Leading Insights

Michelle Schober, MD, MS Audrey Paulson, DNP, FNP-BC, CCRN, CNRN, SCRN Ethical principles common to the various health care professions include the concepts of justice, nonmaleficence, beneficence, and autonomy. The American Nurses Association (ANA) Code contains these concepts and cites three additional principles: veracity, accountability, and fidelity. The ANA Code outlines “the fundamental values and commitments as a nurse,” identifies “the boundaries of duty and loyalty,” and describes “the duties of the nurse that extend beyond individual ...

By Sarah Livesay, DNP, APRN Associate Dean, Rush University, President NCS Mary Kay Bader, RN, MSN, Neurocritical Care CNS, Mission Hospital Mission Viejo CA, Past President NCS Karen Hirsch MD, Associate Professor of Neurology, Division Chief Neurocriticial Care, Stanford University Romer Geocadin MD, Professor of Neurology, Johns Hopkins University, Past President NCS All who watched Monday Night Football this week were shocked and dismayed to witness Damar Hamlin collapse after experiencing a cardiac arrest, when the heart either stops ...

Lindsey Coppiano, PharmD, BCCCP, Neurocritical Care Pharmacist Augusta University Medical Center; Augusta, Georgia Jessica Ringler, PharmD, BCCCP, Neurocritical Care Pharmacist Augusta University Medical Center; Augusta, Georgia Hypertonic solutions are high risk yet life-saving medications which can make the difference between a good or poor outcome during a neurologic emergency. Unfortunately, quick and reliable access to these medications can be challenging. One of the challenges faced is storage, as safety concerns limit where ...

Hera A. Kamdar, MD, MBBS Erin D. Wieruszewski, PharmD, R.Ph. Jennifer A. Kim, MD Minjee Kim, MD Shraddha Mainali, MD Sherif Hanafy Mahmoud, BSc (Pharm), MSc, PhD, FNCS The 20th Neurocritical Care Society (NCS) Annual Meeting celebrated a long-awaited reunion of peers, showcased cutting-edge research, and hosted a wide variety of neurocritical clinical care and career development workshops. The convention was a meeting ground for innovation and community, and at the ...

By Scott DeBoer, MD, PhD, Melissa Dang, PharmD Salia Farrokh, PharmD The ICP program was designed and implemented in 2017 to provide NCS members a venue to initiate or expand clinical pharmacy services in the neuro ICU. Applicants request that a senior member of the pharmacy section visit their institution to meet appropriate stakeholders, give a presentation, and/or round with the clinical team to provide insight and recommendations on developing pharmacist involvement. Both the applicant and ICP are encouraged to present their experiences at the ...

By Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV The DEA Washington Division is warning local residents of a dangerous new drug emerging in the DC area that is as deadly as fentanyl. We as neurocritical care practitioners may therefore soon find ourselves caring for patients that have overdosed on this drug and may be suffering from severe hypoxic injury and coma. In the fall of 2019, a new synthetic opioid named isotonitazene made its debut in the US and Canada. The drug, which is not a derivative of fentanyl but is equally as potent, is legal ...

Erin D. Wieruszewski, PharmD, R.Ph. Hera A. Kamdar, MD, MBBS Shraddha Mainali, MD Jennifer A. Kim, MD The NCS Trainee Section launched the Research Mentorship Program in 2017 with the primary objective of providing support and guidance for Neurocritical Care trainees across multiple disciplines. The program initially started with residents and fellows, but has since expanded to included pharmacists, advanced practice providers, and nurses. Mentor-mentee matches are made by the Trainee Section Mentorship Committee ...

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, ...

Matthew N. Jaffa, DO Matthew P. Kirschen, MD, PhD Krista Lim-Hing, MD Michelle Schober, MD Mitchell Hargis, MD Jamie Labuzetta, MD, MSc, MPhil The art of medicine requires practice honed through careful study of masters. Before we are tasked with snaking a 7Fr catheter into the subclavian vein unsupervised, we’ll have at least reviewed the relevant NEJM video and performed a number of procedures under the careful supervision of a senior clinician. Skill requires instruction, supervision, ...

By 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. Physician compensation in academic and hospital-based employment models has historically involved a base salary and some sort of incentive program. The structure and extent of these incentive programs have varied greatly amongst organizations ranging from incentives based on the individual’s financial productivity to incentives based on the department’s or system’s ...

By Eric Dornoff, MD; Kelly Rath DNP; Vasisht Srinivasan MD Case Details A 38-year-old woman, previously healthy, was admitted to the neuroscience intensive care unit following a thoracic fusion. On post-op day four, the patient suffered a syncopal event and was hypotensive, tachycardic, and hypoxemic. A rapid response was called, she was started on oxygen by nasal cannula, given intravenous fluid boluses, and admitted to the neurocritical unit for further monitoring and work-up. An EKG was obtained, which ...

By 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 ...