Leading Insights

By Peter J Papadakos, MD, FCCM, FCCP, FAARC, FNIV During the worldwide COVID-19 pandemic, critical care practitioners throughout the United States and the world were instructed by health agencies, government leaders and hospital administration to ban family members from visiting critically ill patients.  The question I ask, along with many of my critical care peers, is - did we do more harm than good to our patients and their families?  How did the rush to deal with this pandemic and flatten the curve affect our bedside care?  Did what these leaders ...

By Kia Ghiassi, Department of Neurology, Missouri University, Columbia Missouri;  Jesyree Veitia, Universidad Central de Venezuela, Caracas, Venezuela; and Francisco Gomez, Department of Neurology, Missouri University, Columbia Missouri Adequate cerebral blood flow (CBF) is a key component in ensuring optimal oxygen delivery to brain parenchyma, considered a biomarker of tisular health and function with clinical utility. CBF when combined with MAP allows for inference of cerebral autoregulation, as a measure recommended by the NCS and European Society ...

By Michael Diringer, MD The financial infrastructure for scientific publishing is being completely transformed by a desire to ensure that scientific knowledge is freely accessible to all.  The power behind this transformation resides with those who fund research; they are insisting that reports of work they fund be freely and immediately available.  In the past, scientists published their research in journals at no cost, and publishers made money by charging individuals, universities, and other institutions for subscriptions.  The new concept, referred ...

By Jamie Nicole LaBuzetta, MD, MSc, MPhil, Division of Neurocritical Care,Department of Neurosciences, UC San Diego Health In the early 1990s, most physicians were Republicans.  Three decades later, the demographic composition of the medical workforce has shifted 1, 2 , and so has the overall political alignment of physicians. Now, physicians are roughly split between the two major political parties, though data suggest that some specialties have political tendencies; for instance, practitioners in fields such as surgery lean Republican, whereas those ...

By Tommy T. Thomas, MD, PhD; Ebonye Green MNSc, ACNPC-AC, CNRN, SCRN, APRN; Deepa Malaiyandi, MD and Hana Nobleza, MD Some of us watched the videos. A doctor’s cry for help from the very medical establishment to which she belongs. A CEO expresses contrition by saying that there were “good people” on both sides. A man cries out for his mother as he was robbed of breath. We ask the question, “How we can avoid this situation?” The answers lie far beyond this isolated incident. They are buried in the awareness and analysis of a long history of ...

By Starane Shepherd, MD, Assistant Professor of Neurology, Rush University Medical Center, Chicago, IL Over the last year of this pandemic, I have taken care of a large number of patients with COVID-19 infections in our neurocritical care unit. At the height of the surge in Chicago, our unit became one of the COVID-19 ICU surge units and battled the health crisis sweeping through my city, Chicago, the United States and the world. While taking care of these patients, struggling for their every breath, one factor stood out to me: their race. Most of ...

By Matilda Dervisevic 1 , Chetan Sateesh Nayak 2  and Francisco Gomez 3 1 Univeristy of Missouri Medical School 2 Department of Neurology, University of Missouri 3 Department of Neurology, University of Missouri Refractory status epilepticus (RSE) is a condition in which there is continuing seizure activity despite the administration of two first-line agents. Super-refractory status epilepticus (SRSE) is described as continual RSE for 24 hours, or with recrudescence upon withdrawal of anesthetic agents. As a neurological emergency, RSE confers ...

By Stephen A. Trevick, MD, Northwest Neurology, IL  The emotional impact of the COVID-19 pandemic will be felt throughout society for months and years to come.  This impact will come in many guises and patterns throughout medicine and certainly in the acute care of neurocritical care patients.  Resources will continue to be limited and healthcare providers may be reassigned between specialties and units.  Our neurological patients will have concerns, often justifiably, that their care is suffering. Each human being has a hierarchy of needs.  It is ...

By Lucie Pelunkova, MSc, Critical Care Nursing, Nurse Educational Specialist, Neurologic Critical Care Unit, Cleveland Clinic Abu Dhabi; Nouran Salem, PharmD, BCCCP, MBA, Critical Care Pharmacotherapy Specialist, Cleveland Clinic Abu Dhabi; Seby John, MD, Consultant Neurologist, Vascular Neurology and Neurointerventional Surgery, Neurological Institute, Cleveland Clinic Abu Dhabi; Fadi Hamed, MD, Consultant Intensivist, Section Head, Medical and Surgical Critical Care Unit, Critical Care Institute, Cleveland Clinic Abu Dhabi; and Jamil R. Dibu, MD, Consultant ...

