Nursing Considerations for 3 Neuro ICU Meds

This is some quick info on a few very common meds you run into in the neurointensive care unit. However, please always follow your hospital’s policies and procedures.  This is for informational purposes only and focuses on nursing considerations.. not going in-depth on the drug.

Nursing Considerations for 4 Neuro ICU Meds

Propofol or Diprivan

We love this med with all of our neuro hearts. It is given IV as sedation for patients with increased ICP or for patients with seizures. A continuous propofol infusion is one of the options for someone who is having continuous seizures (status epileptics). It is NOT a pain medication. To get this med, they must be intubated or are the process of being intubated

Why we love it: it works quickly and wears off quickly, allowing us to get a quick neuro assessment. You can detect changes quickly, which is essential.

Interesting fact: they were attempting to use it for executions, but the manufacturer refused to supply it for that need

Nursing considerations:

• You must frequently change the tubing (usually every 12 hours)
• You must pause it to complete a neuro assessment (usually only a few minutes needed to get the assessment)
• Work with your dietician to ensure your enteral feeding formula is appropriate. If you are weaning it or increasing it significantly, they may need to change it. Lots of calories!
• Weight-based, make sure an accurate weight is in the chart
• Watch for hypotension and oversedation
• If a patient is getting this for status, make sure you know if they want you to pause it for assessments (most likely not) – make sure there’s an order
• Always flush the line – never pause and leave for a while.. it will clot your line!
• Titrate to clinical response – don’t just coast. Back off if you need to, increase if you need to.

Mannitol

Mannitol is an osmotic diuretic given to decrease ICP. It doesn’t cross BBB. You increase the plasma osmolality to pull fluid off the brain and out of the body. It increases the intravascular volume (pulls fluid into the vessels) and therefore cardiac output.

Interesting fact: it’s actually sugar alcohol also used in the food industry. It’s a naturally occurring substance found in marine algae and mushrooms.

Nursing considerations:

• Make sure your serial labs are ordered: q6hr BMPs most likely
• Holding parameters! Make sure you have an order or know when the MD wants to be notified
  • Serum sodium: typically around greater than 160 (normal = 135-145)
    • You want to drive the sodium up to remove fluid, but not TOO much
  • Serum osmolality: typically greater than 320 (normal = 275-295)
• Can cause renal failure because of intra-renal vasoconstriction and intravascular volume depletion
• Increases CO so watch patients with CHF
• Administer through a filter set or draw up with filter needle
• If the vial is crystalized, send back to the pharmacy to re-warm

Hypertonic Saline (3%)

Used to treat hyponatremia and cerebral edema.

Interesting fact: hyponatremia is the most common electrolyte imbalance

Basically it is saltwater. Some docs will use this, some will use mannitol for increased cerebral edema. Evidence is not super awesome about if one is much better than the other.

Nursing considerations

• Probably will need a line
  • Use judgment.. mild hyponatremia with only one dose.. talk with the doc
• Watch for a rapid increase in sodium. Shouldn’t rise more than 8-12 mmol/L. in 24 hours. Otherwise, central pontine myelinolysis can occur.
  • Severe damage of the myelin sheaths of the nerve cells in the brainstem. A BIG deal. They can become paralyzed and die. The extent of damage depends on how many axons get damaged.
• Watch for fluid overload signs/symptoms
• Serial sodium labs ordered, q6hrs

Be sure to check out Week 1: Neuro Assessment and Week 2: ICU Time Management.