Leading Insights

Ita Muharram Sari, MD National Brain Center Prof. Dr. Mahar Mardjono Hospital (NBC) is the main referral hospital specializing in brain and nervous systems under the Ministry of Health Republic of Indonesia. As a center of excellence, NBC gives advanced clinical practice on neurological diseases, education, and training for healthcare workers and also provides translational and comprehensive research in the neurological field. NBC is located in Jakarta and launched its first operation in July 2014 with a current capacity of 250 beds. Advance Clinical ...

Renad Abu-Sawwa, PharmD, BCPPS University of Florida, College of Pharmacy “When you adjust for hypoalbuminemia, his phenytoin level was therapeutic at 17.5 mcg/mL following his fosphenytoin load. In addition to starting maintenance phenytoin, I would recommend initiating ketamine rather than pentobarbital as adjunctive therapy given that he is in refractory status epilepticus (RSE). Unlike pentobarbital, ketamine does not have propylene glycol or other carbohydrates, thus it will maintain his state of ketosis.” This is just one example of ...

Steven M. Lazar, MD Chief Resident Neurodevelopmental Disabilities & Child Neurology Baylor College of Medicine Jon A. Cokley, PharmD, BCPPS Clinical Pharmacy Specialist – Pediatric Neurology Department of Pharmacy | Texas Children's Hospital Neurology Instructor Department of Pediatrics | Baylor College of Medicine Best practices in neurocritical care emphasize a multidisciplinary approach (Moheet et al., 2018). While various medical training pathways have been created, refined, and implemented within pediatric neurocritical ...

Masoom Desai, MD, Alexis Steinberg, MD, Fajun Wang, MD, Hana Nobleza, MD, MSCI, Deepa Malaiyandi, MD The journey of foreign physicians in the field of neurocritical care (NCC) can be full of exciting opportunities but also unsettling setbacks. International medical graduates (IMGs) seeking post-graduate education face challenges beyond mastering the requisite clinical and technical knowledge, including recalibrating their workflow and day-to-day life to a completely new world. This venture requires ...

Donald Langan, MD, PharmD, Alexandra Schroeder, PA-C Ischemic strokes in younger adults, those 18 to 50 years old, account for approximately 10% to 15% of all ischemic strokes. Risk factors for stroke between younger and older patients tend to be similar. Younger patients suffer from cardioembolic or embolic strokes of undetermined significance, while older adults, greater than 50 years, tend to have a higher frequency of ischemic stroke due to large vessel atherosclerosis or lacunar infarction. 1 Risk factors for cardioembolic stroke include atrial ...

Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV It is seven in the morning and you are starting your day in the ICU. The sign-out you received was that you have several complex new admissions from overnight. You go into a patient room and do not recognize the nurse or respiratory therapist. The mid-level on service is from an agency. You are also informed that there is a backlog of MRIs that need to be done since the technicians have quit to join a staffing company and leave town. Furthermore, there is a shortage of pharmacists and ECHO technologists. ...

Clio Rubinos MD, MSCR, University of North Carolina, Chapel Hill, NC Maria Jose Bruzzone MD, MSCR, University of Florida, Gainesville, FL Este artículo también está disponible en inglés: https://currents.neurocriticalcare.org/blogs/currents-editor/2022/06/07/continuous-eeg-monitoring-in-intensive-care-units- Introducción El uso del monitoreo continuo electroencefalográfico (cEEG) en la unidad de cuidados intensivos (UCI) ha aumentado significativamente en los Estados Unidos y otros países de ingresos altos (PIA) en los ...

Clio Rubinos MD, MSCR, University of North Carolina, Chapel Hill, NC Maria Jose Bruzzone MD, MSCR, University of Florida, Gainesville, FL This article is also available in Spanish: https://currents.neurocriticalcare.org/blogs/currents-editor/2022/06/07/monitoreo-continuo-de-eeg-en-las-unidades-de-cuida Introduction The use of continuous electroencephalogram (cEEG) monitoring in the intensive care unit (ICU) has increased significantly in the United States and other high-income countries (HIC) over the last few years. 1 ...

Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care. Beginning on January 1, 2022, split-shared critical care billing with APPs is now allowed by CMS and commercial insurance carriers. With this change, physicians can get credit for critical care done by the APP and the physician in their group, thereby avoiding the 15% billing reduction incurred by APP billing. A group is defined as a collection of practitioners practicing ...

Abdullah Al Jadidi, 1 Adil Al-Kharusi, 1 Keshavan H Venkatesh, 1 Sharma Pradeep Kumar, 1 Ruqaiya Al Harthi 2 1. Directorate of Anaesthesia, Critical Care, Pain Medicine 2. Respiratory Care Services, Khoula Hospital, Muscat, Sultanate of Oman The Beginning Neuroscience services in Oman were first established in Khoula Hospital in 1974. Khoula hospital was the first surgical hospital in the Sultanate of Oman and has a current capacity of 530 beds, catering to neurosurgery, neurology, orthopedics, plastic surgery, obstetrics and gynecology, ...

Marry T. Vuong, PharmD, BCPPS, Neurology Clinical Pharmacy Specialist, Nicklaus Children’s Hospital; Miami, Florida Introduction Rates of chronic conditions in pediatric patients are steadily increasing and the medications used to treat these conditions are also showing a proportional increase. Pediatric neurocritical care patients may experience polypharmacy resulting from the management of multiple co-morbidities, organ dysfunction and drug-drug interactions (DDI). In fact, the incidence of DDI in the critically ill can be as high as 58%. 1 ...

Shraddha Mainali MD, Jose Suarez MD, FNCS, FANA, Len Polizzotto PhD, Claude Hemphill MD, MAS, FNCS, DaiWai M. Olson PhD, RN, FNCS, Keri S. Kim PharmD, MS, CTS Following the 1 st NIH symposium held in September 2020, the National Institute of Neurological Disorders and Stroke (NINDS) collaborated with the Curing Coma® Campaign (CCC) to organize the 2 nd Curing Coma NIH symposium. This was a 3-day virtual symposium held from May 3-5, 2021. The symposium was well attended, with 154 participants on day 1 and 127 participants on day 2, and this diverse ...

Renad Abu-Sawwa, PharmD, BCPPS Pediatric Critical Care Clinical Pharmacy Specialist; UF Health Shands Children’s Hospital Clinical Assistant Professor; University of Florida, College of Pharmacy Burnout. Delirium. Both terms have infiltrated their way into medical literature in recent years, especially in the realms of psychiatry and neurocritical care, respectively. It is not my intent to belabor either of these terms to oblivion but rather present a unique perspective with a juxtaposition of the two conditions–opening the door for the clinician ...

During the 2nd annual World Coma Day , NCS and the Curing Coma ® Campaign invited patients and their providers to share their stories of recovery, in video format. Kertisha Brabson was a patient with anti-NMDA encephalitis who woke up from coma after 7 months and is now living a completely normal life as a dental assistant. This interview with Kertisha and her physician, Shraddha Mainali, talks briefly about her condition, her recovery process and her life as a coma survivor. #StoriesofHope #LeadingInsights ​​ ​

Krista M. Lim-Hing, MD Director, Neurosciences Intensive Care Unit at South Shore University Hospital Assistant Professor, Zucker School of Medicine at Hofstra/Northwell Health Michelle Schober, MD University of Utah School of Medicine Professor of Pediatrics Pediatric Critical Care Medicine Circulation of clinical guidelines and release of novel therapeutics, diagnostic technologies and other practice-changing scientific advances all too often precede the development of ethical frameworks needed for appropriate implementation. ...

