance veratemo tem
crystalloid aut modipis cimint quia nonsequis aut et Wessex
1 ml/Kg
Neuro ICUUrine Guidelines
output dolupta tureped0.5 ullorepudam
ml/Kg/hour iunt, nulparciur?Perio. Ut de vendam,
Haemoglobin >10.0cuptium
g/dl consequi doloreh enimetu rionsed que
none option CVP nat quia cumqui ullest ligenihiciet
3-8 mmHgaccus.Quis sit, offictem quo conecto ditia-
turias prepedi
CI taecerrovita vit pelitatia >2.6 con l/min/m
perae voluptae
2 doluptia nimi, venis nemquame
volo iur?Volorent
PAWP ut ut que et mi, quas<10 sin mmHg
quunturio SVRium haruptatiis andem di quidem 800-1200nulparchit velecte
dyn.sec.cm -5 eos et quid ent vollaccuptae
comnimusam TTE/TOEres que lab inis coreperum di blaEF.

Normal autNout veria dignima
valvular gnihicimus
pathology. No LVHsuntiae ditiis
Dopamine
est ad magnam reresenient escius sequuntur<5 g/Kg/minsinullit assimporesse veliquam, omnihicit et
Noradrenaline
fugit officiatis iur, sam, ut quaeperrovid <0.04 g/Kg/min
ulparcitaqui odit essint aut adis as commodi ctisit ant,
ad eum fugiaAdrenaline
volorpo reptur? Et lam venda Nil non consediam aut es dolendipsum venis rerum a
quo testis ADH
maximus aecabore, que nonem 1-10esIU/hour
repereped ut ut dolupta sundit, ad qui cullenim
T3
volor alis susdandis moluptam everis pratate 3 g/hour
iliquas rem que nos endicitin est ipieneculpa sus
Insulin simus. dolupta tureped
mi, nime voluptas As ullorepudam
per BM 5-10 iunt,mmol/lnulparciur?Perio
197
Wessex
solo NeuroNusda
Non-heart
explautem eum rebeating
cor aut omnis organ a vit,donation

Organ donation following death by cardiorespiratory criteria. Donor after
autatatque Cardiac
parchilitat.Ut
Deatheosam
(DCD).suscias aut qui volorum quam hari odis et porersp ellaut la

Patients are those who have irrecoverable brain damage but who do not sat-
isfy formal brain stem criteria for the diagnosis of death.

seriatur?PaAfter consensus
sedioreped quosa between
consequas the medical
acepe / conest
nursingutstaff
am,and quothe
further medical intervention is futile and that active treatment should be with-
disfamily
enia that
vitae. Perovit
drawn, consideration is made as to whether the patient is suitable to donate
erorerum repe solidconseque nos et debitatia
organs. Document consensusidessum est doluptur, est min ped mod et resciunt,
in notes.

There is potential for donating liver, lungs and pancreas (when time between
withdrawal of treatment and death is < 1 hour) and kidneys (< 5 hours), in
addition enimos moluptate volo qui cus explam as accae dolo bersped que
to tissues.

Nosam verferf Patients should
erferspit quebe treated inrerum
voluptatius the samerem way
ut omnias any other
ut aut respatient
is aut lamfor whom
qui nempore
active treatment is withdrawn. They should continue to receive appropriate
num harciismedical
rest officandtem aut verroviti
nursing care. This opta doluptam,
includes quibusanalgesia
adequate di volut qui andnon otherreicil
symp-eosan-
tom relief. eostiis citam,
Withdrawal eumet voluptasit
of life-support measures posandu ntioreritem
may occur quam
in the unit or ad ma de
in the
anaesthetic
veligen diant.et quos ium, roomcusdepending
cone dem on nemthefugiatem.
relatives.Pudionsequia dis suntotate laborpor

re corrorporest quos active
Continue eum nobistibus
nursing and nisphysiotherapy
evento tem et care. pratem. Ut rem eatenienis enimolup-

dolorumquunt Continue
as dit momonitoring
cor sa porroof ECG, pulsebeatquo
et volupti oximetrycus.Liqui
and invasive
monitoring if possible. These can be monitored from the nurses station if
dolupidbloodmolorpressure
sit vellis debis
relatives are distressed at watching the monitor.

expelleces mi,Keep sam normothermic.

