Post on 09-Feb-2017
How a Neurocritical Care Unite
and Education Should Be?
Bijen Nazliel MD
Gazi University Fac of Medicine Department f Neurology-Neurointensive Care Unite
Neurocritical Care-Neurointensive Care
Massive stroke
Subarachnoid Hemorrhage
Intracerebral Hemorrhage
Intravetricular Hemorrhage
Subdural Hemorrhage
Brain Tumor
Traumatic Brain Injury
M.Gravis
Guillian- Barre Syndrome
Neurocritical Care-Neurointensive Care
Postoperative neurosurgical intensive care units were established in 1960-1970’s due to the development of new surgical procedures and monitoringtechniques.
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
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.
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
NCS- Targets of Organization
Improvement of care and quality of life
Professional collaboration
Research
Education and training
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.
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
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.
Neurointensive Care
Neurology Neurosurgery Radiology Interventional Neuroradiology Consultants Physiotherapist and respiratory therapist Speech and swallow therapists Behavioral therapists Dietician Specialized neurointensive care nurses
NICU-Main Targets
Primarily neuroprotection
Secondarily; prevention of neuronal injury
Decreases mortality
Improves prognosis and quality of life
Effective usage of sources
Neurointensive Care Unite
Ischemic stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Status epilepticus
Infectious and inflammatory diseases of central nervous system
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.
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
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
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
Neuromuscular Respiratory Deficiency
M.Gravis
G. Barre Syndrome
ALS
Myositis: Electrophysiological evaluation
Plasmapheresis
IV Ig
Suitability of patients for high dose steroids
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
Infectious Diseases of Central
Nervous System (CNS)
Viral encephalitis and infectious parenchyma diseases of CNS.
Treatment of high ICP
Seizures
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.
Coma
Clinical,radiologic and electrophysiologic differential diagnosis ,follow up and monitoring of toxic ,metabolic and structural comas.
Determining prognosis in coma
Neuromonitoring
EEG
EMG
Transcranial Doppler USG(TCD)
Brain stem auditory evoked potential(BAEP)
ICP monitoring
Jugular bulb pulse oximetry
Biomarkers in Neuromonitoring
SB100
Glial fibrilary aciditic protein
Neuron- specific enolaz
Tau
Alpha II- Spectrin
Brainstem Auditory Evoked Potential(BAEP)
BAEP reflects the function of acoustic nerve and auditory pathways.
A click with an intensity of 60-70 dBgiven to both ears respectively by an ear phone with a determined property.
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
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
Interpretation
Increased Cerebral Blood Flow Velocity:
Cerebral vasospasm
Cerebral artery stenosis
Collateral flow
AVM
Hyperemia
Interpretation
Decreased Cerebral Blood Flow Velocity:
Arterial occlusion
Hypotension
High ICP
Hypometabolism
Small vessel occlusion
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
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
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
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
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
Summary
We hope and wish that no one would have the need of intensive care unite