Corey Fehnel, MD, MPH, FNCS Brandon Merical, MD In our inaugural Currents Researcher Spotlight, Beth Israel Deaconess Medical Center (BIDMC) neurology chief resident Brandon Merical profiles mentor Corey Fehnel, a neurointensivist at BIDMC and Assistant Professor of Neurology and Clinician Scientist at Harvard Medical School. Brandon credits Dr. Fehnel with shaping his own career trajectory, which will culminate in a fellowship in neurocritical care at the University of Pennsylvania starting later this year. Dr. Fehnel’s journey toward ...

Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV Director Critical Care Medicine, University of Rochester The global pandemic has had a major impact on ICU utilization. We have all experienced major shortfalls in being able to admit critically ill patients to properly staffed critical care units. This crisis has also been an opportunity for neurocritical care professionals to look inward and address how we can decrease the incidence of hospital and ICU admissions. One of the major addressable factors leading to hospital admission and ICU care is ...

Subash Phuyal, MD, DM Department of Neuro imaging and Interventional Neuroradiology, Upendra Devkota Memorial National Institute of Neurological and Allied Science Gentle S Shrestha, MD, FACC, EDIC, FCCP, FNCS Associate Professor, Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal Nepal is a small country located in south Asia, with diverse geography ranging from Himalayan regions in the north to plain terrains in the south. It is fully landlocked, bordered by China to the north and ...

Matthew N. Jaffa, DO and Evie G. Marcolini, MD Nearly every clinical decision presents us with the opportunity to lean into the historical ethos attributed to Hippocrates to “first, do no harm”, and to provide appropriate, beneficial, and safe care for our patients. If there is potential for harm, we of course will disclose this to the patients and family. The process of shared decision making and consent takes time; how should one balance the importance of informed consent against the risk that the passage of time would decrease efficacy of care? ...

Brian W. Gilbert, PharmD, MBA, BCCCP, BCPS, Emergency Medicine Clinical Pharmacy Specialist Residency Program Director, Critical Care Pharmacy Wesley Medical Center, Wichita, KS Brooke L. Barlow, PharmD Neurocritical Care Clinical Pharmacy Specialist, UF Health Shands Hospital, Gainesville, FL J. Spencer Dingman, PharmD, BCCCP, Neurocritical Care Clinical Pharmacy Specialist Barnes-Jewish Hospital, St. Louis, MO Optimal reversal strategies for factor Xa (FXa) inhibitor-associated intracranial hemorrhage (ICH) have garnered much attention ...

Dana Bakdach, Hamad General Hospital, Doha, Qatar (NOT PICTURED) Farah Kablaoui Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Nouran Salem, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Rita Jebrin, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Maha Elhamid, Hamad General Hospital, Doha, Qatar Background In the Middle East and North Africa (MENA), the scope of clinical pharmacy practice is relatively new and emerging. Several countries in the Middle East and the Gulf region (including Qatar, United ...

Shivani Ghoshal, MD As the wave of Omicron crashed onto hospitals this winter, memories from 2020 came flooding back, along with concomitant emotional fatigue. This month, Currents is especially honored to highlight creative works from two neurocritical care nurses from New York, at a time when many neurologic and medical ICUs are stretched from limited ICU nursing and staff. Here in two brief interviews, we focus on the creativity of these two nurses and the community the y’ve grown in response to COVID. Sharlene Chisholm, NP Sharlene ...

Mikel Shea Ehntholt Neurocritical Care Fellow, Hospital of the University of Pennsylvania Department of Neurology A 73-year old woman presented to our institution with a three-week duration of headache and dizziness. She had a past known history of an aneurysmal subarachnoid hemorrhage, secondary to a posterior communicating aneurysm that was coiled five years prior, hypertension, and hyperlipidemia. Her symptoms prompted an outpatient evaluation and was recommended for repeat digital subtraction angiography (DSA). On the day of the DSA she ...

Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV Director Critical Care Medicine, University of Rochester Those of us working in neurocritical care are the frontline individuals caring for ICU patients with acute stroke. This allows us a special opportunity to educate patients and families on the risks of Obstructive Sleep Apnea (OSA), both as the possible cause of a stroke and as a potential complication of a neurological event. Many patients and health care providers are totally unware of this relationship between OSA and stroke, and increasing ...

Sarah Jung, PharmD, MS, BCCCP Wellstar Kennestone Hospital; Marietta, Georgia The rise of the COVID-19 pandemic in 2020 was also accompanied by the peak of the Black Lives Matter movement. According to the U.S. Census Bureau, approximately 70% of the largest cities in the US grew more racially and ethnically diverse between 2010 to 2020. 1 We have seen these changes within our patient populations too. Being “woke” to cultural differences and sensitivities is not only expected now, but there is also demand for education on diversity, equity, and ...

Mahammed Khansuheb, MD; Amay Parikh, MD Percutaneous tracheostomy (PcT) is a technique first described by Shelden in 1957. Over 100,000 adults in the United States receive tracheostomies each year.  More than 50% of these are for prolonged mechanical ventilation due to acute respiratory failure.[1] Traditionally, tracheostomy is favored prior to the fourteenth day of mechanical ventilation to minimize injury to the tissue surrounding the endotracheal tube and to initiate aggressive ventilator weaning. Ultrasound-guided PcT (US-PcT) is advantageous ...

Aleksandra Yakhkind, MD MS is a neurointensivist who graduated from the University of Pennsylvania in June 2021. She is doing locums before she starts at Tufts Medical Center in 2022. Her interests include writing and burnout prevention. In her spare time, she enjoys surfing, hiking and skiing. Christa O’Hana S. Nobleza, M.D., MSCI is the Medical Director of the Neurocritical Care service of Baptist Memorial Hospital, affiliated with University of Tennessee Health Sciences University. Her interests include mentorship and diversity, cerebrovascular ...

Erika J. Sigman, MD, Jennifer C. Sarrett, PhD, Elizabeth M. Sivertsen, MBE, CCRN, HEC-C, Gillian E. Hue, PhD, Tommy T. Thomas, MD, PhD A 72-year-old man with Parkinson’s disease was admitted to the intensive care unit (ICU) after a fall. He suffered a high cervical spinal cord injury which required emergent decompression and laminectomy. As he failed to wean from the ventilator and discussion of tracheostomy ensued, we thought, “how could <his future we envisioned> be a good quality of life?” Prior to admission, he had a disability from a progressively ...

Yingying Su, Guoping Ren, Linlin Fan, and Huijin Huang The functional recovery of nerve cells after brain injury is extremely complex and difficult. Finding effective ways to save as many nerve cells as possible while retaining and maximizing neural function has become a common goal for neuroscientists, neurologists, and medical engineers worldwide. Among available interventions, therapeutic hypothermia (TH) and targeted temperature management (TTM) in the early phases of acute brain injury have shown some promise as effective neuroprotective treatments. ...

Halima M. Salisu-Kabara CCRN, BNSC, MPA, PhD, FWACN. Practice Consultant, Kano, Nigeria Shuaibu Dambatta MBBS, FRCS. Northfield Specialist Hospital, Kano, Nigeria Dalhat Salahu, FWACS. Department of Anaesthesia, Bayero University Kano/Aminu Kano Teaching Hospital Kano, Nigeria Abdullahi S. Ibrahim, RN, CCRN, PGDPHEP, BNSc (in view) Intensive Care Unit, Aminu Kano Teaching Hospital, Kano, Nigeria Folakemi Olufunbi Olufemi-Iseyemi, CCRN, BNSc Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria   Introduction Nigeria is a ...

Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care.  In our next issue we will discuss the changes in critical care billing which will take effect on January 1, 2022 When providers are asked to admit patients to the NeuroICU, their initial efforts are focused on stabilization of the patient and placement of admission orders to get the patient access to specialized care. Documentation in the form of an H&P then becomes ...