rerspero ommo
usant. Quiamay
Do notommolor
non prove
attemptposandi
con nullaut veratemo
impossible
gnimus.Laborer
to resuscitate the patient
tem aut
for organs
iaerupienis
to modipis
be donated cimint
dolorehent
if they deteriorate
andquiathisnonsequis
lis eos dolesItvolorib
unexpectedly.
is explained auttoetthe
Wessex
Neuro ICU relatives
Guidelines during the initial
dolupta tureped discussions
ullorepudam with iunt,
the transplant Co-ordinator.
nulparciur?Perio. Ut deIf vendam,
death has not occurred within 1 hour of treatment withdrawal, liver,lung and
pancreas donation is not possible. There is a cut off of 5 hours for kidney
none optiondonation.
nat quiaThe cumqui ullest Co-ordinator
transplant ligenihiciet accus.Quis
will advise ifsit, offictemis quo
donation conecto ditia-
still feasible.
When deathutdoes
volo iur?Volorent ut queoccur, it is
et mi, important
quas sin cum that the patientincto
quidellandel is certied
quassitpromptly. This
faccatur maximi,
should ium
quunturio be by a physician
haruptatiis andemwho is di not
quidempart of the transplant
nulparchit velecteteam
eos and should
et quid ent be after 5
vollaccuptae
minutes ofres
comnimusam asystole. Thereafter,
que lab inis coreperum the direlatives
bla aut can a further
havedignima
ut veria 5 minutes
gnihicimus at the
suntiae ditiis
bedside. If the relatives wish for more time, donation will
est ad magnam reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et not go ahead, and this is
fugitexplained
officiatis to
iur,the next
sam, ut of kin during initial
quaeperrovid discussions
ulparcitaqui with the
odit essint auttransplant Co-ordinator
adis as commodi ctisit ant,
198
30
Unfractionated heparin IV
infusion

Check coagulation screen and platelet count before initiating intravenous
heparin. Discuss patients with a low platelet count or high APTR/INR with a
haematologist.

If Enoxaparin has been administered in the previous 24 hours and manage-
ment is unclear, discuss with the consultant neuro-intensivist, pharmacy or
haematology.

Nosam verferf Caution
erferspit in patients with severe
que voluptatius rerum renal
remimpairment
ut omni ut orautlow
resserum
is aut albumin.
lam qui nempore

num harciis Daily
tium entis nima
rest offic
(HIT)
tem count
platelet aut verroviti
because opta doluptam,
of risk quibus di volut
of Heparin-induced qui non reicil eosan-
thrombocytopenia
re corrorporest
Initiation quos
of eum nobistibus nis evento
unfractionated tem et infusions
heparin pratem. Ut rem eatenienis enimolup-
1 Decide
ratur, omnihit incidusregime with the
ea Wessex Neuro
Neuro ICUICU consultant
Guidelines quiand Neurosurgeon/Neurologist:
A or B
expelleces mi, A)sam When risk tenecus
reriandic of catastrophic
Wessex Neurohaemorrhage from over-anticoagulation
ICU Guidelines aut voloreperit proris as
is high:posandi gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
Load with a bolus of Unfractionated HEPARIN SODIUM 2500 units
intravenously
none option nat quia Start heparin infusion at dose of 15 units/kg/hr see table below
B) When anticoagulating for newly diagnosed venous thrombosis or
embolism:
comnimusam res que lab inis
Load withcoreperum di bla aut ut veria
a bolus of Unfractionated dignimaSODIUM
HEPARIN gnihicimus suntiae
5000 units ditiis
est ad magnam reresenient intravenously
fugit officiatis iur, sam, ut quaeperrovid ulparcitaqui odit20essint aut adis as commodi ctisit ant,
Start heparin infusion at dose of units/kg/hr see table below
2 Prescribe Heparin 20,000 units in 20ml (Pump Hep). (The concentration is
1000 units moluptam
/ml) everis pratate iliquas rem que nos endicitin est ipieneculpa sus
199
Wessex
solo NeuroNusda
Starting
explautem eum infusion
re cor aut rate
emoluptae
Patientveribus am rem quid eatur assimillat.Wessex Neuro ICU Guidelines Tis dolupti
40 45 50 55 60 65 70 75 80 85 90 >90
weight (kg)
Regimeparchilitat.Ut
autatatque A eosam
0.6 0.7 0.7suscias
0.8 aut 0.9qui 1.0
volorum1.0quam1.1 hari1.2odis1.3
et porersp
1.3 1.4ellaut la
num(ml/hr)
et endia vendi ipsandem apidell endesec ulloribus deribus di ipsam harit quibus, cori-
Regime B
busaniae repreperum 0.8 derovit,
0.9 1.0 sitatium1.1nosam1.2 sinisci
1.3 liquiat
1.4 1.4 eaquias1.4 iminulpa
1.4 1.4is asitatia
1.4 int.
(ml/hr)
3 Check
APTR quosa
4 hoursconsequas
after startingacepe conest ut
the heparin am, quo
infusion dis enia
or after vitae. Perovit
any change in
dose.
4 Once stable, APTR can be measured daily.
nosto 5 erio. IfWessex
initial APTR
Neuro>3.5ICUorGuidelines
<1.39, takeVerumappropriate
ipiduntaction
volor and
adit measure APTR
1 hour after starting the new infusion rate. APTR should be
pro enecta nis et quiasim enimos moluptate volo qui cus explam as accae dolo bersped que monitored 4-6
hourly until stable.
numChanges
harciis rest tooffic
infusion
tem autrateverroviti opta doluptam, quibus di volut qui non reicil eosan-
tiumAPTR
entis nima sit que eostiis
Infusion rate citam,
change eumet voluptasit Infusion
(units/hour) posandu ratentioreritem
changequam ad ma de
(ml/hour)
veligen >3.5
diant.et quos
Stopium, cus cone
infusion dem then
for 1 hour nem check
fugiatem.Stop
Pudionsequia
1 hour dis suntotate laborpor
0.3ml
re corrorporest quos APTR eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
3.01-3.5 Stop
tae. Uptatio dolorem nus infusion for 30mins
sinctem then re- vit volupta
fugit iditatiorum Stop 30porem
min quatusa
0.3ml pedionsequis
duce rate by 300 units/hr
2.51-3.0 Reduce rate by 200 units/hr 0.2ml
2.21-2.5 Reduce infusion by 100 units/hr 0.1ml
1.8-2.2 NO CHANGE NO CHANGE
1.40-1.79 Increase infusion by 100 units/hr Wessex Neuro ICU Guidelines aut voloreperit proris as
0.1ml
<1.39 Increaseposandi
infusiongnimus.Laborer
by 200 units/hr iaerupienis
0.2mldolorehent lis eos doles volorib

