I. De-escalation of Intensive Therapies

As neurological stability is achieved, gradual weaning of vasopressors and ventilatory support minimizes ICU-related morbidity and accelerates rehabilitation.

A. Hemodynamic Support Weaning

Indications:

• Neurological improvement with stable MAP target (e.g., ≥65 mmHg or individualized goal)
• End-organ perfusion adequate (urine output >0.5 mL/kg/h, down-trending lactate)

Titration Protocol:

1. Reduce vasopressor dose by 10–20% every 30–60 minutes
2. Monitor for MAP < target; revert to prior dose if hypotension recurs
3. Avoid abrupt cessation to prevent rebound hypotension

Monitoring:

• Continuous BP (invasive or noninvasive)
• Mental status, urine output, serum lactate clearance

B. Ventilator Liberation

Early assessment and weaning reduce ventilator-associated complications and promote mobilization.

Readiness Criteria:

• Rapid Shallow Breathing Index (RSBI) <105 breaths/min/L
• Maximal inspiratory pressure (P0.1) <3.5 cm H₂O
• Glasgow Coma Scale (GCS) ≥8 with ability to follow commands

Spontaneous Breathing Trial (SBT):

• 30–120 min on T-piece or minimal pressure support (PS)
• Watch for tachypnea, SpO₂ <90%, tachycardia, hypertension
• If tolerated, coordinate extubation with multidisciplinary team

Sedation Interruption & Delirium Prevention:

• Daily sedation vacation
• Prefer dexmedetomidine or propofol over benzodiazepines
• Promote sleep hygiene, reorientation, early mobilization

II. Conversion from IV to Enteral Medications

Transition to enteral therapy supports discharge planning, lowers infection risk, and eases resource utilization.

A. Assess GI Function & Access

• Confirm bowel sounds, absence of ileus, tolerance of trophic feeds
• Verify secure NG or PEG tube placement in dysphagic patients

B. Formulation & Tube Compatibility

• Use liquids or crushable tablets; avoid extended-release (ER)/enteric-coated (EC) and sublingual forms unless validated
• Flush tube with 15–30 mL water before/after each drug
• Separate administration from continuous feeds when interactions known (e.g., phenytoin)

C. Dosing Equivalence & Absorption

• Warfarin: may crush tablet; monitor INR closely
• Phenytoin: reduced bioavailability with feeds; hold feeds 1–2 h pre/post dose
• DOACs: apixaban, rivaroxaban tablets can be crushed; avoid enteral nutrition for 2 h post-dose

D. Monitoring Effect & Adverse Events

• Track clinical endpoints (BP, platelet inhibition, glucose control)
• Check levels or anti-Xa/INR where applicable

III. Prevention of Post-ICU Syndrome (PICS)

PICS encompasses physical, cognitive, and psychiatric sequelae; proactive, multidisciplinary care mitigates risks.

A. Risk Stratification

Factors increasing PICS risk include:

• Prolonged sedation (>48 h)
• Advanced age
• Sepsis
• Multi-organ failure
• Baseline cognitive impairment

B. ABCDEF Bundle

• A: Assess & manage pain (use Behavioral Pain Scale, multimodal analgesia)
• B: Both Spontaneous Awakening and Breathing Trials daily
• C: Choice of sedation—favor dexmedetomidine/propofol; minimize benzodiazepines
• D: Delirium monitoring (CAM-ICU) and management of reversible causes
• E: Early mobility—passive/active exercises as tolerated
• F: Family engagement in reorientation and care planning

IV. Medication Reconciliation and Discharge Counseling

Meticulous reconciliation and patient education ensure adherence to secondary prevention and reduce readmissions.

A. Comprehensive Medication Review

Align pre-admission, ICU, and discharge lists; discontinue duplicates/unnecessary agents.

B. Secondary Prevention Pharmacotherapy

1. Antithrombotic Agents
   • Aspirin 81–325 mg PO daily (start 24–48 h post-stroke)
   • Clopidogrel 75 mg PO daily; dual therapy for 21 days in minor stroke/TIA
   • DOACs for Afib: apixaban 5 mg BID (adjust renal), rivaroxaban 20 mg daily; initiate 4–14 days post-event
2. High-Intensity Statins
   • Atorvastatin 40–80 mg or rosuvastatin 20–40 mg PO daily
3. Antihypertensives
   • Resume or initiate ACEI/ARB, thiazide, or CCB in stable patients with BP >140/90 mmHg
4. Glycemic Control
   • Transition from IV insulin to basal/bolus or oral agents; target 140–180 mg/dL

C. Patient & Caregiver Education

Teach drug indications, dosing, side effects; use teach-back and written materials.

