Neurocritical Care
At Santa Barbara Cottage Hospital, a wide range of Neuroendovascular procedures are performed by a group of highly specialized physicians. All members are part of the cerebrovascular team within the department. The decisions of how to best treat complex neurovascular diseases, such as aneurysms, arteriovenous malformations and others are made within the team. In addition, there is close collaboration with the stroke service for acute interventional stroke care. Highly sophisticated image technology is used to treat cerebral aneurysm, arteriovenous malformations, arteriovenous fistulae using coils and various embolic materials. In addition, we use balloon and stent technology for optimal outcome and safety purposes in these patients. Stent placement for cervical or intracranial arteriosclerotic disease is done as well. Adjunctive or stand alone embolizations for brain tumors, tumors of the spine and the head and neck area are performed within our group.
A 12 bed Intensive care unit/stroke unit are available for postoperative care. Daily morning meetings with our physicians, nurse practitioners, critical care nurses and staff takes place for teaching purposes and to optimize patient care. Patients in the Intensive Care unit are all in acute condition, requiring very specialized attention, so we have only the most devoted and highly trained nurses working with our patients. Many of these patients are placed in medically induced comas. When a patient is in critical condition due to a stroke, brain injury, etc., the metabolism of the brain has been significantly altered and there might be areas without adequate blood flow. The intention is to reduce the amount of energy those different brain areas need. As the brain heals and the swelling goes down, it is possible for those areas that were at risk to be protected. Physicians use drugs that allow the coma to be completely reversible and induce no permanent damage. A decrease in blood pressure in this state can be a serious problem, so our nurses are constantly monitoring the patient using many different devices. A good outcome would be reduction of intracranial pressure to more or less normal range to allow the patient to recover.
One way we are able to measure intracranial pressure directly is by using a ventriculostomy. This is a catheter that is placed into the ventricles or fluid-filled spaces within the brain. A small drill hole is made in the skull in order to insert the catheter through the brain and into the ventricle. It is connected, by tubing, to a cerebrospinal fluid collection device, which can be elevated or lowered at the bedside to vary the amount of CSF that is drained. In the case of head trauma, the ventriculostomy allows monitoring of the intracranial pressure and it also allows drainage of CSF to help lower the pressure if it is high. A ventriculostomy can also help patients with Hydrocephalus. This is a general name for conditions in which there is an abnormal amount of cerebrospinal fluid within and around the brain and spinal cord. Many forms of hydrocephalus lead to an accumulation of CSF, which cannot be absorbed normally. While the long-term treatment of this condition usually involves a permanent shunt placement, in acute cases a ventriculostomy may be placed in the hospital to lower the intracranial pressure.
Licox is another neuromonitoring device used for patients in critical care. This is a tissue oxygen monitoring device. With the LICOX monitoring system, the normal value is thought be 20 mm Hg or higher. Striving to maintain a PbtO2 of 20 mm Hg or higher is an acceptable starting point. Practitioners should be concerned and act quickly when the PbtO2 decreases to less than 15 mm Hg. PbtO2 monitoring adds a dimension of care to patients with severe traumatic brain injury. Research has provided a basis for interventions that can affect critical oxygen levels in the brain. By understanding the causes of hypoxia and low oxygen states in the brain and planning interventions to adjust oxygen delivery, the critical care team can maximize patients’ recovery from injury.
Fever is common among neurocritical care patients and the treatment of choice for temperature management in the intensive care unit is an intravascular cooling catheter. Lowering a patient’s temperature through the use of IV Cooling represents a critical aspect of care for stroke patients because it has been shown that patients in the ICU with brain trauma or stroke in combination with fever have a higher mortality rate than patients with normal temperatures.
Microdialysis is another neuromonitoring device being used in neurointensive care. Microdialysis is a technique for continuous sampling of the interstitial fluid chemistry of tissues and organs. It is minimally invasive and simple to perform in a clinical setting. The use of microdialysis in neurointensive care has focused on markers of ischemia and cell damage. A microdialysis catheter could detect early signs of metabolic crises and ischemic episodes that may lead to an increase in intracranial pressure. After Subarachnoid hemorrhage, a microdialysis catheter in the tissue at risk could potentially detect vasospasm hours before clinical signs are evident. This research with microdialysis could be used increasingly as a tool to individualize patient treatment in routine neurointensive care.
PICCO is another device being used by patients in neurointensive care. PiCCO enables continuous hemodynamic monitoring using a femoral or axillary artery catheter and a central venous catheter. This device allows our staff to constantly monitor the heart and see what changes might occur based on different medications that are administered or different conditions that a patient is in.
Nurses working closely with these patients all must go through a course where they are trained to care for patients in Neurointensive care. They are additionally trained to use these different neuromonitoring devices so that they are able to deliver the highest quality care.