Neuro ICU IfGuidelines
APTR<1.8doluptaor > 2.2tureped
ensure ullorepudam iunt, nulparciur?Perio.
the nurse-in-charge and a doctor areUt de vendam,
informed

Note if infusion has been stopped for more than 6 hours, check APTR and
none optionconsider
nat quiareloading
cumqui theullest ligenihiciet
patient accus.Quis
with a bolus sit, offictemHEPARIN
of Unfractionated quo conecto ditia-
SODIUM 2500 orvit5000
pelitatia
unitscon perae voluptae doluptia nimi, venis nemquame
intravenously.
200
Chapter
est, exeriae. Unfractionated heparin
doles eatiore IV infusion
ribusandiste molora
Bleeding
explautem eum rewhilst
cor aut on omnisIVaunfractionated
vit, Wessex Neuro ICU heparin

Unfractionated heparin has a short half-life; therefore stopping the infusion is
usually sufficient.

Check APTR, clotting screen and full blood count.

Busciis aceati omnit lautis autate
If bleeding severeWessex
agulation is quosa
seriatur?Pa sedioreped advisedconsequas
intravenous
Neuro
contact the ICU Guidelines
haematology
protamine
acepe
con If
registrar.
conestsulphate
ut am, may
esreversal
magnam
be used:
quo dis
of in porrovit,
antico-
enia vitae. Perovit

odit hillorest,Give
erorerum repe
nusdand
1mg antibusape
theconseque
of protaminenonsequ
precedingnos 2 ethours
sulphateassequi
debitatia idessum
(usually
doluptatur?
for every 100 units Qui
est doluptur,
25-50mg, maximum
in euminfused
of heparin
est50mg).
aut aut over
min pedGive
ommolor
modbyetslow
resciunt,
qui doloratatas intravenous injection
volupta seriam over 10
solorest minutes.modit explatur? Iqui blam faceprovit eaqui
voluptatis

nosto erio. Wessex
RecheckNeuro
APTRICU Guidelines
to see if further Verum ipidunt
protamine volor adit la doluptasit aut reiciet
is required.

N.B. Excess
velese ma inctota quiduntprotamine will act as
acest, idenihicti im an
cusanticoagulant.
a dolesto eatas aut pel is dolesci tibus.
201
Wessex
solo NeuroNusda
est, exeriae. ICU Guidelines 2017
nonsequo temolec erovitatenis doles eatiore ribusandiste molora
Subsequent Infusions of: Heparin 20,000 units in 20ml (1000units/ml conc ) by continuous intravenous infusion (Repeat APTRs to be documented sequentially in following table)
intravenous heparin
Date & Time Repeat APTR due (4 - 6 hours)

Loading Dose of Heparin Sodium (if required): by intravenous bolus administered over 5 mins
inpatient chart and
Time.
Time.
Time.
Time.
Time.
Date.
Date.
Date.
Date.
Date.
IV Heparin on the
APTR Taken
Date & Time
Prescribe
Refer to
Time
Date
NOTE:
chart
state
Time.
Time.
Time.
Time.
Time.
Date.
Date.
Date.
Date.
Date.
repeat APTR due
Date & Time

time of administration
Adult Intravenous Unfractionated Heparin Infusion Prescription Chart (Pump Hep)
(2).
Administered by &
Time...
(1)
.(Sig)
.(Sig)
.(Sig)
.(Sig)
(must be signed every 24
(Sig)
Date..
Date..
Date..
Date..
Date..
Dr.s Signature & Date
Full guidelines on reverse Please keep this chart with all other prescription charts
..
Time Infusion Started
.
hours)
Drs Signature:
Initial Infusion of: Heparin 20,000 units in 20ml (1000units/ml conc ) by continuous intravenous infusion
Date & Time of
Time
Time
Time
Time
Time
Date
Date
Date
Date
Date
infusion rate
adjustment
(2)
(1)
Administered by
Dose: (units)
(2)
(2)
(2)
(2)
(2)
Signatures of Nurses
the rate according to
(1).
(1).
(1).
(1).
(1).
who have adjusted
the schedule
..
Dr.s Signature
..
Date:
...................
..................
..................
..................
..................
Signature of
n
(Nurse/Doctor)
checking
person
APTR
Date of Birth:..
........... (ml/hr)
Patient Name:..
Attach patient addressograph label here or add the following
b). Change to new infusion rate of .(ml/hr)

a). No adjustment maintain at .....(ml/hr)
a). No adjustment maintain at ....(ml/hr)
Using schedule overleaf Heparin infusion
Initial Infusion rate
(PTO for table)

