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Full download Neurologic Complications of Critical Illness (CONTEMPORARY NEUROLOGY SERIES) [Team-IRA] 4th Edition Eelco F.M. Wijdicks file pdf all chapter on 2024
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Illness (CONTEMPORARY
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NEUROLOGIC COMPLICATIONS
OF CRITICAL ILLNESS
SERIES EDITOR
Eva Feldman, MD, PhD, FAAN, FANA
Russell N. DeJong Professor of Neurology
University of Michigan
© Mayo Foundation for Medical Education and Research in the United States of America 2023
DOI: 10.1093/med/9780197585016.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice.
Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while
this material is designed to offer accurate information with respect to the subject matter covered and to be current as of
the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules
for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers
must therefore always check the product information and clinical procedures with the most up-to-date published product
information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation.
The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy
or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations
or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher
do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a
consequence of the use and/or application of any of the contents of this material.
Preface xiii
v
vi Contents
Index 553
Preface
Writ large in this book is the premise that the evaluation of a critically ill patient with a neurologic
manifestation or complication is the most demanding neurology consultation. This book, when
first published in 1995, provided a practical guide for every disquieted neurologist who entered
the intensive care unit (ICU). Just about what, as a young neurologist, I would have liked to have
known. Keeping this book up to date requires multiple editions because intensive care is one of
the fastest growing and changing specialties. Now, more than 25 years later, we can look back at
the extraordinary expansion in knowledge of critical illness and better understanding of this field
of neurology. Intensivists understand the issues involved and appreciate that a neurologic com-
plication in any medical or surgically critically ill patient is a major cause of mortality and later
morbidity. If recognized in time, treatment of a neurologic complication may greatly improve the
outcome. But neurocritical care in all its forms is also at times informed uncertainty, and many
clinical observations are not understood.
The framework of consults has also changed. New diseases have appeared, such as neurologic
complications of cancer immunotherapy, and older diseases, such as cyclosporine neurotoxicity
in transplant patients, have become rare occurrences. Neurotoxicities of drugs are better under-
stood (e.g., serotonin syndrome and cefepime neurotoxicity). Recent mosquito- and tick-borne
illness (e.g., Zika virus, Chikungunya, and Eastern equine encephalitis) in the United States has
resulted in intensive care admissions. The world since 2019 has been shaken by the SARS-CoV-2
pandemic with its multiple surges and no ICU spared. The pandemic has been a revelation,
certainly since the end of 2021, when ICUs (and morale) were at a breaking point as a result of
treating an unacceptably large number of unvaccinated patients who became infected with the
delta variant. Neurologic complications of SARS-CoV-2 infection have emerged, and this damaging
respiratory virus became the most common reason to consult neurologists, who, like their colleagues
in other specialties, had the disadvantage of dealing with a new disease. It is a prime example of how
suddenly ICU populations can change and have changed again in 2023.
The new edition has responded to changes in ICU care and changes in the ICU population and
is now thoroughly updated. I have added criteria for consultation and how to co-manage patients.
A consultation is often contingent on the following five perceptions: (1) an evolving situation that
requires neurologic expertise; (2) “something” might not be recognized; (3) an unusual CT scan
that does not appear to explain the condition; (4) movements that could indicate seizures requiring
expert evaluation and electroencephalography (EEG); and (5) the patient’s condition looks grim
but needs corroboration, and the family may request a neurologic opinion. All this is addressed.
Neurologic consultations are often requested when patients remain comatose after CPR, and the
neurologist is asked to have the last word. Failure to awaken after surgery or after extended seda-
tion has been discontinued are other typical examples that trigger a request. We have an obligation
to provide the best evaluation and management when the outcome can go either way. We also
have an obligation to evaluate for futility. Neurologic consultation not only provides diagnostic,
therapeutic, and prognostic advice but may also change the approach to the patient. This is a major
responsibility and not one to be taken lightly.
This edition also has new chapters on the interpretation of focal findings, acute movement
disorders in critical illness, cancer immunotherapy, and ethical dilemmas. A separate section
on interpretation of EEG requests (and how to use it in critically ill patients) is added. Several
new drugs (direct oral anticoagulants [DOACs] and chimeric antigen receptor T-cell therapy
[CAR-T]) have made their way into the ICU and are discussed in detail because their side effects
require specific intervention. There is a wealth of new tables, algorithms, and neuroimaging. I
have added a new section of advice for practical management to each chapter to reconcile theory
and practice.
xiii
xiv Preface
ICUs are challenged with an increasingly growing (and aging) population, and admissions are
increasing. Neurologic complications will increase, too. This clinical text will be helpful to a very
wide audience of healthcare providers and, in particular, for any intensivist and general neurologist
who must manage these patients with extremely complex medical disorders, surgeries, comorbid-
ity, and with different clinical trajectories. The book is also aimed at neurointensivists who consult
in ICUs other than their own. This book reaches beyond neurology and additionally targets emer-
gency physicians, neurosurgeons, transplant and vascular surgeons, internal medicine hospitalists,
pharmacists, allied healthcare providers, and ICU nursing staff.
