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Challenges of Neurocritical Care in Latin America Beyond the Pandemic

By Currents Editor posted 06-14-2021 09:15

  
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Luis Rafael Moscote-Salazar, MD
Critical Care Unit, Bogotá, Colombia
Centro Policlínico del Olaya

Iván David Lozada-Martínez, MS
University of Cartagena
Cartagena, Colombia

Blog en Español

Neurological and neurosurgical diseases are a major cause of morbidity and mortality worldwide, and Latin America is no exception [1-3]. The incorporation of neurocritical care has represented a paradigm shift in the management of these diseases [4]. However, the advent of the recent pandemic represented a series of challenges for neurocritical care in low- and middle-income countries [5] such as those in Latin America, and in turn has led to the development of new strengths  along with evidence of ongoing weaknesses. The repercussions of the pandemic have not yet been fully established; health systems have been subjected to  one of their biggest tests in all of history, and the pandemic has shown that there is an imperative need to structure and implement new models of care. 

Since the institution of total confinement, the collapse of the health care systems in this region has led to the inability to manage and follow up acute and chronic neurological and neurosurgical disorders, and has claimed the lives of many people [6,7]. This catastrophe is a reflection of the lack of centers specialized in the management of these pathologies, and the lack of personnel trained in neurocritical care [8]. There are few institutes of higher education or scientific societies that offer fellows or postgraduate degrees in neurocritical care, limiting the care of these critical conditions and saturating the departments of general neurology or general neurosurgery, as there are no other departments for referral of neurocritical patients. 

In addition to the development of postgraduate programs and specialized courses in neurocritical care, there are many other aspects that need to be reinforced. 

Strengthening of clinical research

One of our priorities is the creation of a cultural foundation of research in neurocritical care. Such implementation of research as a bedrock of neurocritical care practice will allow us to keep the physicians and staff of our units updated and active [9,10]. Further strengthening of international collaborations is also key for both research and clinical purposes, as the pandemic has limited the opportunities for internships, observerships, and fellowships in the United States and elsewhere. 

Creation of a culture of continuous improvement

The continuous evaluation of adoption practices, quality standards, safety policies, and an overall approach to neurocritical care that is evidence-based will ensure the best care in the context of available resources. The implementation of tele-rounds and interactive case discussions can also be a useful strategy to fill in gaps in Latin American scenarios. 

Professionalism in neurocritical care

Neurocritical care should be a standard-bearer for the concept of professionalism, with implementation of practices and behaviors that embody the highest professional standards. Neurocritical management based on the codes inherent to medical practice should prevail as the highest representation of medical ethics [11,12]. 

Increasing the recruitment of physicians for critical care and neurocritical care

In Latin America, the management of critical patients does not lead to high reimbursement, so ensuring that working conditions and other work-related factors are adequate is paramount. Further, an increased awareness of burnout and employing local strategies to avoid it are recommended. 

Preparation of clinical practice guidelines adapted for Latin America

It is well known that the implementation of practice guidelines improves the standard of care provided for patients. However, lack of funding and insufficient infrastructure, especially in lower and middle income-level hospitals, prevents the universal implementation of some interventions that are central to neurocritical care (e.g. EEG) [13]. This is one of the most difficult points to advance, since it depends on government support and external funding. 

Teaching neurocritical care concepts beginning with early-stage medical trainees

One of the aspects that hinders the diffusion of knowledge in neurocritical care among physicians and specialists in Latin America is the lack of providers with specialized knowledge of this discipline. Strategies to improve awareness of neurocritical care can begin at an early stage. These include student interest groups in neurocritical care, which can be led by medical students (with oversight from faculty and residents with neurology, neurosurgery, and critical care backgrounds), as well as workshops, seminars, courses, and participation in scientific events [14,15]. Medical students can then empower themselves with these skills and lead the development of neurocritical care, especially in areas where the prevalence of traumatic brain injury caused by motorcycle accidents, cars, or violence, is still very high [2]. 

