Neurocritical Care Quiz

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Questions and Answers

What are the two primary objectives of therapeutic intervention in neurocritical care patients?

Identifying pertinent pathophysiologic and laboratory changes, and developing an evidence-based treatment strategy.

What is the primary goal of monitoring devices used in neurocritical care patients?

To develop and optimize treatment strategies.

What is the significance of a serum sodium level of 128 mmol/L in a neurocritical care patient?

It indicates hyponatremia, which may require therapeutic intervention.

What is the primary complication of acute aneurysmal subarachnoid hemorrhage (SAH) that requires close monitoring?

<p>Hyponatremia and other electrolyte imbalances.</p> Signup and view all the answers

What is the role of the pharmacist in neurocritical care?

<p>To develop and implement evidence-based treatment strategies.</p> Signup and view all the answers

What laboratory values are critical to monitor in neurocritical care patients?

<p>Serum sodium, among other electrolyte and biomarker levels.</p> Signup and view all the answers

What is the significance of hospital day 4 in a neurocritical care patient?

<p>It indicates the patient is in the acute phase of recovery and requires close monitoring.</p> Signup and view all the answers

What is the primary goal of therapeutic intervention in neurocritical care patients?

<p>To prevent further injury and optimize patient outcomes.</p> Signup and view all the answers

What is the recommended limit for sodium increase in the first 24 hours to avoid osmotic demyelination syndrome?

<p>No more than 12 mEq/L</p> Signup and view all the answers

What percentage of patients with subarachnoid hemorrhage (SAH) are prone to hypernatremia?

<p>Up to 22%</p> Signup and view all the answers

What is the role of monitoring devices in developing an evidence-based treatment strategy?

<p>They provide critical data to inform treatment decisions.</p> Signup and view all the answers

What is a potential complication of hypernatremia and hyperchloremia?

<p>Acute kidney injury</p> Signup and view all the answers

What is the primary laboratory test used to diagnose hypernatremia?

<p>Serum sodium</p> Signup and view all the answers

What is the primary characteristic of diabetes insipidus?

<p>Decreased secretion of ADH or vasopressin</p> Signup and view all the answers

What is the typical urinary output in diabetes insipidus?

<p>Voluminous (greater than 250 mL/hour), dilute</p> Signup and view all the answers

What is the primary goal of hypotonic solution therapy in hypernatremia treatment?

<p>Free-water replacement</p> Signup and view all the answers

What is the role of vasopressin analogs in hypernatremia treatment?

<p>Supplementation of ADH to normal functional concentrations</p> Signup and view all the answers

What is the endpoint for titrating vasopressin analog therapy in hypernatremia treatment?

<p>Normalized urinary output, serum sodium, and urine specific gravity</p> Signup and view all the answers

What is the main difference in the success of ketogenic diet in pediatric patients versus adult patients?

<p>Difficulty achieving ketosis in adults</p> Signup and view all the answers

What is the proposed mechanism of action of ketogenic diet in reducing seizures?

<p>Increase sequestration of glutamate and decrease reactive oxygen species</p> Signup and view all the answers

What is the typical time frame for benefits to occur with ketogenic diet?

<p>Within 1-3 months</p> Signup and view all the answers

What is the required ratio of fat to carbohydrate plus protein in ketogenic diet?

<p>4:1 or 3:1 ratio</p> Signup and view all the answers

What is the purpose of continuous EEG monitoring in status epilepticus and RSE?

<p>Necessary for status epilepticus and RSE</p> Signup and view all the answers

Why is it important to proactively monitor serum concentrations of certain agents?

<p>To ensure adequate concentrations and mitigate the risk of toxicity</p> Signup and view all the answers

What is the purpose of vagus nerve stimulation in nonpharmacologic therapies?

<p>As a nonpharmacologic therapy for seizures</p> Signup and view all the answers

What is the role of hypothermia in nonpharmacologic therapies?

<p>As a nonpharmacologic therapy for seizures</p> Signup and view all the answers

What is the significance of surgical management in nonpharmacologic therapies?

<p>As a last resort option when medical therapy fails</p> Signup and view all the answers

What is the primary trigger for muscle rigidity in patients with paroxysmal sympathetic hyperactivity (PSH)?

<p>Pain</p> Signup and view all the answers

What is thought to be the primary cause of paroxysmal sympathetic hyperactivity (PSH) after brain injury?

<p>Somatosympathetic activation and heightened activity of brain stem</p> Signup and view all the answers

What is the name of the tool used to determine the possibility of paroxysmal sympathetic hyperactivity (PSH) at a specific time?

<p>PSH Assessment Measure</p> Signup and view all the answers

What is the primary function of baclofen IT in the treatment of paroxysmal sympathetic hyperactivity (PSH)?

<p>Preventive therapy</p> Signup and view all the answers

What is the dose range of dexmedetomidine IV used as an abortive therapy for paroxysmal sympathetic hyperactivity (PSH)?

<p>0.2-1.5 mcg/kg/hr</p> Signup and view all the answers

What is the primary mechanism of bromocriptine in the treatment of paroxysmal sympathetic hyperactivity (PSH)?

<p>Preventive therapy</p> Signup and view all the answers

What is the dose range of gabapentin used in the treatment of paroxysmal sympathetic hyperactivity (PSH)?

<p>100-300 mg three times daily up to 4800 mg/day</p> Signup and view all the answers

What is the primary mechanism of propranolol in the treatment of paroxysmal sympathetic hyperactivity (PSH)?

<p>Preventive therapy</p> Signup and view all the answers

What is the primary goal of using dantrolene in the treatment of paroxysmal sympathetic hyperactivity (PSH)?

