Leading Insights

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 ...

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 ...

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, ...

By Yingying Su In 2012, the brain injury evaluation quality control center of the National Health Commission of the people's Republic of China (BQCC / PRC / NHC) was established and attached to Xuanwu Hospital of Capital Medical University. So far, the standardized training of brain death (BD) determination in China has gone through a ten-year journey. In the past ten years, we have completed two "five-year plans," and implemented the “Xinghuo” training plan and the “Liaoyuan” training plan.   The training objectives of the “Xinghuo” training program ...

By Jocelyn Owusu-Guha, PharmD, BCCCP and Pamela L. Buschur, PharmD, BCPS, OhioHealth Riverside Methodist Hospital, Columbus Ohio Nimodipine, a lipophilic calcium channel antagonist, has been established as a standard of care in the management of aneurysmal subarachnoid hemorrhage (SAH). Approved by the Food and Drug Administration in 1988, nimodipine has been shown in multiple clinical trials to decrease the incidence of delayed cerebral ischemia and improve neurological outcomes. 1-2 The current American Heart Association and American Stroke Association ...

By: NCS Research Operations Subcommittee: Caitlin Brown PharmD, Michelle Schober MD, Shraddha Mainali MD, Cassia Righy MD, Minjee Kim MD, Tom Lawson CNP, Jennifer Kim MD, PhD, Ruchi Jha MD Can you tell me a little about yourself and how you got involved in the Neurocritical Care Society?   I am a Pediatric Neurointensivist and Associate Professor of Pediatric Critical Care Medicine at Primary Children’s Hospital.  I grew up in the United States and Colombia and completed all my medical training in both countries.  During my pediatric critical ...

Yasser B. Abulhasan, MBChB, FRCPC, FNCS, Chairman, Neurocritical Care-MENA Chapter of IPACCMS It was a great pleasure organizing the 2 nd Neurocritical Care Regional Meeting in the Middle East and Africa in conjunction with the 17 th edition of the Emirates Critical Care Conference (ECCC). The meeting got delayed by more than a year due to the COVID-19 pandemic, ultimately taking place in a hybrid format (both in person and virtual) on June 18 and 19, 2021. This was a challenging yet exciting event from the start. We wanted to exceed expectations ...

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. When assembling and organizing a Neuro ICU team, one must begin with the end in mind. It is important to note that each organization defines financial success of the Neuro ICU differently. To meet the organization’s marker of success, one must first determine how it is defined by the organization and then adapt staffing and documentation to best meet these goals while ...

Misti Tuppeny & Kelly A. Rath  On Behalf of the NCS APP Leadership Section & NCS Ethics Committee: Ethics Committee Chair/Chair Elect: Stephen Trevick, Jamie Nicole LaBuzetta APP Leadership Section Chair/Chair Elect: Rachel Hausladen, Ana Kukulj   Healthcare through the 20 th and 21 st centuries has seen significant change and growth, and through this evolution, the role of the advanced practice provider (APP) developed to fill a need for equitable access to quality patient care. The term advanced practice provider encompasses nurse practitioners ...

Salia Farrokh, Lucia Rivera Lara, Jon Cokley and Hana Nobleza Specialized neurocritical care teams have been found to improve outcomes such as mortality, length of stay, and discharge dispositions for patients who are both neurologically devastated and critically-ill. These teams within the Neurocritical Care Unit (NCCU) can comprise an attending neurointensivist, trainees (fellows, residents, and medical students), a dedicated pharmacist, advanced practice providers (APP), a respiratory therapist, and others. It has been reported that a dedicated ...

By: Jose Miguel Medrano, MD, FPNA; Joanne Robles, MD, FPNA; Isabelita Rogado, RN, MAAN; Geraldine Siena Mariano, MD, FPNA, FPCP, FNCS, FPSCCM   COVID-19 has put a spotlight on the importance of excellent, holistic, multidisciplinary critical care; despite this pandemic, there remains a steady influx of patients with cerebrovascular disease, traumatic brain injury and other severe neurological diseases. It is during this era that neurocritical care continues to adapt, grow and evolve, addressing the ever more complex needs of these most critical ...

Scott DeBoer, MD, PHD Medstar Franklin Square Medical Center Department of Neurology, Georgetown School of Medicine Cari Tobin, PA-C Medstar Franklin Square Medical Center Lauren Koffman DO, MS In 1989 when Benjamin Peace was 29 years old, he had a dental infection that spread to two of his heart valves, known as endocarditis. Unfortunately, the infection in his heart caused a stroke and left him unable to use the left side of his body. He was told he had a 50/50 chance of being able to walk again. Treatment of the infection required ...

Gabrielle Horstman, MD/PhD This month we would like to highlight one of the new programs launched this year by the Inclusion in Neurocritical Care (INCC)  Committee– The INCC Virtual Book Club! This program was created in response to multiple requests from members like you during the 2020 Annual meeting. Fully embracing the virtual nature of the meeting, the idea for a book club stemmed from a very active chat discussion during the Women In Neurocritical Care (WINCC) keynote address given by Dr. Chere Chase-Gregory where she illustrated her personal ...

