How a Neurocritical Care Unite and Education Should Be?

1. How a Neurocritical Care Unite
and Education Should Be?
Bijen Nazliel MD
Gazi University Fac of Medicine
Department f Neurology-
Neurointensive Care Unite

2. Neurocritical Care-
Neurointensive Care
 Massive stroke
 Subarachnoid Hemorrhage
 Intracerebral Hemorrhage
 Intravetricular Hemorrhage
 Subdural Hemorrhage
 Brain Tumor
 Traumatic Brain Injury
 M.Gravis
 Guillian- Barre Syndrome

3. Neurocritical Care-
Neurointensive Care
 Postoperative neurosurgical intensive
care units were established in 1960-
1970’s due to the development of new
surgical procedures and monitoring
techniques.

4. Four Founders of Neurointensive
Care
 Dr. Aleen Rupper – Massachusets
General Hospital
 Dr. Matthew Fink- Colombia University
 Dr. Thomas Black- University of Virginia
 Dr. Dan Hanley- John Hopkins
 Four Fathers of Neurocritical Care
Topcuoğlu MA. Türk Noroloji Derg. 2011;17:7-16

5. Neurointensive Care Unite (NICU)
 New NICU were established in every
hospital in USA due the proven effect
of Iv- tpa in ischemic stroke.
 Due to the complications of this type of
treatment, it’s risky to follow these
kinds of patients in Neurology Clinics.

6. Neurocritical Care Society(NCS)-
1999
 Dr. Bill Coplin
 Dr. Jeff Frank
 Dr. Claude Hemphill
 Dr. Ed Manno
 Dr. Stephan Mayer
 Dr. Wade Smith
 Dr. Gene Sung
 2003 Arizona

8. NCS- Targets of Organization
 Improvement of care and quality of life
 Professional collaboration
 Research
 Education and training

9. NICU in Turkey
 The first NICU in Turkey was installed in
Egean University Medical Faculty
Department of Neurology in 1976.
 An iron lung was present in the unite at
that time.

10. Turkish Neurlogical Society-Neurointensive
Care Group
 Neurointensive Care Study group is first
established in 2003,under the
leadership of Turkish Neurological
Society.
 I.2005- İzmir
 II. 2007- Kapadokya
 III.2009-Çeşme
 IV. 2011- Çeşme
 V.2013-Kuşadası
 VI.2015- Marmaris

11. Turkish Neurlogical Society-
Neurointensive Care Group
 Neurointensive care study group
organizes full day courses in annual
Turkish Neurological Conference.
 Neurointensive care Nurses course is
organized in every two year by the
Neurointensive Care Study Group and
financed by Turkish Neurological
Society.

14. Neurointensive Care
 Neurology
 Neurosurgery
 Radiology
 Interventional Neuroradiology
 Consultants
 Physiotherapist and respiratory therapist
 Speech and swallow therapists
 Behavioral therapists
 Dietician
 Specialized neurointensive care nurses

15. NICU-Main Targets
 Primarily neuroprotection
 Secondarily; prevention of neuronal
injury
 Decreases mortality
 Improves prognosis and quality of life
 Effective usage of sources

16. Neurointensive Care Unite
 Ischemic stroke
 Intracerebral hemorrhage
 Subarachnoid hemorrhage
 Status epilepticus
 Infectious and inflammatory diseases
of central nervous system

19. Ischemic Stroke
 IV trombolitic treatment: With in the first 4.5
hour of acute ischemic stroke
 Occlusion of middle cerebral artery
 Occlusion of T portion of carotid artery:IA
thrombolytic or mechanical embolectomy with
in the first 6-8 hour.
 Recanalisation and reperfusion of basilar
artery occlusion with in the first 12 hour.
 Patients should be followed in NICU prior and
following procedures.

21. Ischemic Stroke II
 Cerebellar infarction with mass effect
 Massive middle cerebral artery occlusion
 Massive internal carotid artery occlusion
 TIMING of DECOMPRESSİVE SURGERY
 Decreases length of stay in hospital
 Decreases mortality
 Improves quality of life

27. Intracerebral Hemorrhage
 Treatment and follow -up of patients in NICU effects
prognosis positevly in patients with cerebral
hemorrhage.
 With in the first 72 hour of an acute cerebral insult,1/3
of patients are send to surgery even though had been
planed to be treated medicaly with collective decision of
neurology and neurosurgery.
 This is important to demonstrate the critical importance
of clinic monitorisation.
 Treatment of high ICP
 Ventricular drainage in patients with intraventricular
hemorrhage