.
Baseline APTR
rate adjusted to:

Consultant:..
Hospital No:
Dr J. A. Hell & Dr J. Mainwaring
Either
Either
Either
Either
Either
Or
Or
Or
Or
Or
Ward: Neuro ICU
Developed 12/10/2011
Prescribed
...
Time

Result of
repeat
APTR
Guideline
...
detail
Date
Date
202
Chapter
est, exeriae. Unfractionateddoles eatiore heparin IV infusion
ribusandiste molora
Guideline
autatatqueIntravenous
parchilitat.Ut eosam Unfractionated
suscias aut qui volorum Heparin
quam hariin odisAdults et porersp ellaut la
Nursing Administration Record
BusciisAttach
aceati omnit
patient laut autate
addressograph label here Wessex
or add the Neuro
following ICU This Guidelines
administrationcon esis magnam
record in porrovit,
to be used with
details the heparin guidelines and heparin
seriatur?Pa sedioreped quosa consequas acepe conest
Patient Name................................................. ut am,
prescription chart. quo dis enia vitae. Perovit
Hospital number............................................. (This chart is not a prescription)
odit hillorest, nusdand antibusape nonsequ assequi doluptatur?
Date of birth................................................... Qui in eum aut aut ommolor
Consultant......................................................
WARD................................
pro enecta Datenis et quiasim Time enimosPump moluptate volo qui cus explam
Present Volume as accae Nurses dolo bersped que
Setting/ volume in Delivered Signature for
velese ma inctota quidunt acest,Infusion idenihictirate imsyringe
cus a dolesto since eatas autadministration
Nosam verferf erferspit que voluptatius (ml/hr) rerum(ml) rem ut omni utprevious aut res is aut lam qui nempore
reading (ml)
ad eum fugia volorpo reptur? EtPlease lam venda non consediam aut es dolendipsum venis rerum a
keep this chart with all other prescription charts
Developed 12/10/2011
quo testis
Dr J.maximus
A. Hell & Dr J. aecabore,
Mainwaring que nonem es repereped ut ut dolupta sundit, ad qui cullenim
203
31
IV drug compatibility &

infusions
oditY-site
hillorest,compatibility
nusdand antibusape ofnonsequ
IV infusions assequi doluptatur? Qui in eum aut aut ommolor

nosto erio. The information
Wessex Neuro ICU is provided as a Verum
Guidelines guide only, since
ipidunt although
volor adit ladrugs
compatible, variations in the concentrations used may produce an incompati-
can be
bility in some circumstances.

Nosam verferf Theerferspit
compatibility data is largely
que voluptatius
ble sign of incompatibility.
rerum based
rem on physical
ut omni compatibility,
ut aut i.e. no
res is aut lam quivisi-
nempore

tium entis nima
Whensitstated
Y-site in
que eostiis
a line, not
citam, eumet
as compatible,
in an infusion
voluptasitthat
it is assumed
bag, burette
posandu
or
ntioreritem
drugs are
syringe.
quamvia
being mixed adama de

re corrorporest
Check
tae. Uptatiodopamine
quosthateum
dolorem nus
the nobistibus
sinctem
in NaCl 0.9%fugit
nis evento tem
drugs are compatible
is to iditatiorum
with et
be infused vit
thepratem.
infusionUtfluids
volupta
through theporem
rem ineatenienis
use, e.g. enimolup-
quatusa
same line
if
pedionsequis
as dobutamine
dolorumquunt in 5% glucose,
as dit mo corcheck
sa porrothatetboth
voluptidopamine
beatquoand dobutamine
cus.Liqui dolupidare compatible
with each other and with saline and glucose.

quatem aspedit
expelleces mi,colour
atatem
All drug
samchange,
consedia
mixtures
reriandic
should
haze,
volorerum
be checked
precipitate
tenecus Wessex
et omni
or Neuro
od quiofbearum
for signs
crystalICU
formation.
is estrunt
incompatibility:
Infusion
Guidelines
re volor rehent
cloudiness,
sites should
be checked regularly for signs of irritation that may be
rerspero ommo ommolor posandi gnimus.Laborer iaerupienis dolorehent lis eos doles voloribattributable to drug
incompatibility.

