Spring 2005

Neurocritical Care

A patient is admitted to an intensive care unit after suffering a subarachnoid hemorrhage (SAH). On the fourth day after admission, he begins to be slightly confused and is more sleepy than usual.

This scenario describes what may be the signs of cerebral vasospasm, a potentially morbid condition whereby cerebral arteries constrict and cause ischemic stroke. Determining whether the patient's condition is due to vasospasm or one of several other causes requires expertise in neurocritical care.

Many California hospitals don't offer this kind of expertise. Timely diagnosis can lead to specific therapies like cerebral angioplasty or use of vasopressor drugs, but judicious use of these therapies is paramount since each therapy involves risks. Neurointensivists are doctors trained in clinical neuroscience -- typically neurology or neurosurgery -- who also are skilled in critical care medicine. Since neurointensivists practice primarily in the neuroscience intensive care unit, they are usually more available to provide immediate care.

"If you don't treat vasospasm urgently, the patient will likely end up with a stroke, so you have to decide when to use treatments like angioplasty," says Dr. Wade Smith, a UCSF neurointensivist. "You don't want to take the patient to the angiography suite if it's not needed and you don't want to be too late to prevent a stroke. Timing is critical."

Situations like this are the primary reason that a few hospitals across the nation have created intensive care units (ICUs) dedicated to neurology and neurosurgery patients. In these neuro critical care units, teams of neurologists, neurosurgeons and nurses trained in intensive care watch over patients with potentially life-threatening damage to the central nervous system.

According to Smith, neurointensivists are physicians who are facile in standard ICU procedures, but also have skills in resuscitating the brain. General intensive care specialists focus less on the brain than on other organs and general neurologists typically aren't well schooled in the specialized care required in ICUs. "In most hospitals, the consulting neurologist who comes into the ICU may not understand critical care issues," Smith says. Neurointensivists not only understand both neurological and critical care issues, but can spend a lot more time at the patient's bedside than a consulting neurologist.

With 20 neuroscience intensive care beds, UCSF has one of the largest dedicated neuroscience ICUs (NICUs) in the country. UCSF also has 13 beds in a neurological transitional care unit, where patients receive intermediate care.

Neuro ICU nurses who are educated in both critical care and neuroscience nursing are vital members of the team. Tina Mammone, patient care manager of the 80 neuro nurses who work in the NICU, notes that neuroscience nursing in an ICU setting requires clinical expertise, strong clinical assessment and critical thinking skills. "If a patient begins slurring their speech or displays subtle motor changes, nurses in other units might not think much about it. In the NICU, this is a significant neurological change that must be communicated immediately," Mammone says.

Also, there are special conditions and protocols that other critical care nurses might not be accustomed to, she says. "We sometimes need to keep the patient's systolic blood pressure elevated to greater than 160 mmHg in order to ensure sufficient brain tissue perfusion," Mammone says.

Smith concurs: "We can make someone look very sick from a cardiology viewpoint in order to save the brain; what is important is to know how hard you can push."

Mammone says that continuous education and staff development is a unit priority. "We strongly support new graduate and experienced NICU nurses to ensure they have the necessary resources and skills to be able to successfully and safely work in this challenging environment," she says. "The Neuro ICU is fortunate to be composed of a group of dedicated and knowledgeable neuro critical care nurses who are compassionate about their practice and the care of neurological and neurosurgical patients."

The skill and dedication of neurointensivists, neurologists, neurosurgeons and neuroscience nurses have led to a high national rating. UCSF ranks fifth among clinical neuroscience departments, according to the annual U.S. News & World Report survey.

Dr. Wade Smith, neurointensivist, may be contacted at (415) 353-1489.

Tina Mammone, a registered nurse and Neuro ICU patient care manager, may be contacted at (415) 353-1891.

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