Linda Dhennin, RN, CNS, APRN Critical care involves an endless series of crucial conversations; among the most difficult is the brain death confirmation/declaration conversation. However, good teamwork and the application of effective systems for communication can ease the burden on both healthcare professionals and families. In the United States, the incidence of brain death is about 2% (Seifi et al., 2020), which translates into approximately over 500,000 of these devastating conversations each year. Research has shown that these conversations ...

Toufic A. Chaaban, MD Neurocritical care units are becoming the standard of care in referral centers for acute brain injury patients in North America 1,2 . There is now ample evidence that neurocritical care improves overall and neurological outcomes 3 of critically ill neurological patients, decreases mortality 3-5 , and shortens hospital stay 4 . This evidence emerged from specialized centers mainly in North America and Europe, but the worldwide implementation of neurocritical care units is lagging. In the following article, the challenges and ...

Logan Pyle, Vasisht Srinivasan, Kelly Rath, Jordan Bonomo Case Details A 30-year-old man with a past medical history of polysubstance drug abuse, chronic Candida bacteremia and endocarditis status post mitral valve (MV) replacement, prior right middle cerebral artery stroke, and left posterior cerebral artery aneurysm rupture (presumed mycotic) presented to an academic tertiary care hospital in January 2020 with abdominal pain and transaminitis after coil embolization for hepatic pseudoaneurysm. While on the surgical service he developed acute ...

Robert Alexander Bodroghy, MD, PGY-2 Neurology Resident, Temple University Lauren Koffman DO, MS Assistant Professor of Neurology, Temple University Hospital, Philadelphia, PA The word summertime usually evokes thoughts of vacations, outdoor activities, and a more easy-going lifestyle, especially for college aged kids. June 5, 2011, put an unexpected end to the spoils of my summertime fun. I was nineteen years old and had just finished my first semester of undergraduate studies, with a major in athletic training. The last exam I took was ...

Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV The worldwide pandemic has developed many stressors on those in the Neuro ICU, such as taking care of critically ill non-Neuro Patients outside of normal comfort level, overworked staff, and working in areas we have not normally had too: such as caring for patients in overflow ICU’s such as recovery rooms. It has also brought into focus an already identified problem, that of ICU staff burnout. The literature defines burnout as “exhaustion of physical or emotional strength or motivation, usually the result ...

Jennifer Mears, PA, Weill Cornell Medicine/New York-Presbyterian Hospital Judy Ch’ang, MD, Weill Cornell Medicine/New York-Presbyterian Hospital Introduction   The incidence of subarachnoid hemorrhage (SAH) patients who develop Takotsubo cardiomyopathy (TCM) is approximately 4-15%. 1 Vasospasm is another common complication of SAH. Treatments of vasospasm can compromise cardiac function. 2 This case report suggests cardiac point of care ultrasound (cPOCUS) may be assistive in frequent monitoring of cardiac status and management ...

Co-Chairs of the Member Sites Module Chethan Venkatasubba Rao, MD, FNCS cprao@bcm.edu Briana Witherspoon, DNP, APRN, ACNP Briana.Witherspoon@UTSouthwestern.edu Curing Coma®  is the signature clinical, scientific, and public health effort of the Neurocritical Care Society. Curing Coma is comprised of several modules, all of which share the common goal of advancing the campaign’s mission (1, 2). The role of the Member Sites module is to create and maintain a platform that engages and facilitates multidisciplinary participation from ...

Diane McLaughlin, DNP, UF Health Jacksonville, Department of Neurology and Kimberly McPhearson, DO, Mayo Clinic Jacksonville, Department of Critical Care Neurological checks (neuro checks) are brief, serial bedside exams performed by nursing to evaluate for changes in clinical status or neurological function. Historically conducted hourly in the neuroscience intensive care unit (NSICU), patients undergo these evaluations regardless of the time of day. A typical neuro check often includes assessment for pupillary response and level of consciousness, ...