Admission to neurological intensive care: who, when, and why?
- The Batten Harris Medical Intensive Care Unit, The National Hospital for Neurology and Neurosurgery, London, UK
- Correspondence to: Dr Robin Howard, The Batten Harris Medical Intensive Care Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK; robin.howard{at}uclh.org
- neurological intensive care
- stroke
- subarachnoid haemorrhage
- status epilepticus
- meningitis
- Guillain-Barré syndrome
The majority of neurologists work in district general or teaching hospitals with large general intensive care units (ICUs). In this setting, ICUs require an increasing input from neurologists, especially with regard to the assessment of hypoxic brain damage and the neurological complications of organ failure, critical illness, and sepsis. In contrast, dedicated neurological intensive care units (NICUs) tend to deal largely with a different population of patients. Such units are primarily concerned with the management of primary encephalopathic patients, the control of raised intracranial pressure (ICP), the management of ventilatory, autonomic, and bulbar insufficiency, and the consequences of profound neuromuscular weakness. This role encompasses the treatment of mechanical ventilatory failure, specific treatments (both medical and surgical) and general medical complications of these disorders.1
In general, NICU patients with primary neurological diseases such as myasthenia gravis, Guillain-Barré syndrome, central nervous system infections, status epilepticus, and stroke have a better outcome than those patients with secondary neurological disease seen on general ICUs. However, such patients remain dependent on ICU support for very much longer periods of time. This results in very significant psychological demands on the patients, their carers, the nurses, physicians, and other health care professionals. In this review we will consider the rationale for managing acute neurological conditions in a dedicated NICU environment.
INDICATIONS FOR ADMISSION
Indications for admission to NICU include:
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impaired level of consciousness
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impaired airway protection
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progressive respiratory impairment or the need for mechanical ventilation (box 1)
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seizures
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clinical or computed tomographic (CT) evidence of raised ICP caused by a space occupying lesion, cerebral oedema or haemorrhagic conversion of a cerebral infarct
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general medical complications (for example, hyper/hypotension, aspiration pneumonia, sepsis, cardiac arrhythmias, pulmonary emboli)
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monitoring (for example, level of consciousness, respiratory function, ICP, continuous electroencephalography (EEG))
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specific treatments (for example, neurosurgical intervention, intravenous or arterial thrombolysis).
