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General medical care on the neuromedical intensive care unit
  1. Robin S Howard,
  2. Jeremy Radcliffe,
  3. Nicholas P Hirsch
  1. The Batten Harris Medical Intensive Care Unit, The National Hospital for Neurology and Neurosurgery, London, UK
  1. 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

https://doi.org/10.1136/jnnp.74.suppl_3.iii10

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    The role of an intensive care unit is to maintain a patient’s normal physiological homeostasis while actively treating the underlying cause of any physiological derangement. Modern neurological intensive care evolved from the neurorespiratory units established in the 1950s to treat patients with respiratory failure caused by poliomyelitis. Thus there has been greater emphasis on the longer term care of the paralysed patient than in the conventional general medical intensive care unit. This review attempts to give an overview of the management of patients treated in the neuromedical intensive care unit (NICU) and is directed towards the general neurologist rather than the intensivist. More detailed texts of neurological and general intensive care are available.1–4 Discussion will be targeted towards a number of areas:

    • respiratory system

    • cardiovascular system

    • alimentary system

    • nosocomial infection and infection surveillance

    • anticoagulation

    • patient comfort.

    RESPIRATORY SYSTEM

    Patients with acute neurological disorders require tracheal intubation and ventilation because of the development of acute respiratory insufficiency or because they are unable to protect their upper airway from obstruction as a consequence of impaired consciousness or bulbar weakness.3 The latter predisposes to pulmonary aspiration of saliva and food that cannot be cleared by the patient because of an inadequate cough secondary to poor diaphragmatic and anterior abdominal wall musculature. Bronchopneumonia often results.

    Respiratory insufficiency and failure is a common manifestation of a wide variety of neurological disease. Central nervous system (CNS) and brainstem diseases cause respiratory depression characterised by central disorders of the respiratory pattern, including hyperventilation, irregular, ataxic or cluster breathing, hiccup, and recurrent apnoea. These may result in inadequate oxygen delivery and hypercapnia, culminating in respiratory arrest. Neuromuscular disease is discussed elsewhere in this supplement and is characterised by symptoms of progressive respiratory impairment or the development of respiratory failure.

    Whatever the aetiology, the resultant respiratory muscle weakness …

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