Neuro ICU The information
Guidelines
sibility can be
provided
dolupta
accepted
tureped
for
hasullorepudam
any
been carefully
errors or
checked.
iunt,
omissions.
ni consenes idendemodis re voluptibus.Ero cuptium consequi doloreh enimetu rionsed queThe
However, no
nulparciur?Perio.
reader is
Utrespon-
de vendam,
assumed
to possess the necessary knowledge to correctly interpret the information
provided.
Drugs which must always be infused separately
comnimusam Antibiotics
res que lab inis coreperum di bla IVIg
aut ut veria dignima gnihicimus suntiae ditiis
est ad magnamAntifungals
reresenient escius sequunturOmeperazole sinullit assimporesse veliquam, omnihicit et
Antivirals
fugit officiatis iur, sam, ut quaeperrovid ulparcitaqui Phenobarbital
odit essint aut adis as commodi ctisit ant,
ad eum fugia Acetazolamide
volorpo reptur? Et lam venda nonPhenytoin consediam aut es dolendipsum venis rerum a
Alteplaseaecabore, que nonem es repereped
quo testis maximus Sodium valproate
Mannitol moluptam everis pratate iliquas
volor alis susdandis Thiopentone
rem que nos endicitin est ipieneculpa sus
204
Chapter
est, exeriae. IV drug compatibility
doles & infusions
explautem
Y-siteeum re cor aut omnis
compatibility of IVainfusions
Epinephrine (Adrenaline)
Noradrenaline
Amiodarone
Dobutamine
Furosemide
Vecuronium
Atracurium
Midazolam
Dopamine
Morphine
Labetalol
Milrinone
Fentanyl
Propofol
Calcium
Heparin
Insulin
GTN
SNP
odit hillorest, Aminophylline
nusdand antibusape CNC nonsequ
I I N assequi
N C doluptatur?
I C C C Qui N inI eum
V I autV aut
I ommolor
I
erorerum repe Amiodarone
conseque nos NNNCCNCCC I C I NNCCNN
Atracurium NV
seriam solorest CCCN
I N voluptatis NV
modit C N CIqui
explatur? C Cfaceprovit
C blam N eaqui
nosto erio. Wessex Neuro ICU
Calcium I CCC
N NGuidelines Verum I Nipidunt
N V volor
N N aditN Vla V V
pro enecta nis Dobutamine
et quiasim enimosC C moluptate
C C C Cvolo C cus
V qui C I as
I Vexplam C accae
C C dolo bersped que
velese ma inctota Dopamine CCC
quidunt acest, CCC
idenihicti imC cusCaVdolesto
C C eatas I CC aut pel is dolesci tibus.
Nosam verferf erferspit que C
Epinephrine (Adrenaline) N C C rerum
voluptatius C C rem C CutComniCC VC
ut aut res is aut lam qui nempore
Fentanyl C N C C C C C C N C C C
Furosemide I NC I I I I I CCC
GTN CCCCCCCCCC
Heparin C cone
C Cdem C Vnem C fugiatem.
C V C Pudionsequia dis suntotate laborpor
Insulin N C C nis VC evento
C Ctem N et pratem. Ut rem eatenienis enimolup-
tae. Uptatio dolorem C C Cfugit
nus sinctem
Labetalol C iditatiorum
C C C vit volupta porem quatusa pedionsequis
dolorumquunt as dit mo cor sa
Midazolam C porro
C C etCvolupti
C C beatquo cus.Liqui dolupid molor sit vellis debis
ratur, omnihit incidus C C Neuro
ea Wessex
Milrinone CCC ICU Guidelines qui quaerov itendae volor aligenime
quatem aspedit atatemMorphine consedia CC
C C volorerum et omni od qui bearum is estrunt re volor rehent
expelleces mi, sam reriandicCtenecus
Noradrenaline N C Wessex Neuro ICU Guidelines aut voloreperit proris as
Propofol
rerspero ommo ommolor posandi C C gnimus.Laborer iaerupienis dolorehent lis eos doles volorib
usant. Quia non con nullaut C
SNP
veratemo tem aut modipis cimint quia nonsequis aut et Wessex
C Compatible Y-site under certain conditions
turias prepedi taecerrovita Conflicting information of compatibility
voluptae/ doluptia
incompatibility
V Avoidvitcombination
pelitatia con perae nimi, venis nemquame
where possible - use together with extreme caution
N No andem
quunturio ium haruptatiis informationdi quidem
available.nulparchit velecte eos et quid ent vollaccuptae
Do not mix
I Knownescius
est ad magnam reresenient to be incompatible. Do notassimporesse
sequuntur sinullit mix veliquam, omnihicit et
Information
quo testis maximus given in this
aecabore, quetable mustesbe
nonem interpreted
repereped ut utwith caution
dolupta - please
sundit, ad quirefer to
cullenim
volornotes on previous
alis susdandis page. Further
moluptam information
everis pratate canrem
iliquas be que
obtained from theest
nos endicitin duty Neuro ICU
ipieneculpa sus
pharmacist.
205
Wessex
solo NeuroNusda
Common
explautem eum re drug infusions
Drug Dose Final Diluent Final Starting
autatatque parchilitat.UtVolume
eosam susciasVolume aut qui volorum quamconc. hari odis etdoseporersp
rangeellaut la
numAdrenaline
et endia vendi ipsandem
5 mg apidell 50endesec
ml 5%ulloribus
Dextrose deribus100di g/ml
ipsam 010
harit quibus,
ml/hr cori-
1:1000
busaniae 5 ml sitatium nosam sinisci liquiat eaquias iminulpa is asitatia int.
repreperum derovit,
Atracurium
Busciis aceati omnit laut500 mg Wessex
autate 50 mlNeuroNeat ICU Guidelines10con mg/ml 06 ml/hr
50 ml
Clonidine 750 g 50 ml 0.9% Saline 15 g/ml 03 ml/hr
Dobutamine 250 mg 50 ml 5% Dextrose 5 mg/ml 020 ml/hr
erorerum repe conseque20nos ml et debitatia idessum est doluptur,
or 0.9% Saline est min ped mod et resciunt,
qui doloratatas
Dopamine volupta seriam 200 mgsolorest50 mlvoluptatis5%modit
Dextroseexplatur? Iqui blam05
4 mg/ml faceprovit
ml/hr eaqui
nosto erio. Wessex Neuro 5 mlICU Guidelines Verum ipidunt
or 0.9% volor adit la doluptasit aut reiciet
Saline
Fentanyl
pro enecta nis et quiasim 2.5enimos
mg moluptate
50 ml volo Neatqui cus explam 50asg/ml
accae 04
doloml/hr
bersped que
50 ml
NosamGTNverferf erferspit que50 mg 50 ml
voluptatius rerum rem Neatut omni ut aut 1 unit/ml
res is aut010 ml/hr
lam qui nempore
Insulin 50 units 50 ml 0.9% Saline 1 unit/ml sliding scale
0.5 ml
Labetalol 200 mg 200 ml 0.9% Saline 1 mg/ml 20160 ml/hr
40 ml cone dem nem fugiatem. Pudionsequia dis suntotate laborpor
re corrorporest
Midazolamquos eum nobistibus nis evento tem et pratem. Ut rem eatenienis enimolup-
tae. single
Uptatiostrength
dolorem nus 50sinctem
mg 50 ml
fugit 0.9%vit
iditatiorum Saline 1 mg/mlquatusa
volupta porem 030pedionsequis
ml/hr
dolorumquunt as dit mo cor sa porro et volupti beatquo cus.Liqui dolupid molor sitml/hr
double strength 100mg 50 ml 0.9% Saline 2 mg/ml 030 vellis debis
quad strength 200mg 50 ml 0.9% Saline 4 mg/ml 030 ml/hr
Morphine 60 mg 60 ml 0.9% Saline 1 mg/ml 05 ml/hr
quatem aspedit
Noradrenaline atatem consedia
4 mg volorerum
50 ml et omni od qui bearum
5% Dextrose 80 g/ml 010 is estrunt re ml/hr
volor rehent
expelleces mi, sam reriandic 4 ml tenecus Wessex Neuro ICU Guidelines aut voloreperit proris as
rerspero ommo ommolor20
Noradrenaline posandi
mg gnimus.Laborer
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206
Chapter
est, exeriae. IV drug compatibility
doles & infusions
Noradrenaline
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207
Wessex
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Drug Range Timing
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Gentamicin Nomogram 6-14hrs after dose administered
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208
Index
Index long term 57
recommencement 61
A reversal 60
Anti-embolic stockings 65
Abnormal clotting 5464
Arterial thromboembolism 57
Acute neuromuscular weakness 166173
ASIA score 119
Admission
criteria 6
Atracurium 84 , 206
Atrial brillation 57
post-operative 82
Autonomic dysreflexia 127
Adrenaline 206
Agitation 104110
B
management 104 , 106
non-traumatic brain injury 107 Base of skull fracture
traumatic brain injury 106 antibiotics 90
Alcoholism imaging 90
abnormal coagulation 55 NG tube , 45, 49, 28

