stroke

1. Neurointensivist’s Role in
Neurosurgical Care & Training
Lori A. Shutter, MD
Director, NSICU/Neurocritical Program
Assoc. Professor of Neurosurgery, Neurology & PMR
University of Cincinnati Medical Center

2. Objectives
 Describe the specialty of neurocritical care.
 Review the requirements for certification in
neurocritical care.
 Discuss the role of a neurointensivist in
neurosurgical residency training.

3. Modern Intensive Care
 “Intensive-care medicine has become the art of
managing extreme complexity—and a test of
whether such complexity can, in fact, be
humanly mastered.”
Atul Gawande, The New Yorker, 1/6/08
 Bundles; Check lists; Time Outs
 Protocols; Guidelines; Evidence-based Care
 Multidisciplinary; Collaborative
 JACHO; CMS

4. What is a Neuro-intensivist?
 A physician devoted to comprehensive multisystem
care of the critically ill neurological patient.
 Assumes a primary care role for patients in the ICU,
coordinating both neurological & medical management.
 Has a unique concern with the interface between the brain
and other organ systems in the setting of critical illness.
 Takes on responsibility for various elements of ICU care
that might otherwise be provided by multiple subspecialists
(i.e. cardiology, endocrinology, infectious diseases,
pulmonary medicine, and neurology).
 Proficiency with standard ICU monitoring, as well as
specialized neuro-monitoring and interventions.

5. Are Neurointensivists Needed?
 Disclosure: I am biased on this topic
 Advances in the treatment of neurological conditions
 Advances in critical care
 Uniqueness of the neurological patient
 Increased patient / family awareness
 Collaboration for professional & academic growth
 Multi-disciplinary team care

6. History of NCC
 Neurological Intensive Care AAN course ’80 – 87
 Gap from ’88 – 99, restarted in 2000
 Subspecialty development: late ’80s – early 90s
 MGH: Allan Ropper
 Columbia: Matt Fink
 Hopkins: Dan Hanley and Cecil Borel
 UVa: Tom Bleck
 Growth through Neurology departments, or other
intensivists in units with high neurosurgical volumes
 Focus changed to Neurocritical Care, NOT specialized
stroke units

7. Organized NCC
 Organized NCC has made major strides in last decade
 AAN CCEN Section*
 Neurocritical Care Society*
 SNACC*
 AANS/CNS Joint Section on Neurotrauma & Critical Care
 German Neurocritical Care Working Group
 Neurocritical Care Society
 2007 saw the 5th Annual Meeting
 651 physician members (105 residents); 774 total members
 NCC recognized as a subspecialty by UCNS* in 2006

9. Neurocritical Care
 Dedicated Neuro-ICUs with fellowship trained neuro-
intensivists in the US = 50*
 29 states; 39 cities & DC
 NCC Program Models
 Division of Neurology vs Neurosurgery vs Anesthesiology
 Department of Critical Care – Multidisciplinary
 Neuro-ICU models
 Closed vs ‘Semi-closed’ vs Open
 Primary providers vs Co-attendings vs Consultants

10. Neurocritical Care Certification
 First certification exam in NCC in 12/07
 Eligibility for exam: fellowship or practice tracts.
 Fellowship tract: documentation of training in an accredited
NCC fellowship program
 Practice tract available until 2012
 Exam components
 Neurological – 48%
 General medical critical care – 47%
 Procedural – 5%
 Current diplomates in NCC = 91.
 Next examination – 12/08

11. Neurocritical Care Training
 Fellowship Training Programs
 39 in the US (in 18 states)
 < 25 currently active
 2 year training curriculum developed based on UCNS /
ACGME guidelines
 Program accreditation through UCNS starting in 2007. 11
programs submitted applications.
 Specialties eligible for training in NCC:
neurology, neurosurgery, emergency medicine,
anesthesia, internal medicine, pediatrics

12. NCC Training Requirements
 Duration of training
 12 months of ICU experience
 > 50% focusing on primarily neurological & neurosurgical
conditions
 Recommend 18 – 24 months to provide adequate elective
& off-service time
 Additional qualifications
 Provider / instructor in ACLS, ATLS, PALS, FCCS
 Faculty
 Provide direct supervision in ICU
 Demonstrate adequate training / experience in NCC
 Minimum of 25% of time dedicated to NCC

13. Neurological Conditions
 Cerebrovascular
 Neurotrauma
 Seizures
 Neuromuscular diseases
 Neuro-oncology
 Infections
 Toxic-metabolic
 Inflammation /
demyelination
 Encephalopathies
 Movement disorders
 Neuroendocrine
 Clinical syndromes
 Peri-operative
neurosurgical care
 Neurorehabilitation
 Pharmacotherapeutics

