By Dheeraj Khurana, MD1 (left); Kiran Jangra, MD2(center); and Gagandeep Singh, MD, DM3(right)
- Department of Neurology, Postgraduate Institute of Medical Education and Research
- Department of Neuroanesthesia, Postgraduate Institute of Medical Education and Research
- Department of Neurology, Dayanand Medical College & Hospital, Ludhiana
Neurocritical care is a vast specialty that covers various subspecialities, including neurology, neurosurgery, neuroanaesthesiology and interventional neuroradiology. In India, this field is most developed in the major cities while it is still emerging in various other cities and underprivileged areas. The rising incidence of neurotrauma and stroke and advances in neurosurgical techniques warrant the need for more neurocritical care setups.
The current population of India is over 1.2 billion and still on rise by approximately 18 million per year. The origins of critical care in India can be traced back to the early 1960s when a formal society of critical care, the Indian Society of Critical Care Medicine (ISCCM), was created in 1993. In 1951, eminent neurosurgeons and neurologists founded the Neurological Society of India (NSI). This society annually organizes various conferences (including Neurological Surgeons’ Society of India) and neurocritical care workshops.
In 1992, Indian neurologists initiated the Indian Academy of Neurology.1
In February 1995, Professor H. H. Dash, head of neuroanaesthesiology at All India Institute of Medical Sciences (AIIMS), New Delhi, organized the first International Symposium on Neuroanaesthesia and Critical Care where anaesthesiologists interested in neuroanaesthesia could interact with many distinguished international faculty. Subsequently, in 1996, a Neuroanaesthesiology Society of India akin to the international body, the Society of Neuroanesthesiology and Critical Care (SNACC), was convened. During that meeting, NSI also initiated its support to the program.
In February 1999, a focused group of neuroanaesthesiologists formed the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC). Since then, the annual conference is a regular feature and is hosted in different cities of India every year. Around a decade later, in 2009, The Indian Neuroanaesthesiology and Critical Care Trust was formed.
Since then, the society has grown and affiliated with international societies such as Asian Society for Neuroanesthesiology and Critical Care (ASNACC) and SNACC. Hosting the second ASNACC Conference along with ISNACC - 2011 at New Delhi under the leadership of Dr. H. H. Dash, was a testimony to that. Neurosonology has also taken off in India with the recently formed Neurosonology Society of India (2014), which also has annual meetings as well as conducts an annual neurosonology certification examination.
In most centers, neurocritical care is instituted in general ICUs. An internet-based survey conducted by Amin in 2013 revealed that out of the 162 respondents, 59 (36.42 percent) had exclusive neurocritical care units.2
There may be approximately 100 to 125 neurosurgical ICUs in India, but their distribution is not uniform throughout the country. Recently (in 2017), AIIMS has initiated a one year fellowship in neurocritical care. There are eight stroke registries in various states in India that have stroke surveillance systems, based on the WHO STEPS guidelines. The Indian Council of Medical Research (ICMR) had tried to integrate these registries, but it is still under development. Although, as per a 2013 publication, approximately 35 stroke units exist in India3, which include a multidisciplinary team comprising of medical, nursing, physiotherapy, occupational therapy, speech therapy and social work staff. Currently, the number of stroke units has increased and a conservative estimate would put them close to over 50. The ICMR has recently sanctioned the Indian Stroke Clinical Trials (INSTRUCT) network to conduct clinical trials for advancement of stroke treatments in India (www.instructnetwork.in
Various monitoring modalities are being used in neurocritical care units including ICP monitoring (intraventricular/optic nerve sheath diameter), Transcranial Doppler, EEG and EEG based monitors, and, in a few research institutes, microdialysis (Figure 1).
Commercially available systems for ICP monitoring are rarely used, and only in a few centers, as these are extremely expensive for the Indian setting.4
The most commonly used modality for ICP monitoring is the intraventricular drain, but it is associated with high incidence of nosocomial meningitis.
Neurocritical care is currently a requirement, especially in the emerging stroke programs since most of these centers, such as AIIMS, Postgraduate Institute of Medical Education and Research (PGIMER) and National Institute of Mental Health & Neuro Sciences (NIMHAS) are routinely carrying out endovascular therapy. Dedicated neurointensive care can improve the outcome of neurological and neurosurgical patients undergoing various procedures.
Recently, a few centers in India have started various training courses in neurocritical care, such as a two year training course of postdoctoral fellowship in neuroanaesthesia and critical care and a one year postdoctoral fellowship in neurocritical care at AIIMS New Delhi and NIMHANS Bangalore. There is an increasing need of establishing more neurointensive care units in India. Neurointensive care training, workshops and seminars are being increasingly organized to train caregivers.
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- Ganapathy K. Neurosurgery in India: an overview. World Neurosurg 2013; 79:621-8.
- Amin P. Indian critical care discussion group survey. Indian J Crit Care Med, Forthcoming 2014.
- Pandian J D, Sudhan P. Stroke Epidemiology and Stroke Care Services in India. J Stroke 2013;15:128-34.
- Joseph M. Intracranial pressure monitoring in a resourceconstrained environment: a technical note. Neurol India 2003;51:333-5.
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