Richard Leston,  APP Supervisor, Department of Neurosurgery, Clinical Preceptor of APP Neurosurgery Clerkship With: Alexis Catania, PA & Krista O’Leary PA-S South Shore University Hospital was preparing to open its brand-new Neuro ICU in March of 2020, eager to become a major neuroscience center in Suffolk County, New York. This effort involved a rapid expansion of the neurosurgery department, adding a team of neurointensivists, and quadrupling the APP staff over the course of one year.  Unfortunately, COVID-19 delayed the launch of our ICU while we ...

Zachary Threlkeld, MD, Ahmad Riad Ramadan, MD, Sara Hefton, MD, Starane Shepherd, MD, H.E. Hinson, MD INCC Sexual and Gender Minority Subcommittee As part of broader diversity, equity, and inclusion efforts within NCS, the Sexual and Gender Minority (SGM) subcommittee of the Inclusion in Neurocritical Care Committee (INCC) aspires to raise awareness about and mitigate health disparities in SGM individuals, support development of culturally sensitive neurocritical care, and promote the recruitment and retention of SGM individuals who are historically ...

Jon Rosenberg, MD, Weill Cornell Medicine/New York-Presbyterian Hospital Laura Chen, DO, Weill Cornell Medicine/New York-Presbyterian Hospital Judy Ch’ang, MD, Weill Cornell Medicine/New York-Presbyterian Hospital A 34-year-old man presented with a high-grade traumatic brain injury (TBI) after being struck by a motor vehicle. In the emergency department he had a GCS of 3 and was intubated for airway protection. His initial CT showed bilateral frontal subarachnoid hemorrhage, left subdural hematoma and temporal contusion with effacement ...

Bryan Boling, DNP, University of Kentucky Jennifer Mears, PA, Weill Cornell Medicine/New York-Presbyterian Hospital Aarti Sarwal, MD, Wake Forest Baptist Health Judy Ch’ang, MD, Weill Cornell Medicine/New York-Presbyterian Hospital Point-of-care-ultrasound (POCUS) is an indispensable tool used in the diagnosis, screening, procedural guidance, and management of critically ill patients across the world. Unlike other imaging modalities, POCUS is performed and interpreted by the intensivist at the bedside, enabling real-time management ...

Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV Over the last decade, many unregulated drugs have appeared on the marketplace and have adversely affected our patients. We are all familiar with artificial marijuana which were sold in thousands of convenience stores throughout the country. These synthetic cannabinoids sold with catchy names such as K2, Spice, Scooby, Bizzaro or Snzx. The FDA acted rapidly to educate the public and make them illegal. They impacted our ICU’s with seizures, unconscious, delirium, aggressive and combative behavior, and the ...

Shweta Goswami, MD, University of Florida Sasha Yakhkind, MD, University of Pennsylvania Every year, neurology residents combine the wisdom of their mentors, their experience, their passion, and their personalities to guide them in the decision of sub-specialization. In 2017, 90% of neurology residents planned to complete fellowship before going into practice (1), and the process of application into subspecialty training is nuanced and evolving. Neurocritical care fellowship is part of the United Council for Neurologic Specialties (UCNS), and the ...

Luis Rafael Moscote-Salazar, MD Critical Care Unit, Bogotá, Colombia Centro Policlínico del Olaya I ván David Lozada-Martínez, MS University of Cartagena Cartagena, Colombia View Blog in English Las enfermedades neurológicas y neuroquirúrgicas son una de las principales causas de morbilidad y mortalidad en todo el mundo, y América Latina no es una excepción [1-3]. La incorporación de la atención neurocrítica ha representado un cambio de paradigma en el manejo de estas enfermedades [4]. Sin embargo, el advenimiento de la reciente ...

Luis Rafael Moscote-Salazar, MD Critical Care Unit, Bogotá, Colombia Centro Policlínico del Olaya I ván David Lozada-Martínez, MS University of Cartagena Cartagena, Colombia Blog en Español Neurological and neurosurgical diseases are a major cause of morbidity and mortality worldwide, and Latin America is no exception [1-3]. The incorporation of neurocritical care has represented a paradigm shift in the management of these diseases [4]. However, the advent of the recent pandemic represented a series of challenges for neurocritical ...

Shivani Ghoshal, MD Currents is excited to launch a new Arts Corner to recognize visual, performing, and creative artworks pertaining to neurocritical care, as well as makers within our own community. The practice of neurocritical care is as humbling as it is rewarding, and requires mindfulness both of oneself and one’s peers. We hope this corner will be a step toward recognizing creative outlets for NCS members and bringing our community closer together even while we are apart.  For its debut, we’d like to introduce Shivani Ghoshal, a neuro-intensivist ...

By Yingying Su, MD, Neuro ICU Professor, Xuanwu Hospital, Capital Medical University In 1998, when the neuro ICU of Xuanwu Hospital of Capital Medical University was established, we initiated a research project with the Beijing Municipal Science and Technology Commission—a study of bedside brain injury monitoring, evaluation, and brain protection treatment. Since then, with the support of nine scientific research projects, we have carried out studies of neuro-electrophysiology (EEG, EPs and ERPs), neuro-biochemical markers (S-100 and NSE), cerebral ...