In summary, the COVID-19 pandemic represents an unprecedented test in Latin America. Facing the new challenges demanded of us by this new international context invites us to strive for the utmost professionalism in neurocritical care, strengthen international collaboration [16] in the design and conduct of prospective multicenter studies to generate high-quality evidence, and to continue to improve ourselves in other ways to mitigate the burden of disease generated by neurological and neurosurgical disorders. 

References 

  1. Avezum Á, Costa-Filho FF, Pieri A, Martins SO, Marin-Neto JA. Stroke in Latin America: Burden of Disease and Opportunities for Prevention. Glob Heart. 2015; 10(4):323-31.
  2. Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017; 16(12):987-1048.
  3. World Health Organization. Global Burden of Neurological Disorders: Estimates and Projections [Internet]. [Consulted 22 May 2021]. Available in: https://www.who.int/mental_health/neurology/chapter_2_neuro_disorders_public_h_challenges.pdf
  4. Lozada-Martínez I, Bolaño-Romero M, Moscote-Salazar L, Torres-Llinas D. Letter to the Editor: "Role of the Neurosurgeon in Times of Coronavirus Disease 2019 (COVID-19): The Importance of Focus in Critical Care". World Neurosurg. 2020; 143:624.
  5. Khan RA, Rahman M, Agrawal A, Garcia-Ballestas E, Moscote-Salazar LR. Global neurosurgery, Bangladesh and COVID-19 era: A perspective from a low-income country. Romanian Neurosurgery. 2020; 34(4), 574–576.
  6. Brucki SMD, Corazza LA, de Queiroz AP, Barros MP, Tatsch JFS, Riso IL, et al. Neurological complications in COVID-19 patients from Latin America. Brain. 2021; 144(3):e29.
  7. Mendes MF, Pitombeira MS, Dias-Carneiro RPC, Ferreira LC, Martins GJ, Brum DG. The challenges of monitoring neurological manifestations associated with COVID-19 in Latin America: does the World Health Organization need changes? Arq Neuropsiquiatr. 2020; 78(8):526-527.
  8. Mateen FJ. Neurocritical care in developing countries. Neurocrit Care. 2011; 15(3):593-8.
  9. Suarez JI, Martin RH, Bauza C, Georgiadis A, Venkatasubba Rao CP, Calvillo E, et al. Worldwide Organization of Neurocritical Care: Results from the PRINCE Study Part 1. Neurocrit Care. 2020; 32(1):172-179.
  10. Suarez JI, Geocadin R, Hall C, Le Roux PD, Smirnakis S, Wijman CA, et al. The neurocritical care research network: NCRN. Neurocrit Care. 2012; 16(1):29-34.
  11. Bohórquez-Rivero J, García-Ballestas E, Moscote-Salazar LR. Letter to the Editor: Role of Morality in Critical Care in COVID-19 Times. World Neurosurg. 2021; 146:389-390.
  12. Bohórquez-Rivero J, García-Ballestas E, Moscote-Salazar LR. Letter to the Editor: "The Neurosurgeon and Medical Professionalism During the COVID-19 Pandemic". World Neurosurg. 2020; 142:559-560. 
  13. Lozada-Martínez I, Maiguel-Lapeira J, Torres-Llinás D, Moscote-Salazar L, Rahman MM, Pacheco-Hernández A. Letter: Need and Impact of the Development of Robotic Neurosurgery in Latin America. Neurosurgery. 2021; 88(6):E580-E581. 
  14. Lozada-Martínez I, Bolaño-Romero M, Moscote-Salazar L, Torres-Llinas D. Letter to the Editor: 'Medical Education in Times of COVID-19: What's New in Neurosurgery?'. World Neurosurg. 2020; 143:603.
  15. Maiguel-Lapeira J, Lozada-Martinez I, Torres-Llinás D, Moscote-Salazar LR, Al-Dhahir M. Letter to the Editor. Academic and research interest groups in neurosurgery: a smart strategy in times of COVID-19. J Neurosurg. 2021. Online ahead of print
  16. Venkatasubba Rao CP, Suarez JI, Martin RH, Bauza C, Georgiadis A, Calvillo E, et al. Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2. Neurocrit Care. 2020; 32(1):88-103. 
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