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1 Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 2013; 382: 311–25. 2 Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high-risk short-term central venous catheters. Am J Infect Control 2010; 38: 149–53. 3 Fearonce G, Faraklas I, Saffl e JR, Cochran A. Peripherally inserted central venous catheters and central venous catheters in burn patients: a comparative review. J Burn Care Res 2010; 31: 31–35. 4 Bonizzoli M, Batacchi S, Cianchi G, et al. Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients. Intensive Care Med 2011; 37: 284–89. 5 Wilson TJ, Stetler WR Jr, Fletcher JJ. Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit. Clin Neurol Neurosurg 2013; 115: 879–82. Risks associated with peripherally inserted central catheters

Analgesia and sedation has been widely used in intensive care units where iatrogenic discomfort often complicates patient management. In neurological patients maximal comfort without diminishing patient responsiveness is desirable. In these patients successful management of sedation and analgesia incorporates a patient based approach that includes detection and management of predisposing and causative factors, including delirium, monitoring using sedation scales, proper medication selection, emphasis on analgesia based drugs and incorporation of protocols or algorithms. So, to optimize care clinician should be familiar with the pharmacokinetic and pharmacodynamic variables that can affect the safety and efficacy of analgesics and sedatives.

Introduction Patients being transferred from outside facilities are often excluded from intra-arterial therapy due to delays in transfer, evaluation and imaging. The Marcus Stroke and Neuroscience Center at Grady Memorial Hospital is a unique prototype for stroke reperfusion therapies in the future. The CT scanner and biplane angiography suite are housed in the intensive care unit. Patients being transferred from outside facilities are brought directly to the intensive care unit where imaging and reperfusion therapies can be performed rapidly. We sought to determine if there were time differences in patients evaluated in our emergency room compared to transfers from outside facilities. Materials and Methods A prospective database of consecutive intra-arterial therapy at the Marcus Stroke Center was reviewed. Patients treated from October 2010–January 2012 were reviewed. We assessed demographic, radiographic and clinical variables in addition to if patients were transferred from outside facilities. We assessed times from CT to groin puncture for patients evaluated in our emergency room and compared them to patients transferred from outside hospitals. Patients with anterior circulation strokes Results A total of 165 patients with a mean age of 66±13 years with a mean NIHSS of 19±5. A total of 109 (65%) patients were transferred from outside hospitals. Patients from outside facilities were significantly less likely to have hypertension (61% vs 81%, p Conclusions The presence of a biplane angiography suite in the neurological intensive care unit may help to reduce times to reperfusion in patients being transferred from an outside facility. Developing systems of care to reduce times to reperfusion will require assessment of systems of care that focus on available resources. Efficient systems to treat patients from outside hospitals may help to improve the ability to offer treatments to more patients. Competing interests R Nogueira: EV3, Rapid Medical, Concentric, CoAxia. B Glenn: None. S Belagaje: None. A Anderson: None. M Frankel: None. F Nahab: None. R Gupta: Concentric Medical, CoAxia, Rapid Medical, Codman Corp.

Alcoholism is a major public health problem causing various neurological diseases (Table 1), the most frequent and most important of them being delirium tremens (DT). In our experience, more than 20% of 1720 patients admitted to the neurological intensive care unit (ICU) during a 7-year period were alcohol dependent. Of these, 78 admissions (4.5%) were because of delirium tremens. Three distinct scenarios associated with alcoholism are frequently encountered in the neurological ICU: 1. A known alcoholic is admitted because of an illness not directly caused by alcohol; prophylactic treatment to avoid DT is required. 2. An alcoholic is admitted with clear signs of alcohol withdrawal (impending delirium tremens); development of full-blown delirium tremens must be prevented. 3. A patient is admitted specifically because of active delirium tremens or has developed DT while being treated for another disease.

Study of a number of routine nursing care activities has suggested a relationship between activities and intracranial pressure (ICP). The purpose of this study was to focus on the relationship between nursing care activities and variations in ICP. A case study method was used to study ICP in five brain-injured patients with a Glasgow Coma Scale (GCS) score of 4 or more. Each patient's condition warranted continuous ICP monitoring with a fiberoptic catheter in a neurological intensive care unit (ICU) of two hospitals in the Upper Midwest. Selected nursing measures--turning, suctioning and bathing--were recorded on the data collection tool as they occurred. Suctioning and turning were noted to be associated with an increase in ICP; however, a sustained increase in ICP was not observed. During the bathing procedures only two baths elicited an ICP greater than 20 mm Hg. All other bathing procedures elicited minimal increases in ICP. These findings further support the need for nurses to be aware of the patient's ICP prior to turning and suctioning.

The hospital soundscape is populated with a number of noise sources that may be detrimental to the occupational environment, including medical equipment, alarms, portable carts, activities, paging/communication, and ventilation systems. This paper describes a study in which sound measurements were made over five days and occupant evaluations were conducted in a neurological intensive care unit (ICU). Forty‐seven nursing staff members completed questionnaires regarding general reactions to the ICU environment as well as perceived psychological and physiological reactions to the noise. Acoustical characteristics such as level distributions, restorative periods, and spectral content were explored in addition to overall equivalent, minimum, maximum, and peak sound pressure levels. Results showed the mean length of restorative periods (LAeq below 50 dB for more than 5 min) was 9 and 13 minutes for day and night, respectively. Sound measurements near the patients showed LAeq values of 53 ‐ 58 dB, and dosimeters...

Primary and secondary carnitine deficiency syndromes are characterized by myopathy, encephalopathy and hepatopathy. We measured plasma levels of free and esterified carnitine in 20 patients from our neurological intensive care unit who required intravenous or tube feeding. After 2–3 weeks 19 patients showed a 30%–60% decrease in the levels of serum free and total carnitine. As soon as oral feeding was recommenced, carnitine levels quickly returned to normal. These data suggest the need for new carnitine-enriched feeding fluids, which are presently under investigation.

Patient survival in neurological intensive care units (NICUs) may be obvious; however, there is currently little evidence regarding the longer term outcome of these patients. In this study the 1-year survival of NICU patients has been defined.

Most clinical trials on the topic of extubation have involved patients outside the neurological intensive care unit. As a result, in this area clinicians are left with little evidence on which to base their decision making. Although tracheostomies are increasingly common procedures, they are not without complications and costs, and hence a decision to perform them should not be taken lightly. In this issue of Critical Care two groups debate the merits of tracheostomy before extubation in a patient with neurological impairment. What becomes very clear is the need for more high quality data for this common clinical problem.

Intracranial pressure (ICP) in patients (Einhaupl et al. 1986) as well as in normal subjects (Gaab 1980, Dirnagel et al. 1988) often shows rhythmic fluctuations with a frequency of 0.5–2 per min, the so called B-waves (Lundberg 1960).

Publisher Summary This chapter describes the use of evoked responses in a neurological intensive care unit (ICU). It discusses the clinical significance of both the auditory brainstem evoked response and the spinal cord evoked response in the monitoring of neurologically compromised ICU patients. The chapter also describes the recording methods. The recording of a stimulus-related response is dependent upon two facts. First, the sensory pathways are well defined and once a neuronal response is initiated, the conduction of the impulse along the pathway produces a well-defined series of potential changes. Second, the background electrical activity recorded from the brain is random. The recorded electrical activity evoked by the stimulus may be 1/20 or less than that of the resting or background activity. The technique involves adding or summing together the scalp-recorded electrical activity after each stimulus is presented to the patient. The stimulus may be in the form of a flash of light, a small shock over one of the peripheral nerves, or a series of clicks presented to the ear.