28. Subarachnoid Hemorrhage
 Timing of aneurismal repair
 Decision of treatment options
(Endovascular vs surgery)
 Treatment of high ICP
 Follow up of vasospasm with
transcranial doppler USG(TCD)
 Clinical and radiologic monitoring of
acute hydrocephalus

30. Neuromuscular Respiratory
Deficiency
 M.Gravis
 G. Barre Syndrome
 ALS
 Myositis: Electrophysiological evaluation
 Plasmapheresis
 IV Ig
 Suitability of patients for high dose steroids

31. Status Epilepticus
 Treatment modalities in refractory forms
of status epilepticus is determined by
EEG parameters.
 Nonconvulsive SE can only be
diagnosed by EEG monitoring; should
be followed in NICU.
 EEG monitoring is necessary in every
patient with coma

32. Infectious Diseases of Central
Nervous System (CNS)
 Viral encephalitis and infectious
parenchyma diseases of CNS.
 Treatment of high ICP
 Seizures

33. Inflammatory Diseases of Central
Nervous System (CNS)
 Multiple sclerosis
 Acute disseminated
encephalomyelitis(ADEM)
 High dose IV methyl prednisolone
 IV Ig
 Plasmapheresis should be administered
in NICU.

34. Coma
 Clinical,radiologic and electrophysiologic
differential diagnosis ,follow up and
monitoring of toxic ,metabolic and
structural comas.
 Determining prognosis in coma

35. Neuromonitoring
 EEG
 EMG
 Transcranial Doppler USG(TCD)
 Brain stem auditory evoked
potential(BAEP)
 ICP monitoring
 Jugular bulb pulse oximetry

36. Biomarkers in Neuromonitoring
 SB100
 Glial fibrilary aciditic protein
 Neuron- specific enolaz
 Tau
 Alpha II- Spectrin

42. Brainstem Auditory Evoked Potential
(BAEP)
 BAEP reflects the function of acoustic
nerve and auditory pathways.
 A click with an intensity of 60-70 dB
given to both ears respectively by an
ear phone with a determined property.

45. Brainstem Auditory Evoked Potential(BAEP)
Interpretation
 Is not affected from:
Anesthetics and sedatives
Metabolic abnormalities
Structural lesions
 Determination of prognosis in coma
 Diagnosis of brain death

48. Transcranial Doppler
USG(TCD)
 Transcranial Dopler (TCD) ultrasound is a
noninvasive technique which allows to
observe velocity, direction and properties of
blood flow in the cerebral arteries by means
of pulsed ultrasonic beam.
 Flow velocities have been found to be
proportional to direct invasive flow
measurements

52. Interpretation
 Increased Cerebral Blood Flow Velocity:
 Cerebral vasospasm
 Cerebral artery stenosis
 Collateral flow
 AVM
 Hyperemia

53. Interpretation
 Decreased Cerebral Blood Flow Velocity:
 Arterial occlusion
 Hypotension
 High ICP
 Hypometabolism
 Small vessel occlusion

56. NICU-Education
 All neurologist should be trained with basic
neurointensive care knowledge as in the case
of cardiology- coronary intensive care unite.
 Should be able to manage a unite completely
on his own.
 An education plan has been prepared in
conjunction with this idea in TUKMOS.
Topcuoğlu MA. Türk Noroloji Derg. 2011;17:7-16

57. NICU- Education-Targets
 Neurointensivits should have the ability to distinguish minor
changes in neurological examination.
 Knowledge on:
 Association between organ systems and brain
 Cerebral physiology
 Intracranial pressure
 Cerebral blood flow-metabolism
 Neuropharmacology
 Electrophysiology
Topcuoğlu MA. Türk Noroloji Derg. 2011;17:7-16

58. NICU- Education-Targets
 Follow- up of patients using
neuromonitoring techniques especially
EEG.
 Determination of prognosis
 Responsibility as a primary physician in
brain death and donation
Topcuoğlu MA. Türk Noroloji Derg. 2011;17:7-16

62. Targets in NICU Education I
 Leadership to staff in unite and service
 Organization of professional duty.
 Standardization of nursing care
 Education
 Multidisciplinary collaboration
 Quality improvement
Topcuoğlu MA. Türk Noroloji Derg. 2011;17:7-16

63. Targets in NICU Education II
 Effective usage of NICU beds.
 Standardization of treatment plans for
discharged patients
 Sufficiency in ethical and legal issues.
 Approach to end of life issues.
 Social and ethical management of patients
with severe neurological disability
 Acquire experience in brain death and organ
donation

64. Summary
 We hope and wish that no one would
have the need of intensive care unite