This document discusses the role of neurointensivists in neurosurgical care and training. It describes neurocritical care as a subspecialty focused on comprehensive care of critically ill neurological patients. It reviews the requirements for board certification in neurocritical care, which was first offered in 2007. It also discusses how neurointensivists can be involved in neurosurgical residency training, such as collaborating on didactic sessions and ensuring adequate intensive care unit exposure for residents.

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