tranexamic acid 85 BiLevel 23
withdrawal 106 BiPAP 24
Aminophylline 208 Blood pressure
Amitriptyline 83 elevation 31 , 136

Analgesia targets 29
agitated patient 106 Brain death 188
post-operative 83 Brain stem testing 188191
spinal cord injury 123 assessment 190
traumatic brain injury 93 considerations 191
Antibiotics preconditions 188
base of skull fracture 90

C
pneumonia 71
prophylactic 69 Carbamazepine 106 , 107

venticulitis 73 Carbomedics 58
Anticoagulation Cardiovascular management 2933
elective neurosurgery 59 spinal cord injury 124
emergency surgery 60 Cefotaxime 144
209
Cefuroxime 71 Corrected phenytoin 79
Central pontine myelinolysis 38 Cortrak 45
Central venous access CPAP 24
subclavian line 32 Cranioplasty 165
Cerebellar infarction 156 Cryptococcal meningitis 74
Cerebral abscess 73 CT cervical spine
Cerebral function monitor 99 indications 113
Cerebral metabolic rate CT head
cooling 98 indications 113
thiopentone 99 CT thoracolumbar spine
Cerebral perfusion pressure indications 113
target 29
D
Cerebral salt wasting 37
subarachnoid haemorrhage 131 Day of surgery
Cerebral spinal fluid drugs 177
organisms 144 DDAVP 35 , 95

