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Clio Rubinos MD, MS; Lia C. Franco Castro MD, Jorge Mejia-Mantilla MD  

 
Vea este artículo en español: https://currents.neurocriticalcare.org/blogs/currents-editor/2022/08/16/cuidados-neurointensivos-en-america-latina-un-futu

The first intensive care unit (ICU), as it is currently known, was created by the Danish anesthesiologist Bjørn Aage Ibsen (1915-2007). Facing one of the world’s worst polio epidemics, Dr. Ibsen treated the first ICU patients at Blegdam Hospital in Copenhagen in 1952. A year later, in December of 1953, he developed a specialized centralized respiratory care unit at his hospital Copenhagen Community Hospital [1]. By 1954, the Batten Respiratory Unit in the Institute of Neurology and National Hospital for Nervous Disease in England opened its door for ICU care [2]. The unit continued caring for patients with other neurological diseases that cause respiratory failure and with time critical care medicine noted that up to 30% of the patient population in the ICU had neurological emergencies and post-neurosurgical needs [3, 4]. Latin America and the Caribbean were not oblivious to the global critical care development, and multiple ICUs were created in the late sixties and early seventies [5]. Since then, with the irrefutable and constant growth of our Neurointensive Care needs, the creation of dedicated units for this patient population is becoming the standard of care. Latin America, with 20 countries and a rich ethnic, cultural, and economic heterogeneity, is a large and diverse territory that is in constant growth and has proven to be in emergent need for the field.   

The beginning and evolution of neurointensive care units in Latin America is rarely described. It’s possible that neurosurgeon Dr. Esteban Roca created the first Neurointensive care unit in Latin America in Hospital Obrero of Lima, Peru, in 1947 [6]. The hospital is now known as Hospital Nacional “Guillermo Almenara Irigoyen” and eventually expanded into a larger polyvalent ICU [6]. In Mexico, neurocritical care started with the “Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez” in 1964. It was a post-surgical ICU run by neurosurgeons, and in 1989 its management was transferred to medical critical care doctors [7]. Colombia opened the “Instituto Neurológico de Colombia” in Bogota in 1973, which eventually started to offer critical care services. It does not exist today but preceded the creation of the now known “Instituto Neurológico de Colombia” in Medellin in the 1990s, offering care for neurological emergencies. Now, like other countries, most neurocritical care is managed in polyvalent ICU, and some have specialist neurology subsections (e.g., the Neurocritical care unit in Fundación Valle del Lili in Cali, Colombia) [8].   

For Brazil, the first known model of a neurocritical care unit can be dated back to 1973, when the School of Medicine of the Universidade de São Paulo was asked to create a unit to care for post-neurosurgical patients and other neurological emergencies. Several decades later, in 2008, a Neurological ICU opened at the Beneficiência Portuguesa Hospital of São Paulo, followed by two more units in 2009 in Sirio-Libanes and Albert Einstein Hospitals [9]. In 2013, Paulo Niemeyer State Brain Institute (IECPN), the largest neuroscience center in Rio de Janeiro, was created with a multidisciplinary Neurocritical care unit leaded by trained neurointensivists and neurosurgeons [10].    

Several other countries soon followed suit. In 1980, Chile established its first Neurological ICU in the “Instituto de Neurocirugia Dr. Alfonso Asenjo,” a public academic hospital solely dedicated to neurological pathologies, with an 8-bed critical care unit [11]. In Argentina, the first Neurocritical care unit was founded in Hospital Italiano of Buenos Aires in 2012, followed by the Neurocritical care unit in Sanatorio Pasteur of San Fernando del Valle de Catamarca, Argentina [12]. In both countries, neurocritical critical care sections have stronger influences as part of their polyvalent ICUs and are noted for their contributions to the local literature and regional societies.   

In other Latin American countries, however, dedicated Neurocritical care units do not yet exist. Reports from Ecuador showed significant steps toward caring for the neurologically ill at the polyvalent ICU within Hospital Eugenio Espejo [13]. Other countries have shown immense educational efforts with local healthcare providers. From recurring seminars and emergency neurological life support (ENLS) courses, to established annual neurocritical care curriculums, our Latin American colleagues are findings ways to successfully care for the neurocritically ill.  

