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 . 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 . 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 . 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 . The hospital is now known as Hospital Nacional “Guillermo Almenara Irigoyen” and eventually expanded into a larger polyvalent ICU . 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 . 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) .
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 . 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 .
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 . 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 . 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 . 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 . 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 . 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 .
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) . 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 . 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
- Reisner-Senelar L (2011) The birth of intensive care medicine: Bjorn Ibsen's records. Intensive Care Med 37:1084-1086
- Marshall J (1961) The work of a respiratory unit in a neurological hospital. Postgrad Med J 37:26-30
- 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
- Lott JP, Iwashyna TJ, Christie JD, Asch DA, Kramer AA, Kahn JM (2009) Critical illness outcomes in specialty versus general intensive care units. Am J Respir Crit Care Med 179:676-683
- Vera Carrasco O (2015) Origen y desarrollo histórico de la medicine crítica y unidades de cuidados intensivos en Bolivia. In: Rev. Med. La Paz. pp 77-90
- Reynoso PDK, J.; Ayala, M. (2017) Perspectiva histórica de la medicina intensiva española. In: Tratado de medicina intensiva. pp 1-13
- Porcayo-Liborio S R-DE, Orta-San-juan D. (2010) The evolution of neuro-critical care in Mexico. . Rev Mexicana de Anestesiologia 33:50-55
- Mejia-Mantilla JH, Aristizabal-Mayor JD (2017) Capacidad operativa de las unidades de cuidados intensivos colombianas y latinoamericanas en el manejo de la hemorragia subaracnoidea: un acercamiento preliminar. Acta Colombiana de Cuidado Intensivo 17:241-246
- Sala Domingues JRM, Edward. (2011) Brazilian neurointensive care: a brief histor. Arq Bras Neurocir 30:166-168
- Kurtz P (2018) Featured program: Neurocritical Care at the Paulo Niemeyer State Brain Institute (IECPN) in Rio de Janeiro, Brazil. In: Currents. Neurocritical care society
- Cariqueo Arriaga M (2017) Clinical Pharmacy Practice in Chile: Focus in Neurocritical Care. In:Neurocritical Care Society, Currents
- (2022) Sección Cuidados Neurocríticos. In, Hospital Italiano de Buenos Aires
- Maldonado NJ, M.; Scherle, C.; Suarez, J. (2017) Neurocritical Care in Ecuador. In: Currents. Neurocritical care society
- Suarez JI (2006) Outcome in neurocritical care: advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med 34:S232-238
- Suarez JI, Zaidat OO, Suri MF, Feen ES, Lynch G, Hickman J, Georgiadis A, Selman WR (2004) Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med 32:2311-2317
- Llompart-Pou JA, Barea-Mendoza JA, Sanchez-Casado M, Gonzalez-Robledo J, Mayor-Garcia DM, Montserrat-Ortiz N, Enriquez-Giraudo P, Cordero-Lorenzana ML, Chico-Fernandez M, en representacion del Grupo de Trabajo de Neurointensivismo y Trauma de la S (2020) Neuromonitoring in the severe traumatic brain injury. Spanish Trauma ICU Registry (RETRAUCI). Neurocirugia (Astur : Engl Ed) 31:1-6
- Chesnut RM, Temkin N, Videtta W, Petroni G, Lujan S, Pridgeon J, Dikmen S, Chaddock K, Barber J, Machamer J, Guadagnoli N, Hendrickson P, Aguilera S, Alanis V, Bello Quezada ME, Bautista Coronel E, Bustamante LA, Cacciatori AC, Carricondo CJ, Carvajal F, Davila R, Dominguez M, Figueroa Melgarejo JA, Fillipi MM, Godoy DA, Gomez DC, Lacerda Gallardo AJ, Guerra Garcia JA, Zerain GF, Lavadenz Cuientas LA, Lequipe C, Grajales Yuca GV, Jibaja Vega M, Kessler ME, Lopez Delgado HJ, Sandi Lora F, Mazzola AM, Maldonado RM, Mezquia de Pedro N, Martinez Zubieta JR, Mijangos Mendez JC, Mora J, Ochoa Parra JM, Pahnke PB, Paranhos J, Pinero GR, Rivadeneira Pilacuan FA, Mendez Rivera MN, Romero Figueroa RL, Rubiano AM, Saraguro Orozco AM, Silesky Jimenez JI, Silva Naranjo L, Soler Morejon C, Urbina Z (2020) Consensus-Based Management Protocol (CREVICE Protocol) for the Treatment of Severe Traumatic Brain Injury Based on Imaging and Clinical Examination for Use When Intracranial Pressure Monitoring Is Not Employed. J Neurotrauma 37:1291-1299
- Petroni G, Quaglino M, Lujan S, Kovalevski L, Rondina C, Videtta W, Carney N, Temkin N, Chesnut R (2010) Early prognosis of severe traumatic brain injury in an urban argentinian trauma center. J Trauma 68:564-570
- Maldonado NJR-E, C.; Suarez, J. (2017) The Neurocritical Care World Society Launches First South American Regional Conference and ENLS Course in Spanish. In: Currents. Currents