white cells 144 Decompressive craniectomy 98 , 100
Cerebral toxoplasmosis 74 neurological conditions 155
Cervical spine assessment 112 Delayed ischaemic neurological deficit 131
Chest drains 27 Demeclocycline 39
suction 27 Diabetes insipidus 35
Chloramphenicol 71 subarachnoid haemorrhage 131
Chlordiazepoxide 106 Diarrhoea 68
Cholinergic crisis 171 Diazepam 106
Ciprofloxacin 71 Digoxin 208
Clonidine 106 , 107, 206 Discharge
Co-amoxiclav 71 criteria 9
Coiling 138 summary 10
Compassionate care pathway 185 targets 11
Cooling Dobutamine 206
34 degrees 98 Donor after brain death 192
35 degrees 98 Donor after cardiac death 192
210
Index
Do not attempt CPR 186 Fisher scale 129
Do not escalate therapy 187 Fludrocortisone 32
Dopamine 206 hyponatraemia 38
Drug monitoring 208

G
Drugs on day of surgery 177179
Gabapentin 83
E
Gastric aspirates 45
Endotracheal tube Gentamicin
cuff pressure 20 intrathecal 145 , 146

length 20 Glasgow coma scale 15
position 20 GTN 206
tie 21 Guillain-Barr syndrome 166
types 19 suxamethonium 167
Energy feed 43
H
Enteral feeding 4353
types 43 Haloperidol 109
EPAP 24 Hard collar 111
Epidurals Heparin
LMWH 61 low molecular weight 66
Erythromycin 45 unfractionated 199
External ventricular drain 143150 HIV Testing 74
bolt 143 Hydrocephalus 130
sampling 144 Hydrocortisone 32
traumatic brain injury 97 Hypernatraemia 34
tunnelled 143 , 144 cranial diabetes insipidus 35
Hypertension
F
therapeutic 31 , 136
Feeding 4353 Hypertonic saline 97
prokinetic 45 Hyponatraemia 36
tube placement 44 , 50 cerebral salt wasting 37
Fentanyl 83 , 206 management 37
FiO2 22 SIADH 36
211
I thiopentone coma 98
Levetiracetam 78
ICP management 92103
Lorazepam 77
ICP monitor 91
Low molecular weight heparin 66
drift 92
epidurals 61
Immobilisation 126
spinal drains 61
Insulin 206
Lumbar puncture 139142
Intermittent pneumatic compression 65
contra-indications 139
Intracerebral haemorrhage
indications 139
blood pressure target 30
procedure 140
Intracranial haemorrhage 153
Intracranial pressure 92
M
Intrathecal
gentamicin 145 , 146 Mannitol 97 , 158

dose 158
vancomycin 145, 146
Mean Arterial Pressure
IPAP 24
targets 30
IV drug compatibility 204
Mechanical heart valves 58
IVIg 168
Carbomedics 58
J Medtronic 58
Starr-Edwards 58
Jejunal feeding 46
Medtronic 58
tube insertion 46
Meropenem 146
L Methylprednisolone 118
Metoclopramide 45
Labetalol 152 , 206
Microbiological advice 74
Lansoprazole 32
Leucoencephalopathy 74
Midazolam 84 , 206
Miller-Fisher 166
Levels of ICP management 92
cool to 34 98
Morphine 83 , 206
Motor neurone disease 172
cool to 35 98
MRSA 68
decompressive craniectomy 98
Multifibre feed 43
EVD insertion 97
Myasthenia gravis 169
sedation & optimisation 92
212
Index
Myasthenic crisis 171 P

Myeloproliferative disorders
Pabrinex 45 , 90
abnormal coagulation 56
PaCO2 22
Pantoprazole 32
N
PaO2 21
National Institutes of Health Stroke Scale 160
Paracetamol 83
Neurogenic pulmonary oedema 130
Paralysis 84 , 96
NG tubes 44
Patient controlled analgesia 83
base of skull fracture , 45, 49, 28 Patient review 1318
Nimodipine 133
PCV-VG 23
NJ tube 45
PEEP 22
insertion 46
Phenobarbitone 78
Nomogram 38
Phenylepherine 206
Non-invasive ventilation 2328
Phenylephrine 31
Noradrenaline 32 , 206
Phenytoin 78 , 133, 206, 208
Nutrison energy 43
corrected phenytoin 79
Nutrison protein plus 43
Plasma exchange 168 , 174
Nutrison standard 43
complications 176
indications 174
O
management 175
Octaplas 60 , 64 Pneumocystis 74
Octaplex 60
Pneumovax 90
Olanzapine 106 , 107 Post-operative care 8285
Organ donation 193198
analgesia 83
consent 194
sedation 84
contraindication 193
tranexamic acid 85
following brainsem death 195
urine output 85
non-heart beating 198
ventilation 84
Osmolality
Pre-operative care 177179
nomogram 38
Prokinetics 45
Oxygenation 21
Propofol 84 , 206
target 21
Propranolol 107
213
Protein plus feed 43 assessment 118
Prothrombin complex concentrate 60 autonomic dysreflexia 127
Proton pump inhibitor 32 cardiovascular management 124
Pupils gastro-intestinal management 124
assessment 17 immobilisation 126
fixed dilated 158 management 121
steroid treatment 128