By Yingying Su, MD, PhD The 11th National Conference of Neurocritical Care Committee of the Chinese Society of Neurology (NCC/CSN) was held on Aug. 23-29 2020. We would like to thank Prof. Jose, the director of Neurocritical Care, and Prof. Gene and Brophy, the former director of Neurocritical Care, for their emails and videos to wish the conference a success. May the COVID-19 epidemic end soon, and the neurointensivists of Neurocritical Care Society (NCS) around the world will meet again.  The whole conference was held online for the first time. ...

By Thomas D. Bernier, PharmD; and Michael Schontz, PharmD, BCPS, BCCCP Aneurysmal subarachnoid hemorrhage (aSAH) accounts for 5% of all strokes, and due to a multitude of complications, patients are at exceptional risk of mortality and morbidity. 1 The incidence of aSAH is geographically diverse varying between 2 and 16.5 per 100,000 hospitalized adults globally. 2 Patients are at risk of multifactorial mortality and morbidity in aSAH, as patients can experience rebleeding, hydrocephalus, seizures, infections and notably delayed cerebral ischemia ...

By Ahmad Abdussalam, MD, MRCP UK, neuro intensivist, UCNS Certified; Dana Bakdach, BSC, PharmD, clinical pharmacist; Sundus Sardar, MBBS, medical resident; Nadir Kharma, pulmonary critical care and sleep medicine; Ali Ait Hssain, MD, DESAR, ECMO consultant; Adel Royce Mangodato, senior RN; and Ashraf Molokhia, MD, consultant intensivist and anesthetist In Qatar, the first case of COVID-19 was confirmed on Feb. 27, 2020. While the global death toll continues to climb, Qatar stands out with a low mortality rate of 0.14%, and 150 deaths to date. 1 ...

By Padmaraj Duvvuri, MD; Editor Lauren Koffman, DO, MS Over the past two years, there has been an ongoing effort to establish a Midwest Chapter within the Society of Critical Care Medicine (SCCM). I have tried to become an active member of the chapter and will be speaking at the upcoming inaugural conference on Aug. 29, 2020. During the COVID-19 pandemic I believe most of us have developed a renewed sense of comradery amongst all specialties and support staff. Now more than ever, we should work together to facilitate education across various aspects ...

By Anthony Jaworski, PharmD, BCCCP  A reported 6% of new onset seizures and 9% of status epilepticus cases are attributed to drug neurotoxicity. 1,2   Over the years, there has been a decline in cases of seizures from cocaine, theophylline and tricyclic antidepressant (TCA) toxicity. There are increasing reports of seizures from newer antidepressants, such as bupropion in the United States and citalopram in Switzerland. In Iran and Australia, the trend in tramadol poisonings are increasing, and seizure is a common complication.  In developing countries, ...

By Brian R. Schuler, PharmD, senior pharmacist;   Kaylee K. Marino, PharmD, BCCCP, BCPS, clinical pharmacy specialist; and   Michael Reznik, MD As pharmacists and clinicians working in the neurosciences intensive care unit (ICU), we understand the importance of agitation and delirium management and acknowledge the lack of evidence related specifically to the neurocritical care population. Although we do use propofol and antipsychotic medications in many cases, and prefer quetiapine or olanzapine because of less potent antidopaminergic effects, ...

By Telmo E. Fernandez-Cadena, Intensive Care, Guyaquil, Ecuador; Manuel Jibaja, director, Intensive Care Unit, Hospital Eugenio Espejo, Quito, Ecuador; Nelson Maldonado, MD, Neurocritical Care, Universidad San Francisco de Quito (USFQ); Miguel Andrade, MD Perspectives from Guayaquil, Ecuador On Feb. 29, 2020, the first case of SARS-CoV-2 in Ecuador was announced in Guayaquil. What we saw as a distant problem in Wuhan and New York had finally arrived. A city hospital was enabled with 24 intensive care beds for COVID-19, and the opening of ...

