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Alabsi H, Emerson K, Lin DJ. Neurorecovery after Critical COVID-19 Illness. Semin Neurol 2023. [PMID: 37168008 DOI: 10.1055/s-0043-1768714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.
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Affiliation(s)
- Haitham Alabsi
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristi Emerson
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Lin
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Dimitriadis K, Schmidbauer M, Bösel J. [Neurointensive care medicine and COVID-19]. DER NERVENARZT 2023; 94:84-92. [PMID: 36520214 PMCID: PMC9751507 DOI: 10.1007/s00115-022-01417-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/16/2022]
Abstract
This review article summarizes important findings on the interfaces between the coronavirus disease 2019 (COVID-19) pandemic and neurology with an emphasis of the implications for neurointensive care medicine. More specifically, the prevalence, pathomechanisms and impact of neurological manifestations are reported. The most common neurological manifestations of critically ill COVID-19 patients are cerebrovascular complications, encephalopathies and intensive care unit-acquired weakness (ICUAW). A relevant direct pathophysiological effect by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) itself has not yet been established with certainty. In fact, indirect systemic inflammatory processes triggered by the viral infection and side effects of intensive care treatment are much more likely to cause the reported sequelae. The impact of the pandemic on patients with neurological disorders and neurointensive care medicine is far-reaching but not yet sufficiently studied.
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Affiliation(s)
- Konstantinos Dimitriadis
- Neurologische Klinik, Universitätsklinikum LMU München, München, Deutschland.
- Institut für Schlaganfall- und Demenzforschung (ISD), LMU München, Feodor-Lynen-Str. 17, 81377, München, Deutschland.
| | - Moritz Schmidbauer
- Neurologische Klinik, Universitätsklinikum LMU München, München, Deutschland
| | - Julian Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Dimitriadis K, Meis J, Neugebauer H, Barlinn K, Neumann B, Gahn G, Lochner P, Knier B, Lindemann S, Sühs KW, Szabo K, Pfefferkorn T, Schirotzek I, Freilinger T, Burc B, Günther A, Wittstock M, Schramm P, Reimann G, Godau J, Nagy G, Koenig FB, Essig F, Klinker H, Hartmann C, Schmidbauer ML, Steinberg T, Lefterova L, Klose C, Bösel J. Neurologic manifestations of COVID-19 in critically ill patients: results of the prospective multicenter registry PANDEMIC. Crit Care 2022; 26:217. [PMID: 35842675 PMCID: PMC9287707 DOI: 10.1186/s13054-022-04080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/29/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Neurologic manifestations are increasingly reported in patients with coronavirus disease 2019 (COVID-19). Yet, data on prevalence, predictors and relevance for outcome of neurological manifestations in patients requiring intensive care are scarce. We aimed to characterize prevalence, risk factors and impact on outcome of neurologic manifestations in critically ill COVID-19 patients. METHODS In the prospective, multicenter, observational registry study PANDEMIC (Pooled Analysis of Neurologic DisordErs Manifesting in Intensive care of COVID-19), we enrolled COVID-19 patients with neurologic manifestations admitted to 19 German intensive care units (ICU) between April 2020 and September 2021. We performed descriptive and explorative statistical analyses. Multivariable models were used to investigate factors associated with disorder categories and their underlying diagnoses as well as to identify predictors of outcome. RESULTS Of the 392 patients included in the analysis, 70.7% (277/392) were male and the mean age was 65.3 (SD ± 3.1) years. During the study period, a total of 2681 patients with COVID-19 were treated at the ICUs of 15 participating centers. New neurologic disorders were identified in 350 patients, reported by these centers, suggesting a prevalence of COVID-19-associated neurologic disorders of 12.7% among COVID-19 ICU patients. Encephalopathy (46.2%; 181/392), cerebrovascular (41.0%; 161/392) and neuromuscular disorders (20.4%; 80/392) were the most frequent categories identified. Out of 35 cerebrospinal fluid analyses with reverse transcriptase PCR for SARS-COV-2, only 3 were positive. In-hospital mortality was 36.0% (140/389), and functional outcome (mRS 3 to 5) of surviving patients was poor at hospital discharge in 70.9% (161/227). Intracerebral hemorrhage (OR 6.2, 95% CI 2.5-14.9, p < 0.001) and acute ischemic stroke (OR 3.9, 95% CI 1.9-8.2, p < 0.001) were the strongest predictors of poor outcome among the included patients. CONCLUSIONS Based on this well-characterized COVID-19 ICU cohort, that comprised 12.7% of all severe ill COVID-19 patients, neurologic manifestations increase mortality and morbidity. Since no reliable evidence of direct viral affection of the nervous system by COVID-19 could be found, these neurologic manifestations may for a great part be indirect para- or postinfectious sequelae of the infection or severe critical illness. Neurologic ICU complications should be actively searched for and treated.
