© Thieme Medical Publishers
Neurological Consultation in the ICU
29 December 2008 (online)
Romergryko G. Geocadin, M.D. Matthew A. Koenig, M.D.
Consultation to intensive care units (ICUs) continues to be a major clinical responsibility of neurologists worldwide. The subspecialty of neurological critical care began largely as a consultation service for patients with neurological illness that had concomitant life-threatening diseases or complications. These consultations were undertaken mostly in specialty ICUs, such as the medical ICU, surgical ICU, postanesthesia units (anesthesia recovery rooms), and the critical care section of emergency departments. In the early 1980s, a handful of pioneering institutions organized and established dedicated ICUs focusing on patients with life threatening neurological diseases. This movement led to the formal amalgamation of neurocritical care as a subspecialty of Neurology. The Neurocritical Care Society (NCS) (www.neurocriticalcare.org) was subsequently established and membership has swelled to nearly 1000 worldwide. The first certification of neurocritical care specialists was undertaken last year under the auspices of the United Council for Neurologic Subspecialties. While the growth of dedicated neuroscience ICUs has augmented knowledge about critically ill patients with brain and spinal cord injuries, the dissemination of this knowledge to general neurologists at the front lines of ICU consultation remains vital.
As we prepared for this issue of Seminars in Neurology, we understood that we would not be able to cover all of the topics that neurological consultants are faced with in ICUs. When we looked at the published literature, we found no report detailing the most common sources of and indications for neurological consultation to the ICU. So, we did two things. First, in consultation with Seminars in Neurology Editor in Chief Dr. Karen Roos, we constructed a list of topics that we felt represented the important and common neurological topics in ICU consultations. Second, we worked with one of our Chief Residents, Dr. Wei Xiong, to query the database of the adult Neurology consult service at the Johns Hopkins Hospital from July 1, 2006 to June 30, 2008.
From the database, we found that 327 of 1527 (21%) adult inpatient neurological consultations at the Johns Hopkins Hospital originated from ICUs. Of these, 29% came from the medical ICU, 39% from the cardiac or cardiac surgical ICU, 32% from the surgical ICU, and a few neurosurgical patients from the neurosciences ICU. Collectively, the most frequent indications for consultation were as follows: 89 (27%) for possible ischemic stroke or TIA, 70 (21%) for altered mental status, 56 (17%) for seizures, and 40 (12%) for determining neurological prognosis. Less frequent requests included: 16 (5%) for evaluation of diffuse weakness, 11 (3%) for possible neurogenic hypoventilation, 10 (3%) for intracranial hemorrhage, 9 (3%) for evaluation of unidentified brain lesions seen on imaging, and 8 (2%) for peripheral neuropathy. The remaining indications for consultation were for brain death examination, movement disorders, anisocoria, meningitis, and others.
In this issue of Seminars in Neurology, we compiled topics that reflected the findings in our own practice, as well as topics that we deemed important to neurological consultants but not well addressed in the literature. We have gathered the leading experts in the field to provide the most up-to-date insight in these very challenging clinical topics. The first topic cluster involves the preoperative evaluation of neurological patients by Drs. Lien and Selim; pain and sedation of neurological patients by Drs. Mirski and Lewin; and updates on brain imaging in the ICU by Drs. Stevens, Pustavoitau, and Chalela. The second topic cluster focuses on the common neurological problems requiring ICU care, such as ischemic stroke by Dr. Llinas; updates on the care of intracerebral hemorrhages by Drs. Elijovich, Patel, and Hemphill; the care of seizures and status epilepticus in the ICU by Drs. Ziai and Kaplan; and CNS infections in the ICU by Dr. Greenberg. And the last cluster of articles provide updates on the complications and consequences of life-threatening neurological injuries, with an update on the approach to intracranial hypertension by Drs. Bershad, Humphreys, and Suarez; the approach to neurological complications of cardiac surgery by Drs. Gottesman, McKhann, and Hogue; a comprehensive review on the autonomic complications of CNS injury by Dr. Baguley; and withdrawal of life-sustaining therapies and brain death in the ICU by Drs. Varelas, Abdelhak, and Hacein Bey.
While we tried to cover the important topics of neurological consultation in ICUs, many specific and equally important topics could not be included because of space constraints or redundant publications. One such topic is on brain injury and cardiac arrest. This area of neurological consultation has recently advanced tremendously, with the recommendation by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) on the use of therapeutic hypothermia in ameliorating post–cardiac arrest brain injury, and the American Academy of Neurology practice parameter on the prediction of outcome in comatose survivors after cardiopulmonary resuscitation. All of these advances were recently put together into a landmark ILCOR consensus statement on the Post Cardiac Arrest Syndrome.
The many advances into the understanding of pathogenesis and therapeutics for neurologically relevant aspects of critical illness have made these times exciting for health care providers. It is clear that neurology consultants have so much more to offer to these challenging clinical problems. These advances also provide hope for all, especially our patients and their families that are the ultimate beneficiaries.
In closing, we thank Dr. Karen Roos, Linda Hagan, and the staff at Thieme for working with us, and our colleagues for their expert contributions that make up this issue. Dr. Geocadin expresses gratitude to his family—Effie, Ginno, and Sofia for their patience and understanding—and to Dr. Joven Cuanang, the outstanding Neurologist and his Medical School Dean who guided and inspired him to an academic career in Neurology.
And last, but most important, we thank our patients for inspiring us to give our best everyday.
- 1 Xiong W, Koenig M A, Geocadin R G. Neurology consultation requests in intensive care units at a tertiary referral hospital. Neurocrit Care. 2008; 9 S195
- 2 Geocadin R G. Hypoxic Ischemic Encephalopathy. Semin Neurol. 2006; 26(4) 367-460
- 3 Nolan J P, Morley P T, Vanden Hoek T L et al.. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation. 2003; 108(1) 118-121
- 4 Wijdicks E F, Hijdra A, Young G B, Bassetti C L, Wiebe S. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006; 67(2) 203-210
- 5 Neumar R W, Nolan J P, Adrie C et al.. Post-Cardiac Arrest Syndrome. Epidemiology, Pathophysiology, Treatment, and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation. 2008; , October 23 (Epub ahead of print)
Romergryko G Geocadin, M.D.
Associate Professor, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Division of Neurosciences Critical Care
The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 8-140, Baltimore, MD 21287