By Pravin George, DO, assistant professor of Neurology, Cleveland Clinic Lerner School of Medicine; staff, Neurointensive Care,   Cerebrovascular Center, Cleveland Clinic More than three months ago, New York City experienced the largest reported metropolitan surge of COVID-19 patients in the entire country, possibly in the entire world. In the blink of an eye, every NYC hospital census took an unprecedented upswing, and ICU teams were all swamped with a single, common, unknown adversary. At several hospitals, no longer was there a division between ...

Do you have questions regarding your professional life? Is there a conundrum at work that requires an outside perspective? The Trainee Section and Women in Neurocritical Care (WINCC) Section have teamed up to publish a column in Currents to serve your professional advice needs. Submit question s to winccmentorship@gmail.com, and we will get them answered by a seasoned advisor.   We believe in lifelong learning and mentorship, and this column along with our mentorship programs are tools for your professional success. Christa O’Hana S. Nobleza, ...

By Peter J. Papadakos, MD, FCCM, FAARC, FCCP, professor of Anesthesiology, Surgery, Neurology and Neurosurgery at the University of Rochester; and Thomas J. Kallstrom, MBA, RRT, FAARC, executive director of the American Association of Respiratory Care The COVID-19 worldwide pandemic has brought to light the importance of proper mechanical ventilation strategy in that the majority of patients succumb with acute respiratory distress syndrome (ARDS).  Even prior to this viral pandemic, ARDS had a high mortality of approximately between 36-52% per 100,000 ...

Stefanie P. Cappucci, MD Neurology Resident Beth Israel Deaconess Medical Center Corey R. Fehnel, MD, MPH Assistant Professor of Neurology Beth Israel Deaconess Medical Center Harvard Medical School Section Editor: Michael Reznik, MD Assistant Professor of Neurology & Neurosurgery Brown University/Alpert Medical School       “A year ago, I was thrilled to survive…and looked forward to what the future would bring. I would have never imagined a year from that day I would be getting ready to go to ...

By Mary Presciutti, NP, CCRN, CNRN, Mount Sinai Hospital, Department of Neurosurgery Weeks before deployment, my fellow advanced care providers (APP) and I were told that our New York City hospital was in the process of rearranging healthcare personnel to meet the impending surge of patients with COVID-19. Like most of us, I was filled with anxiety and many questions:  How will things be? What will our path be moving forward? Two weeks later, I received my schedule and learned that I had been assigned to the COVID-ICU. Prior to my current position ...

Taking a Closer Look into Neurocritical Care Mechanical Ventilation During the COVID19 Pandemic and the Use of Anesthesia Machines in the Neuro ICU By Shaun Golden, MSN, RN; and Sarah Beth Thomas, MSN, RN, CCRN, CNRN, SCRN Since the beginning of the COVID-19 global pandemic, ventilators have been at the forefront of public discourse. Discussions on social media, stories in various news outlets and even sound bites offered by prominent politicians in Washington and beyond have made ventilators a new buzzword for the American public.  ...

By Francisco Gomez, MD 1 ; Alyssa B. Polotti, PharmD, BCCCP 1 ; and Fawaz Al-Mufti, MD 2   1 Deparment of Neurology, University of Pennsylvania 1 Department of Neurology, Rutgers - New Jersey Medical School 2 Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College   The authors have no actual or potential conflict of interest in relation to the topics discussed in this column. This article may discuss non-FDA approved devices and “off-label” uses. The NCS and Currents do not ...

By Jeong-Ho Hong, MD, PhD, Department of Neurology, Keimyung University School of Medicine, Daegu, Korea Recently, I was working as a neurointensivist at one of the hub-hospitals treating COVID-19 patients, Daegu Dongsan Hospital (branch hospital) and one of tertiary hospitals, Keimyung Univerisity Dongsan Hospital (main hospital), in Daegu, South Korea. Daegu is the center of South Korea’s expanding COVID-19 outbreak. Government-designated Hub-hospital for Only COVID-19 Patients vs. General Tertiary Hospital: A Neurointensivist’s Point of ...

Cardiac Arrest and Cooling Out-of-hospital cardiac arrest (OHCA) has an incidence of about 110.8 per 100,000 in all ages, while in-hospital cardiac arrest (IHCA) has an estimated incidence of about 292,000 cases per year in the United States.   In view of the recent HYPERION trial, finding for the effectiveness of targeted temperature management (TTM) in non-shockable rhythm arrest, TTM is again at the forefront of discussion and remains the standard of care for acute management of all unresponsive post-cardiac arrest patients. Several modalities ...

