By Sana Alkhawaja, MD, CABEM; Nehad Al Shirawi, MD, MRCP; Hasan Mohammed Naser, MBBS, Najat S. Hameed Naser, RN; Asrar A. Majeed Al Asheeri, RN; Redha Abdulla Al Hammam, RN; Amina Maki Husain, RN
The Kingdom of Bahrain, home of the ancient Dilmun civilization, is a Middle Eastern island situated in the Arabian Gulf. Bahrain is made up of an archipelago of 33 natural islands. The capital city of Manama lies in the heart of the island, the most densely populated area, with over two thirds of Bahrain’s 1.7 million people residing there. The total land area is 760 Km2 (293 sq. miles) which makes it the third-smallest country in Asia after Maldives and Singapore. This small country is considered one of the most densely populated countries with a density of 2239 per kilometre square. The Bahraini population is relatively young with a median age of about 32 years. Bahrain’s culture shares many similarities with those of its Arab neighbours in the Gulf region. Islamic rules govern the country’s cultural life.
Salmaniya Medical Complex (SMC) is the main public hospital situated in the Salmaniya district of Manama. It was established in 1957 and has a bed capacity of more than 1200 beds. SMC is considered the largest tertiary hospital in Bahrain. The hospital meets the secondary and tertiary health care needs of citizens and residents in Bahrain, in addition it acts as an educational and research centre for health professionals. SMC receives an average of 900-1000 patients per day and employs more than 2000 doctors, nurses, and other allied healthcare workers.
The intensive care department at SMC, is a state-of-the-art unit, consisting of 22 beds. The unit is in close proximity to the emergency department, operating rooms, and Imaging departments to facilitate safe and rapid transfer of patients between these areas when required.
It received a variety of critically ill patients aged ≥14 years old, it is a mixed unit treating all specialties including medical, surgical, trauma and neurosurgical patients.
The intensive care department at SMC follows the closed ICU model whereby multidisciplinary rounds are conducted on daily basis that include intensivists, nurses, clinical pharmacists, dieticians, and physiotherapists .
We have conducted a single-centre retrospective cohort study of all treated patients in our ICU from first of January 2016 tell thirty first of December 2020. The aim of the study was to characterize age, diagnosis, length of stay and mortality of patients with neurological disorder admitted to ICU.
A total of 4,869 patients were admitted to the ICU during the study period and 17 % (845) of these patients were admitted with a primary diagnosis of neurological disorder. (Fig. 1)
Among these patients, two thirds (66.3%) were males (Fig. 2), with a mean age of 48.5 ±17.3 years (Fig. 3). We have found a great variation in the ages as the youngest was 14 years old and eldest patient was 91 years old. More than half of the patients were aged between 14 and 55 years (n=553, 65.4%).
The most frequent admitting diagnosis was spontaneous non-traumatic intracerebral haemorrhage (ICH) which accounts for one quarter of the cases (25.1%), followed by central nervous system neoplasm which accounts for 24%. Meningioma was the most frequent neoplasm in our centre, and the main reason for admitting these patients to the ICU was for observation after excision of the tumour. Traumatic brain injury is very common especially among young age groups and it accounts for 17.3% of the total admission; while ischemic stroke represent 12.3%; and subarachnoid haemorrhage accounts for 9.8%. Details are shown in Table 1.
Sixty four percent of the patients underwent surgical intervention during their ICU stay (Fig.4). More than half of the patients (60.2%) were on mechanical ventilation for airway protection (Fig. 5)
The vast majority of patients with neurological disease stayed in the ICU for more than 48 hours (n=684, 80.9%). On the other hand, only 19.1% stayed for less than 48 hours (Fig.6). Those who stayed in the ICU for more than 48 hours had an average length of stay (LOS) of 11.3 days and those who stayed less than 48 hours had an average LOS of 1.4 days.
Patients admitted with neurological disorders had a lower ICU mortality rate in comparison to patients admitted with other disorders; 8.5% and 13.8% respectively (Fig.7).
Our data revealed that patients with acute neurological disorders accounted for a significant number of all ICU admissions with the majority being male and at a young age group (between 14- 55 years old).
One quarter of the admissions were secondary to spontaneous intracerebral haemorrhage (ICH) which was the most frequent cause of admission. These patients have a high risk of early neurological deterioration, which is usually secondary to early hematoma expansion or the development of acute hydrocephalus secondary to interventricular haemorrhage.1,2 Early admission of theses patient to the ICU with frequent neurological examinations, to detect early clinical deterioration and signs of increased intracranial pressure, can result in prevention of hematoma expansion and timely appropriate early surgical interventions if needed.
Invasive blood pressure monitoring is an integral part of our protocol in managing these with aggressive reduction of blood pressure for patients who present with systolic blood pressure (SBP) SBP >220 mmHg with a continuous intravenous infusion of antihypertensive medication. For those who present with SBP between 150 and 220 mmHg, SBP is lowered to 140 mmHg, in accordance with guideline recommendations for the management of spontaneous intracerebral haemorrhage.3 Keeping in mind that it is not recommended to reduce SBP below 140 mmHg in the first hours after ICH onset as this could result in disability and may increase the risk of renal adverse events.4
Airway protection is one of the main concerns in dealing with patients with neurological disorders; accordingly having found that more than half of our patients were on mechanical ventilation.
Length of ICU stay depends strongly on the indication for ICU admission, regarding the group with short lengths of stay (less than 48 hours), most of them were admitted post-operative for observation and monitoring. On the other hand, patients with vascular or inflammatory diseases stayed for an average of 11.3 days.
Patients with neurological disorders had a lower mortality rate compared to the general cases admitted to the ICU; which could suggest that optimizing the care of these patient with a multidisciplinary team and close observation inside the ICU can result in reduction of mortality rates. Accordingly we have adapted a specific approach inside our unit for dealing with such critical patients despite being a closed ICU unit, in which the ICU consultant takes full responsibility for all critical decisions regarding the patients and refers to the primary team only for consultation regarding specific issues. A different approach was used in this scenario for patients with neurological disorders, through continuous collaboration and overlap action between neurosurgeon, neurology speciality and intensivist.
Creating a separate neurocritical care unit is one of the top priorities of our hospital and was planned to have opened by the beginning of 2021, but due to the COVID-19 pandemic this project has been postponed. Nevertheless, the inpatient care of neurocritically ill patients has not been affected as we continue receiving them in the main ICU.
Photos from the Authors
- Mayer SA, Sacco RL, Shi T, Mohr JP. Neurologic deterioration in noncomatose patients with supratentorial intracerebral hemorrhage. Neurology. 1994;44(8):1379–84
- Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997;28(1):1–5
- Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018; 138:e484.