Page 1131 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

770 PART 6: Neurologic Disorders

demonstrated safety and benefit. Specifically, early mobilization can be CHAPTER Cerebrovascular Disease
59
safely implemented during mechanical ventilation via an endotracheal
tube, during infusions of vasopressors and relatively higher levels of William J. Powers
oxygen need, and in patients with multiple critical care devices. 60-63 These 84 Dedrick Jordan
studies, spanning physical and occupation therapy services to bedside
cycle ergometer use, are detailed extensively in Chap. 24. Overall, these
studies demonstrate improved patient physical function and shorter
durations of ICU and hospital lengths of stay. 59 KEY POINTS
• Etiology
SUMMARY
• Cardioembolic and other nonarteriosclerotic causes of cerebral
ICUAW is a common morbidity of critical illness, represents an infarction occur more commonly in patients admitted to the ICU
important patient-centered outcome, and has substantial implications and should be carefully sought by appropriate diagnostic tests.
on quality of life and patients’ ability to return to prior health and life- • In hypertensive patients with hemispheric lobar hemorrhages
style. The ability to measure the presence of ICUAW in a reproducible and in patients without hypertension, causes for intracerebral
fashion via history and physical examination has yielded significant hemorrhage such as coagulopathies, arteriovenous malforma-
improvements in global awareness of neuromuscular dysfunction. The tions, or saccular aneurysms should be sought.
practicing clinician needs to be aware when the presentation is atypical
and more advanced diagnostic testing is needed. For the research envi- • Nontraumatic spontaneous subarachnoid hemorrhage is almost
always due to a ruptured saccular aneurysm and should be
ronment, longer term outcomes focusing on neuromuscular strength
and patient functional autonomy need to be considered when evaluating evaluated by arteriography.
the effect of new interventions. Although it seems doubtful that a single • Clinical and Laboratory Diagnosis
therapy might prevent weakness in varied populations, the meticulous • X-ray computed tomography (CT) is the diagnostic neuroimag-
application of multidisciplinary care—including early patient engage- ing test of choice for patients with acute stoke. It is rapid, can be
ment and mobilization—may help to improve strength and function in performed easily on acutely ill patients and acute intracerebral
survivors of critical illness. or subarachnoid hemorrhage are easily identified.
• Lumbar puncture is the most sensitive test for detection of SAH;
it should be performed when there is a strong clinical suspicion
KEY REFERENCES and a negative CT scan, or when CT is not available or feasible.
• Batt J, dos Santos CC, Cameron JI, Herridge MS. Intensive care • In suspected ischemic stroke, diffusion-weighted MRI can be
unit-acquired weakness: clinical phenotypes and molecular mech- helpful for improving diagnostic certainty when there is no
anisms. Am J Respir Crit Care Med. 2012;187:238-246. clear history of an abrupt onset or the localization of the neuro-
• De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in logical findings is confusing. MRI has not been shown to be of
the intensive care unit: a prospective multicenter study. JAMA. value in selecting patients for thrombolytic therapy.
2002;288:2859-2867. • Early electrocardiographic (ECG) monitoring detects previ-
• Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. ously unsuspected atrial fibrillation in 3% to 5% of patients
Interventions for preventing critical illness polyneuropathy and with acute cerebral ischemia.
critical illness myopathy. Cochrane Database of Systematic Reviews • Patients with transient ischemic attacks (TIAs) or mild stroke who
(Online). 2009:CD006832. are good surgical candidates for carotid endarterectomy should
• Herridge MS, Batt J, Hopkins RO. The pathophysiology of long- be evaluated for symptomatic carotid stenosis immediately since
term neuromuscular and cognitive outcomes following critical the risk of stroke can be as high as 1 in 20 within the first 2 days.
illness. Crit Care Clin. 2008;24:179-199, x. • Treatment of Cerebral Infarction
• Kress JP, Hall JB. ICU-acquired weakness and recovery from criti- The following statements can be made based on good clinical trial data.
cal illness. N Engl J Med. 2014; 370:1626-35. • Routine use of supplemental oxygen does not reduce mortality.
• Lacomis D. Electrophysiology of neuromuscular disorders in criti-
cal illness. Muscle Nerve. 2013;47:452-463. • Early treatment of hyperglycemia to achieve levels <7 mmol/L
does not improve outcome.
• Latronico N, Peli E, Botteri M. Critical illness myopathy and neu-
ropathy. Curr Opin Crit Care. 2005;11:126-132. • In patients with systolic blood pressures of 160 to 200 mm Hg,
• Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle pharmacological reduction of systolic pressure by 20 to 25 mm Hg
within the first 24 hours is safe, but does not improve outcome.
wasting in critical illness. JAMA. 2013;310:1591-1600.
• Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, • In hemiplegic patients, subcutaneous low-dose heparin or
Pronovost PJ, Needham DM. Neuromuscular dysfunction enoxaparin reduces deep venous thrombosis.
acquired in critical illness: a systematic review. Intensive Care • Intravenously administered t-PA improves outcome in carefully
Med. 2007;33:1876-1891. selected patients with acute ischemic stroke when instituted
• Stevens RD, Marshall SA, Cornblath DR, et al. A framework for within 4.5 hours of onset.
diagnosing and classifying intensive care unit-acquired weakness. • The clinical value of any intra-arterial pharmacological or
Crit Care Med. 2009;37:S299-S308. mechanical revascularization therapy for acute ischemic stroke
• Stiller K. Physiotherapy in intensive care: an updated systematic has not been demonstrated.
review. Chest. 2013;144:825-847. • Aspirin 160 or 300 mg/d of aspirin begun within 48 hours of
the onset of ischemic stroke results in a net decrease in further
stroke or death.
REFERENCES • Full anticoagulation with heparin or similar drugs in patients
with acute ischemic stroke provides no clinical benefit in general
Complete references available online at www.mhprofessional.com/hall

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