Neurological critical care in Latin America has flourished, whether it involves taking care of post-surgical patients or the complex resuscitation of patients with severe neurological injuries. There is no doubt that the creation of a Neurological ICU provides specialized care for this specific population, with improved clinical outcomes including shorter ICU and hospital stays, and likely a lower mortality rate when compared to polyvalent ICUs [14, 15].  Indeed, neurointensivists have received specific training in relevant clinical physiology including intracranial pressure, cerebral blood flow, cerebral perfusion, and central nervous system metabolism, as well as neuromuscular and cerebral electrophysiology and systemic complications involving the nervous system. However, this specialized training is not always available in Latin America and there are few physicians, nurses, pharmacists, and other providers with a formal background in neurocritical care.   

Prevention of secondary brain injury after an acute brain insult is the goal of neurocritical care, and we strive to achieve this using all the tools and medical technology at our disposal. This includes bedside vital sign monitoring and assessment of subtle clinical changes, and advanced monitoring modalities that measure intracranial pressure, cerebral oxygenation, and electrographic seizures. However, neurocritical care for these illnesses is costly and resource-intensive; as a result,  comprehensive care is unsurprisingly unavailable in many Latin American healthcare systems. For example, the use of intracranial pressure monitoring in severe traumatic brain injury is highly variable, with its use being less prevalent than might be expected due to resource limitations and clinical attitudes [16]. Because of this limitation, the CREVICE (Consensus REVised Imaging and Clinical Examination) protocol was developed after the BEST-TRIP trial as part of a project supported by the National Institutes of Health. The CREVICE protocol provides an evidence-based system for noninvasive neuromonitoring in centers with ready access to a computed tomography scanner and the capacity for close bedside monitoring of the neurologic examination [17].  The CREVICE protocol is not only useful in Latin America, but potentially also in high resource countries, in which similar patients are also managed without ICP monitoring in 23-89% of the cases [17].     

Neurointensive Care Societies 

Neurocritical Care Society (NCS), a non-profit organization, was created in 2002 with the support of the Society of Critical Care Medicine. NCS is the professional society representing multidisciplinary teams of neurocritical care providers around the world whose mission is to improve outcomes for patients with life-threatening neurological illnesses. Parallel to the creation of NCS, Consorcio Latinoamericano de Lesion Cerebral (Latin American Brain Injury Consortium, Labic.la) was founded in Latin American in October 2003.  During its first years, LABIC focused on participating in symposiums and conferences to strengthen neurocritical care education for physicians, nurses and therapists in Latin America. LABIC also conceived and executed a series of studies assessing the state of brain trauma management in Latin America, which eventually led to a prospective randomized trial on the utility of intracranial pressure monitoring in trauma called BEST-TRIP (although this later study was not a LABIC project) [18]. More recently, LABIC has strengthened as an association, and one of its priorities is disseminating knowledge about neurocritical care and collaborating with other associations to promote research (Table 1).   

NCS, LABIC, and other local societies (Table 1) have worked together for over a decade in the training of healthcare providers in Latin America. The first ENLS course in Spanish took place in 2017 during the first Latin America Neurocritical care world society regional conference in Quito, Ecuador [19]. In 2018, the first online Spanish course, “Electroencephalography for Non-Experts,” was launched on LABIC’s website. This virtual course aimed to spread and strengthen the knowledge of electroencephalography among intensive care professionals, and in 2019 LABIC started biweekly scheduled online webinars. These webinars cultivate skills and knowledge in important topics related to neurocritical care and are available throughout Latin America 

There has been an enormous effort to further advance neurocritical care in Latin America, but there is still more work to be done. With the innovative but short-lived neurointensive care unit in Peru in the late 1940s, followed by Mexico’s neurocritical care unit in the 1960s, Brazil’s in the 1970s, and Chile’s in the 1980s, Latin America’s presence in the field has been stronger than previously recognized. Even in the last 10 years, several additional units and sections of neurocritical care have been created, particularly in Brazil and Argentina. Neurointensivists have the challenging task of leading the effort to advance this field further. This requires implementing systems of care, establishing international collaborations and research to collect global data on the practice of neurocritical care, and proposing curriculums and advanced training programs for a future generation of subspecialists.  

Table 1. List of critical care societies per region and country.  

** Not officially part of Latin-America, but culturally and regionally recognized  

References 

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3. Ruiz CD, Miguel Angel; Zapata, Juan Marcelo; Bravo, Sebastian; Panay, Sergio; Escobar, Cristina; Godoy, Jorge; Andresen, Max; Castro, Ricardo. (2016) Characteristics and evolution of patients admitted to a public hospital intensive care unit. Rev méd Chile 144
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