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
Objectives
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Describe the specialty of neurocritical care.
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Review the requirements for certification in
neurocritical care.
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Discuss the role of a neurointensivist in
neurosurgical residency training.
Modern Intensive Care
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“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
q Protocols; Guidelines; Evidence-based Care
q Multidisciplinary; Collaborative
q JACHO; CMS
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What is a Neuro-intensivist?
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A physician devoted to comprehensive multisystem
care of the critically ill neurological patient.
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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.
Are Neurointensivists Needed?
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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
History of NCC
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Neurological Intensive Care AAN course ’80 – 87
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Subspecialty development: late ’80s – early 90s
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Gap from ’88 – 99, restarted in 2000
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
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Focus changed to Neurocritical Care, NOT specialized
stroke units
Organized NCC
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Organized NCC has made major strides in last decade
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Neurocritical Care Society
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AAN CCEN Section*
Neurocritical Care Society*
SNACC*
AANS/CNS Joint Section on Neurotrauma & Critical Care
German Neurocritical Care Working Group
2007 saw the 5th Annual Meeting
651 physician members (105 residents); 774 total members
NCC recognized as a subspecialty by UCNS* in 2006
Neurocritical Care
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Dedicated Neuro-ICUs with fellowship trained neurointensivists in the US = 50*
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NCC Program Models
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29 states; 39 cities & DC
Division of Neurology vs Neurosurgery vs Anesthesiology
Department of Critical Care – Multidisciplinary
Neuro-ICU models
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Closed vs ‘Semi-closed’ vs Open
Primary providers vs Co-attendings vs Consultants
Neurocritical Care Certification
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First certification exam in NCC in 12/07
Eligibility for exam: fellowship or practice tracts.
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Exam components
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Fellowship tract: documentation of training in an accredited
NCC fellowship program
Practice tract available until 2012
Neurological – 48%
General medical critical care – 47%
Procedural – 5%
Current diplomates in NCC = 91.
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Next examination – 12/08
Neurocritical Care Training
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Fellowship Training Programs
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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
NCC Training Requirements
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Duration of training
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Additional qualifications
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12 months of ICU experience
> 50% focusing on primarily neurological & neurosurgical
conditions
Recommend 18 – 24 months to provide adequate elective
& off-service time
Provider / instructor in ACLS, ATLS, PALS, FCCS
Faculty
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Provide direct supervision in ICU
Demonstrate adequate training / experience in NCC
Minimum of 25% of time dedicated to NCC
Neurological Conditions
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Cerebrovascular
Neurotrauma
Seizures
Neuromuscular diseases
Neuro-oncology
Infections
Toxic-metabolic
Inflammation /
demyelination
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Encephalopathies
Movement disorders
Neuroendocrine
Clinical syndromes
Peri-operative
neurosurgical care
Neurorehabilitation
Pharmacotherapeutics
EEG box
ICP monitor
PbtO2
Feeding Tube
ET Tube
CVL
EEG leads
Tube feed
pump
EEG
Monitor
Ventilator
IV Pumps
PbtO2
General Medical Conditions
Cardiovascular
q Shock / resuscitation
q Coronary Ischemia
q Neurogenic Cardiac Abnormalities
q Cardiac Arrhythmias
q Hypertensive Crisis
q Pulmonary edema: cardiogenic & non-cardiogenic
q Pulmonary embolism
q Acute aortic / peripheral vascular disorders
q Advanced cardiovascular monitoring & derived
parameters
General Medical Conditions
Pulmonary
q Respiratory failure
q Pneumonitis / pneumonia
q Adult Respiratory Distress Syndrome
q Upper airway obstruction
q COPD / asthma
q Neurogenic breathing patterns
q Mechanical ventilation: modes, weaning, monitoring
q Pleural diseases: empyema, effusion
q Pulmonary hemorrhage / hemoptysis
q Sleep apnea
General Medical Conditions
Renal
q Fluids / electrolytes
q Acute Renal Failure
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Drug dosing
Acid-base disorders
Hemodialysis
Rhabdomyolysis
UTI / Urosepsis
GI
q GI bleed
q GI perforation
q Ileus
q Obstruction
q Hepatic failure
q Pancreatitis
General Medical Conditions
Metabolic/ Endocrine
q Nutrition
q Thyroid function
q Adrenal crisis
q Diabetes
q Pheochromocytoma
q Systemic Inflammatory
Response Syndrome
q Fever/thermoregulation
Infectious
q Antibiotics
q Drug resistance
q Hospital acquired
infections
q AIDS
q Central fever
General Medical Conditions
Hematologic
q Hemostasis defects &
therapy
q Blood component rx
q Hemolytic disorders
q Hypercoagulable states
q DVT prophylaxis
q Anticoagulation
q Transfusion reactions
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Immunology
Transplantation
General Trauma
Burn management
ICU Agitation
Monitoring
Prognostication
Procedural Competencies
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Arterial catheters
Central venous catheters
Pulmonary artery catheters
Management of vasoactive medications
Airway Management
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Non-intubated
Direct laryngoscopy
Endotracheal intubation
Mechanical ventilation
CPAP/BiPAP ventilation
Interpretation of bedside pulmonary function
CPR/ACLS (with certification)
Procedural Competencies
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Lumbar puncture; Shunt / ventricular drain tap
Conscious sedation & barbiturate anesthesia
Neuro-monitoring
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ICP, CPP, PbtO2, SjvO2 management
Management of EVDs
TCDs
EEGs
Management of plasmapheresis & IVIG
IV & intraventricular thrombolysis
Interpretation of neuroimaging studies
Moderate hypothermia
Training Residents in NCC
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Work hour restrictions have damaged the ICU
experience for residents
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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
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BUT – even the best ones have trouble being alone in an
ICU that early
Training Residents in NCC
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Neurotrauma / Critical Care Fellowships
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It will not meet criteria for NCC Certification
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Is this adequate critical care training?
Does that matter?
That Depends
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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?
Training Residents in NCC
I don’t have the answer
q Exposure to the specialty
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q Division
of Neurosurgery
q Collaboration
q Interwoven in didactic / conference sessions
q Dedicated ICU time
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just 30 minutes on am rounds!
q PGY-1 year
q As part of neurology requirement
q Advanced training / Enfolded ‘fellowship’
What to do?
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Develop connections with NCC organizations
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Work with NCS leadership to address issues
specific to neurosurgical training
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Decide if NCC should be a focus of your program
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Develop a curriculum with your neurointensivist
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on fellowship training requirements
Thank You