Yingying Su COVID-19: Difficulties and Countermeasures in the Prevention and Control of Neuro ICU Infection and Medical Quality Control in China By Yingying Su From February to March 2020, the epidemic of COVID-19 peaked in China. The situations for neuro ICU were as follows: In addition to some medical staff sent to the designated hospital or ward of COVID-19 to combat the epidemic, most of them were still on duty at their local neuro ICU, routinely guarding against the outbreak of COVID-19, taking responsibility of quality and safety in the ...

By Alexis Steinberg, MD; Matthew R. Leach, MD; Angela Hays Shapshak, MD; and Lori Shutter, MD The Covid-19 pandemic has dramatically changed the practice of critical care, and neurocritical care has not been immune to these changes.  As ICUs across the country experience a swell in COVID-positive patients, neurointensivists have been called upon to practice outside their normal scope, dealing with increased patient volumes and greater proportions of general critical care patients, despite ongoing acute neurologic emergencies.  We interviewed attending ...

By Stephen Trevick, MD  I am writing from Chicago on March 20. I feel this is important to share as the COVID-19 pandemic is developing so rapidly that some concerns that I discuss here may be less relevant by the time you read this. There is an incredible amount of uncertainty in the pathophysiology, epidemiology and social impact of this disease. The eyes of the world are on healthcare providers now, and we have all become leaders of our communities. We will be called upon not only to provide medical care and information, but, ideally, to help guide ...

The ongoing pandemic of Coronavirus Disease 2019 (COVID-19) is unprecedented in scale, with devastating effects seen in the economic and social spheres of society. The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020, after the number of cases outside of China skyrocketed 13-fold since late February.  The micro-organism causative of COVID-19 infection is a β-Coronavirus, an enveloped positive sense single-stranded RNA virus, which shares the same family as severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and ...

By Alberto Hernandez, MD, PhD, DESA, Director, Anaesthesia & ICU, Grupo Policlinica, Ibiza, Spain; and Peter J. Papadakos, MD, FCCM, FAARC. Director, Critical Care Medicine, Professor Anesthesia, Surgery, Neurology and Neurosurgery, University of Rochester, New York, US.   These days, there are multiple papers emerging daily about COVID-19 management, protocols, guidelines, etc. Many research protocols are in play, but c urrent management of COVID-19 still remains supportive .   We were intially told the virus would only seriously affect older ...

By Lauren Koffman DO, MS Months ago, I had plans for a weekend trip with a friend, and despite my multiple reassurances, she cancelled. She had family and friends in China and had deep concerns about the COVID-19 situation evolving. She would tell me about the horrific scenes unfolding as hospitals were overwhelmed and under prepared.  Thinking back two or three months ago, the virus and its casualties on another continent felt like an isolated health crisis. Now, not much time has passed, and COVID-19 is here.  While we as intensivists are ...

By Peter J. Papadakos, MD, FCCM, FAARC As an individual who studies the effect of technology on the practice of medicine, one of the most amazing aspects of this terrible pandemic is how the medical community around the world has joined together as one to share protocols, guidelines and disaster plans with each other. I have a broad network of colleagues in both trauma critical care and neurocritical care, and it’s been outstanding how rapidly we all joined together via e-mail, WhatsApp forums, Zoom conferences and others to share our patient care ...

By Peter J. Papadakos, MD, FCCM, FAARC  As neurocritical care providers, we are confronted with an increased number of individuals who are on blood thinners who are involved in falls during the winter months.  Many will become neurocritical care patients with major subdural hematomas (SDH). Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006.  The mortality associated with acute subdural hematomas has been reported to range from 36-79%, with many survivors not regaining previous levels of functioning, especially after ...

By Erika Bassett, PA-C and Alexis Steinberg, MD  When graduating from a nurse practitioner or physician assistant program, an advance practice provider (APP) can launch themselves into a broad range of specialties and subspecialties.  So why enter the world of neurology, and specifically, why neurocritical care?  Throughout the years, we have seen APPs come and go in our neurological ICUs (NICU). Some enter neurocritical care, learn the nuances of neurological patients, but ultimately leave and transition themselves into a different subspecialty. ...