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CC-BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2016; 03(04): S62-S65
DOI: 10.4103/2348-0548.174739
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Thieme Medical and Scientific Publishers Private Ltd.

Neuro-critical care versus general critical care for neurological injury: Beneficial evidence

Ian Tweedie
1   Walton Centre, Liverpool, UK
2   Immediate Past President, Neuroanaesthesia and Critical Care Society of Great Britain and Ireland
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Publikationsdatum:
05. Mai 2018 (online)

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INTRODUCTION

In many parts of the world, patients with neurological injury requiring critical care are managed in one of three models of intensive care; General Intensive Care Units (GICU) without direct neurosurgical/neurological input, ICUs co-located with a neuroscience unit, which may be a mixed speciality GICU with direct input from neuroscience specialists or a stand-alone Neuro-ICU (NICU) embedded within a neuroscience unit. Thus, it would be useful to start with a definition of neuro-critical care as opposed to critical care. Smith and Menon[1] provide a good definition in their chapter in the new Guide to the Provision of a Critical Care Service (GPICS) document from the Intensive Care Society:

“Neuro-critical care is devoted to the comprehensive care of critically ill patients with neurological or neurosurgical disease. Care of such patients requires an understanding of the physiology and pathophysiology common to brain diseases in general, as well as the skills and knowledge to treat a range of specific conditions. Given the exquisite vulnerability of the injured brain to physiological insults, optimal care of such patients also demands meticulous attention to maintenance of systemic and cerebral physiological targets while ensuring appropriate protection of extra-cranial organs.”

In 2004 Smith[2] asked the question “Neuro-critical care: Has it come of age?” In his conclusion, he noted that available data suggest that outcomes in neuro-specific ICUs might be better than in GICUs. He also states that we need to demonstrate this conclusively and show why. More than 10 years later can we answer this question more conclusively and for all areas of neurologic injury? Kramer and Zygun in 2011[3] and again in 2014[4] asked similar questions. Both times, they concluded that the body of evidence is strongly supporting the case for better outcomes but that there is still much to understand as to the how and why. In 2015, Smith and Menon briefly review the evidence in the GPICS[1] document and comment that it now seems clear that the care does not necessarily need to be in a single speciality unit NICU, but more importantly that multidisciplinary expertise in the care of the sick brain is available directly to the patient.

Neuro-critical care is a relatively newly recognised and emerging area of sub-speciality care, although it has been a recognised speciality for training and accreditation in the USA since the early 2000’s. Its origins come from critical care units developing within neuroscience centres, to care initially for severe traumatic brain injury (STBI), subarachnoid haemorrhage (SAH) and postoperative neurosurgical patients. Most have now expanded to also include both neurological and neurosurgical life-threatening disease such as intra-cerebral haemorrhage (ICH), ischaemic stroke, neuromuscular diseases, refractory status epilepticus and central nervous system infections. There is currently much literature about this subject, with the majority coming from North America. Many of them are single centre studies with historical controls, with few multicentre prospectively controlled studies. There is evidence of the benefits of specialist critical care for the most of the above diseases, which I have briefly summarised in the separate sections below.