I appreciate the help of so many. Lea Dacy not only dutifully edited the full manuscript, but
she has always been absolutely necessary to improve the prose. I am grateful for the work by the
illustrators of Mayo Clinic Media Support service and, in particular, David Factor, who predictably
provided beautiful and informative drawings. I appreciate my long-time working relationship with
Oxford University Press, and they are peerless when it comes to academic work.
The interest in the acute neurosciences in practice is the unexpected. I have lived the subject
matter for several decades, and our neurocritical care group sees several hundred patients in ICUs
other than our own Neurosciences ICU each year. I hope the book I set out to write reflects that
experience. The diagnosis and management of neurologic complications in critical illness, in my view,
has always been one of the major pillars of neurocritical care.
March 2023
Eelco Wijdicks
PART I
CATEGORIES OF CONSULTS
BENEFITS OF A CONSULTATION
Teams working in intensive care units (ICUs) may presenting with a de novo neurological prob-
bring in a neurologist and for all kinds of reasons.1 lem related to their illness—questions . . . and
When called to action, most neurologists enter- issues concerning the effects of antiseizure and
ing an ICU are immediately confronted with the antiparkinson medication for prior diagnosed
complexity of critical illness. The modern ICU is illness are entirely different. These patients
a unique place, with patients presenting with an are seen in consultation for diagnosis and
array of different conditions and with consultants management—often expediently—but remain
having specific expertise in handling critical ill- under the care of intensivists and surgeons.
ness. Patients enter the ICU in a life-threatening The complications observed may be quite spe-
state with failing organ systems and become cific (or mundane), but intensivists may intui-
hypotensive, hypoxemic, hypercapnic, and tachy- tively feel uncomfortable in overseeing these
cardic; the initial resuscitation generally does not new neurologic conditions themselves. They
concentrate on neurologic manifestations. Most request not only assistance in identifying the
intensivists briefly check for pupil responses or neurologic disorder but also help in manage-
major asymmetries, but they accept an altered ment. This is particularly pertinent with recur-
level of consciousness as a common consequence rent seizures or progressive neurologic decline.
of an evolving critical illness. Some manifesta- Once the patient is seen, continuous attention
tions may not be considered atypical enough is necessary, which may involve prolonged bed-
for an urgent neurologic consult. This logically side care and, later, calls at night from nursing
implies that neurologists will see a selection of staff or attending intensivists and, ultimately,
neurologic manifestations in critical illness. direct management. Interpretation of electro-
ICU consultative neurology focuses on those encephalograms and neuroimaging is often
patients admitted to medical and surgical ICUs repeatedly required.2
3
4 Part I Criteria, Urgency, and Importance
More than in any place in the hospital, ICU consultation is summarized in Table 1.1 and
consultations involve questions about de-escalating shows common clinical neurologic problems
care. The attending team and family may consider facing the intensive care specialist and consult-
withdrawing intensive care or, at least, consider ing neurologist in everyday decisions.
a do-not-resuscitate status and thus need a neu-
rologist’s input. This involvement partly reflects
the high prevalence of neurologic catastrophes
in patients with a critical illness. Frequently, the CATEGORIES OF CONSULTS
clinical situation is clear, as in persistently coma-
tose survivors after prolonged cardiopulmonary We must assume that ICU consults are urgent
arrest and in elderly patients with polytrauma or emergent. The urgency is often determined
and severe traumatic brain injury; in other situ- by an inability to understand the full clinical pic-
ations, the degree of brain injury may be more ture and particularly when the initial presenta-
difficult to ascertain. Neurologists are asked tion is disturbing. Examples are ICU consults for
to participate in family conferences, and they acutely impaired consciousness, which require
can be helpful in clarifying the bigger picture. a quick but comprehensive assessment of the
Sometimes, the neurologic complication is a cause of coma and whether it can be immediately
defining moment, and little more can be done for reversed. Upon receiving a call to consult in the
the patient. Neurologists can be conclusive and ICU, we typically expect three clinical scenarios:
advise the managing ICU team against treating acute loss of consciousness, failure of patients
a patient in a futile situation. In other situations to awaken fully after recuperation from a major
the neurologic situation could be misjudged as surgical procedure, and occasionally, coma in a
irrecoverably poor while there is a possibility for developing but undiagnosed critical illness. We
another more favorable trajectory. This is not an are often consulted to evaluate and treat delirium,
uncommon scenario, and neurologists can shed and we now have a better sense of what this acute
more light on why they think that way. Another brain dysfunction could entail.3–6
fundamental rule of ICU consultation is to prog- Any consult in a critically ill neurologic
nosticate decisively when certain but to hold back patient must proceed through the steps out-
when information is incomplete or the clinical lined in Table 1.2. Any consult in a critically
situation is not fully understood. ill patient may lead to a diagnosis not initially
Critical illness increases the probability of considered by the managing team; in our expe-
a neurologic complication, and, according to rience, this occurs rather frequently.7 These
current best estimates and excluding perva- recognized neurologic disorders may all have
sive delirious states, approximately 10–20% of major consequences diagnostically, prognosti-
patients will develop some sort of neurologic cally, and therapeutically.