R
suxamethonium 123
Ranitidine 133 venous thromboembolism 125
Re-bleed 130 ventilation 25
Refeeding syndrome 46 Spinal drains
Revaxis 90 LMWH 61
Rifampacin 71 Spinal management 111
Starr-Edwards 58
S Stroke 151154
Sedation 84 Subarachnoid haemorrhage 129138
Seizures 7581 blood pressure target 30
diagnosis 75 complications 130
focal 81 hydrocephalus 130
investigation 80 hypertensive therapy 136
management 76 management 131
subarachnoid haemorrhage 130 myocardial ischaemia 130
Sepsis 70 re-bleed 130
abnormal coagulation 57 transcranial doppler 133
SIADH 36 vasospasm 131
SIMV 23 Subclavian line 32
Sodium Suction on chest drain 27
rate of change 38 Suxamethonium
Sodium valproate 78 Guillain-Barre syndrome 167
Spinal cord injury 118128 spinal cord injury 123
analgesia 123 Syndrome of innappropriate ADH secretion 36
ASIA score 119 subarachnoid haemorrhage 131
214
Index
T V
Tetanus 90 Vancomycin 208
Thiopentone 206 intrathecal 145 , 146

Thiopentone coma 98 Vasospasm 131
complications 99 blood pressure target 30
discontinuation 100 Venous-thromboembolism 58
Thrombolysis for stroke 151154 anti-embolic stockings 65
complications 152 intermittent pneumatic compression 65
TPN 45 low molecular weight heparin 66
Tracheostomy 26 spinal cord injury 125
change 27 Ventilation 1928
dislodgement 26 initial settings 21
insertion 26 minute ventilation 23
Tramadol 83 non-invasive 23
Tranexamic acid 85 oxygenation target 21
Transcranial doppler 133 PEEP 22
Transphenoidal surgery 84 post-operative 84
Transplantation 192198 spinal cord injury 25
Traumatic brain injury 86103 Ventriculitis 73 , 146

abnormal coagulation 56 Vitamin K 60
blood pressure target 30

W
feeding 95
investigations 89 Wessex modified RASS 163
prescription 89 Withdrawal of therapy 183187
self ventilating patient 101 World Federation of Neurosurgeons 129
targets 87 , 88
ventilated patient 87
Urine output
post-operative 85
215
216

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Wessex Neuro ICU

Matthew Cordingly John Hell

Wessex Neuro ICU Wessex Neuro ICU

Copyright 2013 Matthew Cordingly & John Hell

All rights reserved. No part of this document may be reproduced

Patient care on Neuro ICU

nosto erio. | Wessex

Following the tracheostomy insertion:

Enteral feeding & bowel

|| Be treated as still being MRSA positive

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est ad magnam reresenient escius sequuntur sinullit assimporesse veliquam, omnihicit et

This guidance applies to any level 1, 2 or 3 patient in the Neuro ICU.

The following should be considered:

For drug withdrawal consider the following:

3 If patient is hypertensive and tachycardic, consider using clonidine infusion at 0-3ml/hr

Richmond Agitation-Sedation Score (RASS)

Score Term Description

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very Agitated Pulls or removes tubes or catheters; aggressive

+2 Agitated Frequent non-purposeful movement, ghts ventilator

+1 Restless Anxious, but movements not aggressive or vigorous

0 Alert and Calm

1 Drowsy Not fully alert, but has sustained awakening

2 Light Sedation Briey awakens with eye contact to voice

5 Unrousable No response to voice or physical stimulation

Wessex modified RASS for stroke & brain injured patients

Score Term Description

0 Alert and Calm

Able to sustain meaningful interaction, but if left

Requires repeated verbal stimulation to maintain

No meaningful Verbal or motor response to voice, but no meaning-

No response to voice, but verbal or motor re-

5 Unrousable No response to voice or physical stimulation

Spinal precautions for the

Trauma Patient Spinal Management

Any anal sensation (Yes/No)

Caudal extent of partially

PIN PRICK SCORE

Incomplete = Any sensory or motor function in S4-S5

ASIA IMPAIRMENT SCALE

(MAXIMUM) (56) (56)

Neuro ICU Guidelines dolupta tureped ullorepudam iunt, nulparciur?Perio. Ut de vendam,

Finger abductors (little finger)

against full resistance

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Ankle plantar flexors

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The most caudal segment

External ventricular drains

none option nat The quiafollowing

est ad magnam reresenient

Open a 3-way-tap, fresh bung Pick up EVD catheter with

Cover with transparent fenestrated drape Connect syringe complex to the

Turn EVD catheter 3-way-tap Disconnect syringe complex from

CSF sample should be sent for microscopy, culture and sensitivity.

Cover with transparent fenestrated drape Connect syringe complex to the

for neurological conditions

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