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Affiliation(s)
- Konstantinos Dimitriadis
- Department of Neurology, University Hospital LMU Munich, Munich, Germany.
- Institute for Stroke and Dementia Research (ISD), LMU Munich, Munich, Germany.
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
| | - Georg Gahn
- Department of Neurology, Klinikum Karlsruhe, Karlsruhe, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Benjamin Knier
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim and Mannheim Center for Translational Neurosciences (MCTN), Heidelberg University, Mannheim, Germany
| | | | - Ingo Schirotzek
- Department of Neurology, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Bassa Burc
- Department of Neurology, Krankenhaus Nordwest, Frankfurt, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Patrick Schramm
- Department of Neurology, Universitätätsklinikum Giessen und Marburg, Standort Giessen, Justus-Liebig-University, Giessen, Germany
| | - Gernot Reimann
- Department of Neurology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Jana Godau
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Gabor Nagy
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | | | - Fabian Essig
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Hartwig Klinker
- Department of Internal Medicine II, Division of Infectious Diseases, University Hospital Würzburg, Würzburg, Germany
| | - Christian Hartmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Tim Steinberg
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Regensburg, Germany
| | - Lora Lefterova
- Department of Neurology, Klinikum Karlsruhe, Karlsruhe, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, Klinikum Kassel, Kassel, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Förster M, Weyers V, Küry P, Barnett M, Hartung HP, Kremer D. Neurological manifestations of severe acute respiratory syndrome coronavirus 2-a controversy 'gone viral'. Brain Commun 2020; 2:fcaa149. [PMID: 33210085 PMCID: PMC7543269 DOI: 10.1093/braincomms/fcaa149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 first appeared in December 2019 in Wuhan, China, and developed into a worldwide pandemic within the following 3 months causing severe bilateral pneumonia (coronavirus disease 2019) with in part fatal outcomes. After first experiences and tentative strategies to face this new disease, several cases were published describing severe acute respiratory syndrome coronavirus 2 infection related to the onset of neurological complaints and diseases such as, for instance, anosmia, stroke or meningoencephalitis. Of note, there is still a controversy about whether or not there is a causative relation between severe acute respiratory syndrome coronavirus 2 and these neurological conditions. Other concerns, however, seem to be relevant as well. This includes not only the reluctance of patients with acute neurological complaints to report to the emergency department for fear of contracting severe acute respiratory syndrome coronavirus 2 but also the ethical and practical implications for neurology patients in everyday clinical routine. This paper aims to provide an overview of the currently available evidence for the occurrence of severe acute respiratory syndrome coronavirus 2 in the central and peripheral nervous system and the neurological diseases potentially involving this virus.
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Affiliation(s)
- Moritz Förster
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
| | - Vivien Weyers
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
| | - Michael Barnett
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
- Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
- Center of Neurology and Neuropsychiatry, LVR Klinikum, Medical Faculty, Heinrich-Heine-University, 40629 Düsseldorf, Germany
| | - David Kremer
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, 40225 Düsseldorf, Germany
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Ajzenberg H, Newman P, Harris GA, Cranston M, Boyd JG. A "Neurological Emergency Trolley" reduces turnaround time for high-risk medications in a general intensive care unit. Intensive Crit Care Nurs 2017; 44:40-44. [PMID: 29029947 DOI: 10.1016/j.iccn.2017.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications. RESEARCH METHODOLOGY/DESIGN In this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses. SETTING 33-bed general medical-surgical intensive care unit in an academic teaching hospital. MAIN OUTCOME MEASURES Time to medication administration. RESULTS In the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts. CONCLUSION The implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times.
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Affiliation(s)
| | | | | | | | - J Gordon Boyd
- Queen's University Dept. of Critical Care Medicine, Canada.