14. ET Tube
Feeding Tube
ICP monitor
CVL
EEG leads
EEG box
PbtO2

15. Monitor
Ventilator
EEG
PbtO2
IV Pumps
Tube feed
pump

16. General Medical Conditions
Cardiovascular
 Shock / resuscitation
 Coronary Ischemia
 Neurogenic Cardiac Abnormalities
 Cardiac Arrhythmias
 Hypertensive Crisis
 Pulmonary edema: cardiogenic & non-cardiogenic
 Pulmonary embolism
 Acute aortic / peripheral vascular disorders
 Advanced cardiovascular monitoring & derived
parameters

17. General Medical Conditions
Pulmonary
 Respiratory failure
 Pneumonitis / pneumonia
 Adult Respiratory Distress Syndrome
 Upper airway obstruction
 COPD / asthma
 Neurogenic breathing patterns
 Mechanical ventilation: modes, weaning, monitoring
 Pleural diseases: empyema, effusion
 Pulmonary hemorrhage / hemoptysis
 Sleep apnea

18. General Medical Conditions
Renal
 Fluids / electrolytes
 Acute Renal Failure
 Drug dosing
 Acid-base disorders
 Hemodialysis
 Rhabdomyolysis
 UTI / Urosepsis
GI
 GI bleed
 GI perforation
 Ileus
 Obstruction
 Hepatic failure
 Pancreatitis

19. General Medical Conditions
Metabolic/ Endocrine
 Nutrition
 Thyroid function
 Adrenal crisis
 Diabetes
 Pheochromocytoma
 Systemic Inflammatory
Response Syndrome
 Fever/thermoregulation
Infectious
 Antibiotics
 Drug resistance
 Hospital acquired
infections
 AIDS
 Central fever

20. General Medical Conditions
Hematologic
 Hemostasis defects &
therapy
 Blood component rx
 Hemolytic disorders
 Hypercoagulable states
 DVT prophylaxis
 Anticoagulation
 Transfusion reactions
 Immunology
 Transplantation
 General Trauma
 Burn management
 ICU Agitation
 Monitoring
 Prognostication

21. Procedural Competencies
 Arterial catheters
 Central venous catheters
 Pulmonary artery catheters
 Management of vasoactive medications
 Airway Management
 Non-intubated
 Direct laryngoscopy
 Endotracheal intubation
 Mechanical ventilation
 CPAP/BiPAP ventilation
 Interpretation of bedside pulmonary function
 CPR/ACLS (with certification)

22. Procedural Competencies
 Lumbar puncture; Shunt / ventricular drain tap
 Conscious sedation & barbiturate anesthesia
 Neuro-monitoring
 ICP, CPP, PbtO2, SjvO2 management
 Management of EVDs
 TCDs
 EEGs
 Management of plasmapheresis & IVIG
 IV & intraventricular thrombolysis
 Interpretation of neuroimaging studies
 Moderate hypothermia

23. Training Residents in NCC
 Work hour restrictions have damaged the ICU
experience for residents
 Attitude change – from physicians to shift workers
 They are less involved and many are less happy
 Frequent transfers to other services rather than managing
the problems
 Attendings aren’t reading sleep deprivation literature
because we are doing the resident’s work!
 PGY-1s (neurosurgery, neurology, others) have been
added to the ICU rotation
 BUT – even the best ones have trouble being alone in an
ICU that early

24. Training Residents in NCC
 Neurotrauma / Critical Care Fellowships
 Is this adequate critical care training?
 It will not meet criteria for NCC Certification
 Does that matter?
 That Depends
 Are you managing anything other than trauma?
Do you want to?
 Does it provide adequate exposure to medical
critical care?
 What are you going to focus on for your career?
 Do you want extra certifications?

25. Training Residents in NCC
 I don’t have the answer
 Exposure to the specialty
 Division of Neurosurgery
 Collaboration
 Interwoven in didactic / conference sessions
 Dedicated ICU time
 Not just 30 minutes on am rounds!
 PGY-1 year
 As part of neurology requirement
 Advanced training / Enfolded ‘fellowship’

26. What to do?
 Develop connections with NCC organizations
 Work with NCS leadership to address issues
specific to neurosurgical training
 Decide if NCC should be a focus of your program
 Develop a curriculum with your neurointensivist
 Based on fellowship training requirements

27. Thank You