›Levetiracetam preferred for ongoing seizure prevention
›500 mg PO or IV twice daily adults (adjust for renal function)
›Low drug interaction profile and no hepatic metabolism required
›Duration guided by neurology based on clinical course and EEG
›Osmotic therapy
›Mannitol 20% solution
›0.5–1 g/kg IV over 20 minutes
›Repeat every 4–6 hours as needed
›Hold if serum osmolality > 320 mOsm/kg
›Hypertonic saline 3% as alternative
›250 mL IV bolus for acute ICP crisis
›Sodium target 145–155 mmol/l in severe ICP
›Monitor serum sodium and osmolality every 4–6 hours with osmotic therapy
›Positioning and general measures
›Head of bed 30 degrees, head and neck neutral
›Minimize stimulation and pain
›Antipyretics to control hyperthermia
›Paracetamol (acetaminophen) 1 g IV or PO every 6 hours
›Hyperthermia worsens neuronal injury
›Avoid hyponatremia correction too rapidly
›Maximum sodium rise 10–12 mmol/l per 24 hours to prevent osmotic demyelination
Empiric antiviral and antimicrobial therapy
›Acyclovir empiric therapy (mandatory until HSE excluded)
›Adult dosing
›Acyclovir 10 mg/kg IV every 8 hours (normal renal function)
›Duration until CSF HSV PCR result returns negative
›Renal dose adjustment
›GFR 25–50 mL/min: 10 mg/kg every 12 hours
›GFR 10–25 mL/min: 10 mg/kg every 24 hours
›GFR < 10 mL/min: 5 mg/kg every 24 hours
›Hydration requirement with acyclovir
›IV hydration to prevent crystalline nephropathy
›Urine output target >= 0.5 mL/kg/hour
›Empiric bacterial meningitis coverage
›Ceftriaxone 2 g IV every 12 hours adults
›Covers Neisseria meningitidis and Streptococcus pneumoniae
›Discontinue when bacterial meningitis excluded
›Add vancomycin 15–20 mg/kg IV every 8–12 hours if MRSA or PCN-resistant pneumococcus risk
›Dexamethasone 0.15 mg/kg IV every 6 hours for 4 days if bacterial meningitis confirmed
›Reduces mortality and neurologic sequelae in pneumococcal meningitis
›Do not administer if viral etiology confirmed
JE-specific treatment (supportive)
›No proven antiviral therapy for JE
›Controlled trials showed no benefit for:
›Corticosteroids (randomized controlled trial evidence)
›Interferon alfa-2a (randomized controlled trial evidence)
›Ribavirin (randomized controlled trial evidence)
›Minocycline (randomized controlled trial evidence)
›IVIG as standard therapy (limited evidence)
›Management is entirely supportive
›Investigational approaches (not standard of care)
›TAGMIC combination (ganciclovir + methylprednisolone + IVIG)
›One retrospective study suggested possible mortality reduction in severe JE
›Not established standard of care; consider ID consultation before use
›High-dose IVIG in pediatric severe JE
›Retrospective pediatric data suggests possible benefit
›Evidence remains limited; not routinely recommended
›Fluid and electrolyte management
›Hyponatremia management
›Fluid restriction if SIADH (urine osmolality > serum osmolality)
›Isotonic saline if volume depleted
›Correction rate maximum 10–12 mmol/l per 24 hours
›NPO and enteral nutrition
›NPO if altered mental status or aspiration risk
›Nasogastric tube for prolonged unconsciousness
›Early enteral nutrition within 24–48 hours of ICU admission
›DVT and skin prophylaxis
›Pharmacologic VTE prophylaxis when not contraindicated
›Enoxaparin 40 mg SC daily (adjust for weight and renal function)
›Delay if active hemorrhagic transformation on imaging
›Sequential compression devices for immobile patients
›Repositioning every 2 hours for skin integrity
›Physical and rehabilitation
›Early physiotherapy and occupational therapy consultation
›30–50% of survivors have permanent neurologic sequelae
›Motor, cognitive, behavioral, and psychiatric rehabilitation needs
›Speech therapy when dysphagia or communication deficits identified