manifestation. The neurology of critical illness Consultations may have a varying degree of
is an important field that requires more pro- complexity and may involve management of
spective research. The rationale for neurologic major acute neurologic injury. Consultation
may evolve from a simple question, to being
physically present, to continuously managing
Table 1.1 The field of neurology of
critical illness
Table 1.2 Essentials of a neurology
Neurologic consultation in the ICU requires a consult in the intensive care unit
broad base of medical knowledge
Neurologic consultation provides diagnostic, Assess details on severity of critical illness
therapeutic, and prognostic advice Assess blood pressure and extent of blood pressure
Neurologic consultation often involves assessment support
of abnormalities of responsiveness or seizures Assess drug administration over 5–7 days
Neurologic consultation may detect an unsuspected Verify onset of symptoms with nursing staff
neurologic disorder Assess major confounders
Neurologic consultation in the ICU may change Assess for focal localizing sign
approach to the patient Assess for movements, twitching, new rigidity
Neurologic consultation involves end-of-life Assess for drugs strongly related to movement
decisions for patients disorders
1 Indications for a Neurologic Consult 5
Table 1.3 Reasons for a consult in the intensive care practices, it is often easier to call
intensive care unit a consultant rather than to ask for a formal con-
sult. Both parties often agree that some type of
Acutely comatose
Failure to awaken after resuscitation advice will pragmatically direct testing or treat-
Acute focal deficit ment. For the intensivist, there may be other
Acute agitation immediately pressing priorities in the complex
New seizure(s) care of the patient, and a new neurologic prob-
Acute repetitive movements lem is best solved quickly. Many of the neurology
Generalized weakness “curbsides” in the ICU are indeed simple phone
Abnormal neuroimaging calls to ask a simple question, but some ques-
Abnormal EEG tions should probably generate a formal consult.
Consultants should generally and deliberately
an acute injury to the brain or spine and, as avoid a practice of mostly taking phone calls for
such, may even involve palliation and end-of- curbsides, which are a set of quick questions that
life discussions (Table 1.3). pertain to critical illness. These include interpre-
There is a spectrum of close participation tation of a CT scan of the brain, a question about
with the consulting neurologist (Figure 1.1). electroencephalograph (EEG) interpretation, or
In some cases, a consult consists of picking up the need for EEG monitoring. Other common
the phone and asking an expert, and in many questions are how to manage neurologic medi-
cation such as antiepileptic drugs, assess the risk
of anticoagulation, or interpret specific neuro-
logic manifestations of acute neurologic disease.
It is often better to see the patient briefly and
then determine if a formal consult can be helpful.
The consulting neurologists will also have
to consider the following questions. How can
I best ask pointed questions? Am I able to
provide advice with limited information and
without having the opportunity to examine
the patient in detail? Am I confident enough
to dismiss or diagnose certain CT scan abnor-
malities? Does this clinical problem require a
close follow-up and thus a formal consultation?
Acute (STAT) consults in the ICU are the
most challenging in the hospital because (1)
decisions may have to be made in an evolving
situation; (2) the primary diagnosis may be
unclear and puzzling; (3) neurologic exami-
nation can be compromised when patients
are markedly swollen, jaundiced, immobile,
bruised, or have major operation sites or an
open chest; and (4) none of the neuroimaging
and electrophysiology results may be particu-
larly helpful. Any consulting neurologist will
ask him- or herself the following additional
questions: Are the neurologic findings com-
mensurate with the cause and degree of criti-
cal illness? Are the focal findings significant
or difficult to judge? How is neuroimaging or
electrophysiology best interpreted in the set-
ting of critical illness?2,8–10 Are there urgent
treatment options or treatment adjustments
that have not been considered? Will this neu-
Figure 1.1. Types of consultations. rologic manifestation set the patient back
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