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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Ryu JA, Bang OY, Suh GY, Yang JH, Lee D, Park J, Cho J, Chung CR, Park CM, Jeon K. Ischemic Stroke in Critically Ill Patients with Malignancy. PLoS One 2016; 11:e0146836. [PMID: 26751213 PMCID: PMC4709055 DOI: 10.1371/journal.pone.0146836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/21/2015] [Indexed: 11/18/2022] Open
Abstract
Background Cerebrovascular diseases are a frequent cause of neurological symptoms in patients with cancer. The clinical characteristics of ischemic stroke (IS) in patients with cancer have been reported in several studies; however, limited data are available regarding critically ill patients with cancer who develop IS during their stay in the intensive care unit (ICU). Methods All consecutive patients who underwent brain magnetic resonance imaging (MRI) for suspicion of IS with acute abnormal neurologic symptoms or who developed signs of IS while in the ICU were retrospectively evaluated. We compared the clinical characteristics and diffusion-weighted imaging (DWI) lesion patterns between patients finally diagnosed as having or not having IS. Results Over the study period, a total of 88 patients underwent brain MRI for suspicion of IS, with altered mental status in 55 (63%), hemiparesis in 28 (32%), and seizure in 20 (23%). A total of 43 (49%) patients were ultimately diagnosed with IS. Multiple DWI lesions (41%) were more common than single lesions (8%). The etiologies of IS were not determined in the majority of patients (n = 27, 63%). In the remaining 16 (37%) patients, the most common aetiology of IS was cardioembolism (n = 8), followed by large-vessel atherosclerosis (n = 3) and small-vessel occlusion (n = 2). However, brain metastases were newly diagnosed in only 7 (8%) patients. Univariate comparison of the baseline characteristics between patients with or without IS did not reveal any significant differences in sex, malignancy type, recent chemotherapy, vascular risk factors, or serum D-dimer levels at the time of suspicion of IS. Thrombotic events were more common in the IS group than in the non-IS group (P = 0.028). However, patients who were ultimately diagnosed with IS had more hemiparesis symptoms at the time of suspicion of IS (P = 0.001). This association was significant even after adjusting for potentially confounding factors (adjusted odds ratio 5.339; 95% confidence interval, 1.521–19.163). Conclusions IS developed during ICU stays in critically ill patients with cancer have particular features that may be associated with cancer-related mechanism.
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Affiliation(s)
- Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Daesang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinkyeong Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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Abstract
BACKGROUND Neurologists are frequently called to evaluate patients in the intensive care units who are not waking up. This often poses a diagnostic and prognostic dilemma. REVIEW SUMMARY The initial evaluation starts with abstracting the prehospital and in-hospital history, followed by bedside clinical and neurologic examination to establish a differential diagnosis. The subsequent work-up is based on clinical suspicion where reversible life-threatening causes should be immediately identified. After confirming the diagnosis and implementation of the appropriate medical management, a prompt family meeting and counseling is recommended. The role of neurologists in clinical diagnosis and prognostication of the coma patient, as well as diagnosing brain death is instrumental. CONCLUSIONS In this review, we explore a practical systematic approach to patients with decreased level of consciousness. The most common causes of impaired alertness in different non-neurologic critical care units and commonly used prognostication tools are presented. Finally a brief introduction of hypothermia, a novel therapeutic approach is also discussed.
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Salerno D, Marik PE, Daskalakis C, Kolm P, Leone F. The role of head computer tomographic scans on the management of MICU patients with neurological dysfunction. J Intensive Care Med 2009; 24:372-5. [PMID: 19875389 DOI: 10.1177/0885066609344940] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurological dysfunction is common in patients admitted to the medical intensive care unit (MICU). However, the indications for head imaging in those patients are unclear. The objective of this study was to assess whether clinical variables would be useful in selecting patients who are likely to have an abnormality on head computerized tomographic (CT) scanning and to determine the impact of such scans on management decisions. We reviewed the charts of 740 patients admitted to our MICU between October 2002 and July 2004. A total of 123 patients (16.6%) had a head CT scan performed, with a new finding being present in 26 (21.1%) patients. In the patients with a new CT finding, there was a change in diagnosis in 11 (42%) patients and a change in treatment in 6 (23%) patients. Logistic regression analysis failed to determine any clinical characteristic that could predict a new finding on the CT scan. This study suggests that clinicians should have a low threshold for ordering a CT scan in MICU patients with acute neurological dysfunction.
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Affiliation(s)
- Daniel Salerno
- Division of Pulmonary and Critical Care Medicine, Christiana Health Care System, Newark, Delaware 19805, USA.
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Abstract
Neurologic complications in intensive care occur as the result of critical illness, intensive care therapies and procedures, or medical or surgical conditions; perioperatively; or because of underlying primary neurologic disease. These complications occur at greater frequency and are often unrecognized because critically ill patients are often intubated, sedated, and/or receiving neuromuscular blocking agents. Encephalopathy is the most common neurologic complication in the ICU and is usually multifactorial in origin. Sepsis is associated with the highest incidence of neurologic complications. Neurologic complications are associated with increased disability, longer hospital stay, and increased mortality. This review focuses on neurologic complications that are the result of critical illnesses and intensive care management.
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Affiliation(s)
- I Barlas
- Department of Surgery, Division of Critical Care Medicine, Mount Sinai Medical Center, City University of New York, New York, New York, USA
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