Critical Care Management of Patients With Neurological Injury
In this issue of Critical Care Nursing Quarterly, we provide a series of review articles aimed at increasing familiarity with medical management of those with severe neurologic injuries. The issue was completed in partnership with the Neurocritical Care Society (NCS) Pharmacy Section. The NCS is an international organization that aims to advance care for patients with life-threatening neurologic illnesses. The society has more than 2500 multidisciplinary members and has collaborated with more than 20 international organizations to deliver high-quality education on neurosciences best practices. The NCS Pharmacy Group began in 2012 and was officially recognized as a section within the society in 2017. Membership has grown to 164 total members today and consists of pharmacists practicing in a variety of specialty settings across the world. Members of the section coordinated with each other to construct each article in this issue, with the goal of highlighting important treatment considerations or controversies within neurocritical care. Articles related to ischemic stroke, traumatic brain injury (TBI), subarachnoid hemorrhage, and specialized neurologic conditions are included, as well as overviews of supplemental therapies that may be used in a variety of patients with neurologic injuries.
In our first article, Tucker and colleagues summarize the literature on blood pressure management following acute ischemic stroke and provide recommendations to help clinicians apply this literature into practice. Over the last 5 years, numerous trials have highlighted the role of mechanical thrombectomy in those with large-vessel ischemic strokes; however, controversies remain regarding the appropriate blood pressure target in those populations. There also is unfamiliarity with the literature supporting blood pressure goals in patients receiving thrombolytic medications and in those experiencing hemorrhagic transformation of an acute ischemic stroke. Next, a second article related to ischemic stroke discusses the indications and evidence surrounding dual antiplatelet therapy (DAPT). The publication of recent trials has led to practice changes related to DAPT in this population. All providers, including critical care nurses, will benefit from understanding the indications, risks, benefits, and monitoring parameters for DAPT regimens for secondary prevention of ischemic stroke.
Next, the articles move into treatment of a specialized population of patients with hemorrhagic stroke: aneurysmal subarachnoid hemorrhage (aSAH). This condition is responsible for up to 10% of all strokes in the United States and is associated with significant morbidity and mortality. This review summarizes the available literature on the pharmacologic management of cerebral vasospasm, a common complication of aSAH. To supplement the discussion on aSAH, our next article discusses the role of intraventricular medication administration in patients with various forms of hemorrhagic stroke or central nervous system (CNS) infections. Significant benefits and risks are associated with direct administration of medications into the CNS. This article provides key information for clinicians regarding the administration, dosing, monitoring, and adverse effects associated with this unique treatment option. Traeger and colleagues next discuss the use of neurostimulants in patients with TBI, which is one of the leading causes of disability in the United States. These centrally acting medications are used to modify post-TBI symptoms, with this review providing recommendations to guide appropriate usage of these agents to help improve patients' symptoms and optimize safety.
The next sequence of the articles debate specialized disease state management strategies within neurocritical care. Recently approved chimeric antigen receptor (CAR) T-cell therapies have revolutionized the treatment of various hematologic malignancies. However, 2 commonly recognized neurologic complications associated with their use are cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). This review discusses the pathophysiology, clinical manifestations, treatment paradigms, and nursing considerations associated with CAR-T therapies, aiming to increasing familiarity with this complex treatment. Next, we provide a case-based review summarizing the management of hospitalized patients with Parkinson's disease, a population that faces unique challenges when admitted to the hospital. The nature of the disease, complexity of home medication regimens, and the medication-related policies of institutionalized care all contribute to the challenges patients and providers face. Education of the hospital staff regarding the unique needs of this patient population will help promote improved patient care, with the article overviewing multiple strategies to help promote this. This article is followed by an in-depth summary of the history and potential role of cannabanoids in neurocritical care. Medicinal cannabinoid use continues to evolve across the United States, although legitimate federal recognition for medicinal purpose is lacking. Variability exists across states with respect to legislation, and health care institutions encounter challenges when patients present with a history of medicinal cannabinoid use. Developing evidence suggests a role of cannabinoids for various neurologic medical conditions, and this article highlights the need for providers to have applicable knowledge regarding cannabinoids in the hospitalized setting.
The final two articles review essential supportive care topics that are applicable to patients with and without neurologic injuries. The first of these two articles provides a review of melatonin, ramelteon, suvorexant, and dexmedetomidine for sleep and delirium and discusses practical applications for utilizing these medications in intensive care unit patients. Finally, the issue wraps up with a discussion of pharmacologic and nonpharmacologic management strategies for the prevention and treatment of shivering in patients undergoing targeted temperature management (TTM). Armaheizer, Strein, and Pajoumand provide an overview of thermoregulation and devices used during TTM, implementation and monitoring strategies, common complications, and considerations for alterations in drug metabolism.
-G. Morgan Jones, PharmD, BCCCP, FCCM
Issue Editor