1. Protocol for Weaning Intensive Therapies

Short summary: Criteria-driven de-escalation prevents rebound intracranial pressure (ICP) elevation, cerebral hypoperfusion, and shortens ICU stay.

A. Criteria for Initiating De-escalation

• Neurological stability: sustained Glasgow Coma Scale (GCS) plateau and stable imaging (no new bleed or hydrocephalus)
• ICP <20 mmHg and Cerebral Perfusion Pressure (CPP) >60 mmHg off escalating therapies
• Hemodynamic stability: Mean Arterial Pressure (MAP) ≥70 mmHg on minimal/no vasopressors

B. Sedation and Analgesia Weaning

• Use Richmond Agitation-Sedation Scale (RASS) and Critical-Care Pain Observation Tool (CPOT) to target light sedation (RASS –2 to 0)
• Reduce infusion rates by 10–20% every 4–8 hours; perform daily spontaneous awakening trials
• Monitor for agitation, pain, neurologic changes; taper benzodiazepines slowly to avoid withdrawal

C. Mechanical Ventilation Liberation

• Spontaneous Breathing Trial (SBT) eligibility: FiO₂ ≤0.4, PEEP ≤8 cm H₂O, stable MAP
• Wean with pressure-support or CPAP trials; assess cough/gag reflex and perform cuff-leak test

D. Hemodynamic Support Tapering

• Decrease vasopressors by 10–20% every 1–2 hours while keeping MAP ≥65 mmHg
• Target euvolemia; avoid prophylactic hypervolemia that may worsen cerebral edema

E. Intracranial Pressure Device Weaning

• Gradual External Ventricular Drain (EVD) clamping trials: raise drip chamber height or brief clamp periods
• Observe for ICP spikes >20 mmHg or new deficits; remove device after 24–48 hours of stable ICP

2. Conversion from Intravenous to Enteral Medications

Short summary: Transitioning to enteral therapy enables step-down care but requires attention to formulation, absorption, and monitoring.

A. Enteral Access and GI Function Assessment

• Confirm tube placement (radiograph or pH) and assess gastric residuals, bowel sounds
• Recognize delayed gastric emptying in neurocritical illness may impair absorption

B. Drug Formulation and Absorption Considerations

• Prefer liquid or crushable immediate-release tablets; avoid extended-release (ER)/enteric-coated forms via tube
• Separate feeds and drugs by 1–2 hours to optimize bioavailability

C. PK/PD Adjustments and Dosing Equivalence

• Adjust enteral doses for reduced bioavailability; use Therapeutic Drug Monitoring (TDM) for narrow-TI drugs (e.g., phenytoin, levetiracetam)
• Account for first-pass metabolism when converting high-extraction agents

D. Administration Techniques and Tube Maintenance

• Flush tube with 15–30 mL water before and after each medication; prevent occlusion with routine flushes
• Administer each drug separately; avoid mixing incompatible agents

E. Monitoring Efficacy and Safety

• Track key endpoints: blood pressure control, seizure frequency, pain scores
• Monitor for tube clogging, GI intolerance, and drug-feed interactions

3. Mitigating Post-ICU Syndrome (PICS)

Short summary: Early, multidimensional interventions reduce PICS incidence and improve long-term functional outcomes.

A. Identification of High-Risk Patients

• Prolonged sedation (>48–72 hours), CAM-ICU delirium positive, mechanical ventilation >72 hours
• Early signs of ICU-acquired weakness (MRC sum score <48)

B. ABCDEF Bundle Implementation

The ABCDEF bundle is a set of evidence-based practices to improve ICU patient outcomes:

• A: Assess, prevent, and manage pain.
• B: Both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs).
• C: Choice of analgesia and sedation (minimize benzodiazepines).
• D: Delirium: assess, prevent, and manage (e.g., using CAM-ICU).
• E: Early mobility and exercise, tailored to patient neurologic status.
• F: Family engagement and empowerment in care.

C. Adjunctive Interventions

• Optimize sleep hygiene: noise and light control, day-night orientation
• Engage Physical Therapy (PT)/Occupational Therapy (OT) early; refer for psychological support to address mood and Post-Traumatic Stress Disorder (PTSD) risk

4. Medication Reconciliation and Discharge Counseling

Short summary: Thorough medication review and structured education ensure continuity, reduce errors, and lower readmission risk.

A. Comprehensive Medication List Review

• Reconcile pre-ICU, ICU, and planned discharge medications; identify omissions, duplications, interactions
• Focus on high-risk drugs: antihypertensives, antiepileptics, antithrombotics

B. Standardized Reconciliation Processes

• Use Electronic Health Record (EHR)-based tools; involve pharmacist, nurse, and physician in handoff

C. Patient and Family Education

• Explain each medication’s purpose, dose, schedule; discuss side effects and warning signs
• Use teach-back method and provide written materials in lay language

D. Structured Handoff to Next Care Setting

• Provide concise written/verbal summary of hospital course, medication changes, and follow-up needs
• Coordinate outpatient appointments and specify duration of therapies (e.g., nimodipine 21 days)