<p>Abortive therapy</p> Signup and view all the answers

What is the approximate osmolality of Gentamicin when administered intraventricularly?

<p>293 mOsm/kg</p> Signup and view all the answers

What is the common adverse effect of intraventricular administration of Amikacin?

<p>Seizures</p> Signup and view all the answers

What is the daily dose of Vancomycin administered intraventricularly in adults?

<p>10-20 mg</p> Signup and view all the answers

What is the volume of sterile water for injection used to administer Amphotericin B deoxycholate intraventricularly?

<p>3 mL</p> Signup and view all the answers

What is the approximate osmolality of Polymyxin B when administered intraventricularly?

<p>10 mOsm/kg</p> Signup and view all the answers

What is the common adverse effect of intraventricular administration of Colistimethate?

<p>Meningeal inflammation</p> Signup and view all the answers

What is the daily dose of Daptomycin administered intraventricularly in adults?

<p>5 mg</p> Signup and view all the answers

What is the common adverse effect of intraventricular administration of Tobramycin?

<p>Seizures</p> Signup and view all the answers

What is the volume of normal saline used to administer Gentamicin intraventricularly?

<p>1 mL</p> Signup and view all the answers

Flashcards

Neurocritical Care

Therapeutic intervention for acute pathophysiologic and laboratory changes after neurologic injuries.

Hyponatremia

Low serum sodium levels (< 128 mmol/L) after neurologic injuries. Requires controlled correction.

Hyponatremia Correction Limit

Limit serum sodium correction to 12 mEq/L in the first 24 hours or <18 mEq/L in 48 hours.

Hypernatremia

High serum sodium levels (> 150 mmol/L), common after SAH and TBI.

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Hypernatremia & Hyperchloremia

Associated with increased risk of acute kidney injury.

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Hypernatremia Diagnosis

Serum sodium, urine sodium, urine osmolality, urine specific gravity, and urine volume.

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Hypotonic Solutions

Dextrose 5% in water or 0.45% sodium chloride to correct hypernatremia.

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Vasopressin Analogs

Desmopressin to supplement ADH and normalize urinary output and serum sodium.

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Continuous EEG Monitoring

Necessary for status epilepticus and RSE to monitor brain activity.

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Drug Level Monitoring

Monitoring serum concentrations to ensure efficacy and avoid toxicity.

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Intraventricular Antimicrobials

Vancomycin, gentamicin, polymyxin B. Used for severe infections.

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Paroxysmal Sympathetic Hyperactivity (PSH)

Episodic sympathetic nervous system surges triggered by various stimuli.

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PSH Pathophysiology

Somatosympathetic activation and brain stem excitation after injury.

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PSH Assessment Measure

Tool to assess the likelihood of PSH, including the Diagnosis Likelihood Tool and Clinical Feature Scale.

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PSH Preventive Therapies

Baclofen IT, clonidine, gabapentin, and propranolol to prevent PSH.

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Paroxysmal Sympathetic Hyperactivity(PSH) Abortive Therapies

Dantrolene, dexmedetomidine, diazepam, fentanyl and morphine to stop PSH episodes.

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Study Notes

Neurocritical Care

  • Neurocritical care patients require therapeutic intervention for acutely occurring pathophysiologic and laboratory changes after neurologic injuries.
  • Monitoring devices are used to develop and optimize treatment strategies.

Hyponatremia

  • Hyponatremia (serum sodium < 128 mmol/L) can occur after neurologic injuries and requires careful correction to avoid osmotic demyelination syndrome.
  • Serum sodium correction should be limited to 12 mEq/L in the first 24 hours or less than 18 mEq/L in the first 48 hours.

Hypernatremia

  • Hypernatremia (serum sodium > 150 mmol/L) is common in patients with neurologic injury, particularly in SAH (up to 22%) and TBI (up to 21%).
  • Hypernatremia and hyperchloremia are associated with an increased risk of acute kidney injury.
  • Diagnosis involves laboratory tests, including serum sodium, urine sodium, urine osmolality, urine specific gravity, and urine volume.

Treatment of Hypernatremia

  • Hypotonic solutions for free-water replacement, such as dextrose 5% in water or 0.45% sodium chloride, are used to correct hypernatremia.
  • Vasopressin analogs, like desmopressin, can be used to supplement ADH and normalize urinary output and serum sodium.

Monitoring

  • Continuous EEG monitoring is necessary for status epilepticus and RSE.
  • Proactive monitoring of serum concentrations is essential for agents like phenytoin and valproic acid to ensure adequate concentrations and mitigate toxicity risk.

Intraventricular Administration of Antimicrobials

  • Various antimicrobials, such as vancomycin, gentamicin, tobramycin, amikacin, polymyxin B, colistimethate, and amphotericin B, can be administered intraventricularly.
  • Each antimicrobial has a specific daily dose and osmolality.

Paroxysmal Sympathetic Hyperactivity (PSH)

  • PSH is characterized by episodic increases in sympathetic nervous system activity, often triggered by pain, bladder distension, turning, tracheal suctioning, or unprovoked events.
  • The pathophysiology of PSH is largely unknown but thought to be caused by somatosympathetic activation and heightened brain stem activity after brain injury.
  • The PSH Assessment Measure is a tool used to determine the possibility of PSH at a specific time, consisting of the Diagnosis Likelihood Tool and Clinical Feature Scale.

Preventive and Abortive Therapies for Paroxysmal Sympathetic Hyperactivity

  • Preventive therapies include baclofen IT, bromocriptine, clonidine, gabapentin, and propranolol.
  • Abortive therapies include baclofen IT, dantrolene, dexmedetomidine, diazepam, fentanyl, morphine, and propranolol.

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