D. Coordination & Follow-Up

Communicate changes to PCP/neurology; schedule outpatient visits within 1–2 weeks.

V. Pharmacotherapy Considerations

A. Vasopressors

B. Sedatives & Analgesics

C. Antiplatelet Agents

D. Anticoagulants

E. Statins

F. Antihypertensives

G. Antidiabetic Agents

VI. Algorithms and Checklists

A. De-escalation Algorithm for Vasopressor Taper

B. IV-to-Enteral Conversion Checklist

• GI Assessment:
  • Bowel sounds present?
  • No signs of ileus (distension, vomiting)?
  • Trophic feeds tolerated (if applicable)?
  • Enteral access (NG/PEG) secure and patent?
• Formulation Review:
  • Is liquid formulation available?
  • Is tablet crushable (not ER, EC, SL unless validated)?
  • Any known interactions with enteral feeds?
• Dosing Considerations:
  • Equivalent enteral dose calculated?
  • Specific instructions for administration with feeds (e.g., hold feeds for phenytoin, warfarin)?
  • Need for dose adjustment based on bioavailability?
• Monitoring Plan:
  • Clinical endpoints for efficacy defined?
  • Monitoring for adverse effects established?
  • Plan for therapeutic drug monitoring (e.g., INR, anti-Xa, drug levels) if applicable?
  • Re-evaluation of efficacy scheduled (e.g., 24-48h post-conversion)?

C. PICS Risk Tool & ABCDEF Bundle Implementation Checklist

PICS Risk Assessment:

• Patient age > 65?
• Baseline cognitive impairment (e.g., dementia)?
• Duration of mechanical ventilation > 48 hours?
• Duration of deep sedation > 48 hours?
• Presence of sepsis or septic shock?
• Presence of ARDS?
• Occurrence of delirium during ICU stay?
• Multi-organ failure?

(Higher number of “yes” answers indicates increased PICS risk)

ABCDEF Bundle Daily Checklist:

• A (Assess, Prevent, and Manage Pain): Pain assessed regularly? Multimodal analgesia used?
• B (Both Spontaneous Awakening Trials and Spontaneous Breathing Trials): SAT performed? SBT performed if SAT successful and patient meets criteria?
• C (Choice of Analgesia and Sedation): Sedation targeted and light? Benzodiazepines minimized? Non-pharmacological anxiolysis attempted?
• D (Delirium: Assess, Prevent, and Manage): Delirium screening performed (e.g., CAM-ICU)? Reversible causes addressed?
• E (Early Mobility and Exercise): Mobility level assessed? Early mobilization activities implemented as tolerated?
• F (Family Engagement and Empowerment): Family updated regularly? Involved in care and reorientation?

VII. Pearls and Pitfalls

General Pearls:

• Taper vasopressors slowly; reassess volume status with each step to avoid hypotension.
• Coordinate sedation holds with Spontaneous Breathing Trials (SBTs) to optimize ventilator liberation and reduce ventilation duration.
• When converting IV to enteral, crush only formulations confirmed to be safe for crushing; monitor closely for changes in absorption and efficacy.
• Implement the full ABCDEF bundle consistently for the best outcomes in preventing PICS and improving patient recovery.
• Engage in multidisciplinary discharge planning involving pharmacy, nursing, physical/occupational therapy, and outpatient care teams to ensure a smooth transition.

Common Pitfalls:

• Abrupt cessation of vasopressors leading to rebound hypotension.
• Failure to assess and optimize volume status before vasopressor weaning.
• Prolonging mechanical ventilation due to uncoordinated weaning efforts or excessive sedation.
• Crushing extended-release or enteric-coated medications, leading to dose dumping or inactivation.
• Overlooking potential drug-nutrient interactions with enteral feeding (e.g., phenytoin, warfarin).
• Inconsistent application of the ABCDEF bundle components, diminishing its overall benefit.
• Inadequate patient and caregiver education at discharge, leading to medication errors or non-adherence.
• Poor communication between inpatient and outpatient providers during care transitions.