Neurocritical Care In India: Past, Present, And Future
Girija Prasad Rath, MD, DM
Secretary, Indian Society of Neuroanaesthesiology and Critical Care (ISNACC)
Professor, Department of Neuroanaesthesiology and Critical Care
Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
Ponniah Vanamoorthy, MD, DNB
Secretary, Neurocritical Care Society of India (NCSI)
& Past Secretary, Indian Society of Neuroanaesthesiology and Critical Care (ISNACC)
Head, Department of Neurocritical Care and Neuroanaesthesiology
Institute of Neurosciences & Spinal Disorders, MGM Health Care Pvt Ltd, Chennai, Tamilnadu, India
Radhakrishnan, MD, DM
Past Treasurer, Indian Society of Neuroanaesthesiology and Critical Care (ISNACC)
Professor, Department of Neuroanaesthesia & Neurocritical Care
National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
G.S. Umamaheswara Rao, MD
Past President, Indian Society of Neuroanaesthesiology and Critical Care (ISNACC)
Ex-Professor, Department of Neuronaesthesia and Neurocritical Care
National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
Neurocritical care has developed very recently as an independent subspecialty across the world for better care of critically ill neurologically-injured patients. The burden of neurocritical illness and trauma is increasing rapidly in the Indian subcontinent, and there is an associated demand for physicians who have received a formal training in neurocritical care. The incidence of stroke in India is about 120-150 cases per 100,000 population(1), and traumatic brain injury affects more than 1.5 million people annually(2). These statistics stress the immediate need for neurocritical care in order to minimize mortality and morbidity. With a population of over 1.3 billion, India faces unique problems when it comes to providing quality healthcare, as well as ensuring access to such healthcare for all. Another consideration in offering specialty critical care in this country is ensuring affordability since per capita income in India remains low and less than 50% population is covered by health insurance. Critical care services in India are offered mainly by trained anesthesiologists or intensivists, with neurocritical care patients often being cared for in general intensive care units (ICUs). Stand-alone neurocritical care units are few and are restricted to apex medical institutions and metropolitan cities such as Delhi (National Capital Region of Delhi), Mumbai, Kolkata, Chennai, Bangalore, Hyderabad, Chandigarh, Trivandrum, and Pune.
HISTORY OF NEUROCRITICAL CARE IN INDIA
Historically, the first neurological critical care unit (NCCU) was opened in Johns Hopkins Hospital in 1932 by Dandy. These units used to admit both neurological and neurosurgical patients, including neurotrauma patients. The advent of closed NCCUs necessitated the development of a new subspecialty, namely, the Neurocritical Care. The neurointensivists working in these specialized ICUs assume a leading role and are well trained in both general ICU protocols as well as specialized neuro-critical monitoring and intervention. (3,4)However, specialty neurointensivists are extremely rare, even in developed healthcare systems such as the USA, where only 45 centers have access to such physicians.
General critical care medicine, as well as neurointensive care as independent specialties, have developed in India over the past four decades, with the pioneers in the field opting to receive subspecialty training quite often from abroad. Before that, neurocritical care was practised in the Institutions of national importance like All India Institute of Medical Sciences (AIIMS), New Delhi, and National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore. These institutions started the three years residency program in which residents received training in both neuroanesthesia and neurocritical care. A formal three-year Doctor of Medicine (DM) degree course in Neuroanesthesiology, with neurocritical care being an integral part of it, was introduced for the first time in India at AIIMS, New Delhi, in 2002. Subsequently, the DM course was started in other institutes such as Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum (2004), NIMHANS, Bangalore (2011), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh (2013), AIIMS, Rishikesh (2018), AIIMS, Bhubaneswar (2019), and Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry (2019). As there was a shortage of neurointensivists, a dedicated one-year fellowship program in neurocritical care was first started at NIMHANS, Bangalore (2014), followed by AIIMS, New Delhi (2017). The Indian Council of Medical Research (ICMR), a statutory body, through its Centre for advanced research (CAR) program, sponsored the PDF Neurocritical care at NIMHANS. It recognized the need for neurointensivist in the country and decided to sponsor this program for manpower development. In the next stage, ICMR is planning to initiate such a program across the country.
The Neurological Society of India (NSI) was formed by a group of neurologists, neurosurgeons, and allied neuroscientists in 1951. This Society conducts annual conferences and workshops on neurosciences regularly until today. In 1992, a separate organization named the Indian Academy of Neurology (IAN) was formed by neurologists to keep the interest of their specialty. Despite the presence of these scientific bodies, neurocritical care remained mainly with the practitioners of neuroanesthesia, who by default contributed to the neuro-intensive care management. In the month of May 1983, Dr. Malathi, Head of the Department of Neuroanaesthesia at NIMHANS, organized the first two-day National Seminar on Neuroanaesthesia. In February 1995, Prof. HH Dash, the then Head of the Department of Neuroanesthesia at AIIMS, New Delhi, organized the first International Symposium on Neuroanesthesia & Critical Care. In 1999, a group of specialty Neuroanesthesiologists in India under his leadership formed the Indian Society of Neuroanesthesiology and Critical Care (ISNACC), which got registered in 2001 and became the torch-bearer of Neurocritical Care in India apart from its regular contribution to the specialty of neuroanesthesia. Since then, the Society (ISNACC) has grown by leaps and bounds and is now affiliated with leading international societies within the field, such as the Asian Society for Neuroanesthesiology and Critical Care (ASNACC), Society of Neuroscience in Anesthesiology and Critical Care (SNACC), The Neuro Anaesthesia & Critical Care Society of Great Britain and Ireland (NACCSGBI), and Neurocritical Care Society (NCS). Meanwhile, ISNACC started its journal in 2014, the Journal of Neuroanaesthesiology and Critical Care (JNACC) which publishes papers related to neuroanesthesia, neurocritical care, and interventional pain management. The ISNACC has now established itself as the representative body of neurointensivists in India. In 2018 leading Neurointensivists of the country, after discussion with the ISNACC Governing Council, decided to float a new society to meet the rapid demand and the upsurge of this subspecialty. This Society is now called the Neurocritical Care Society of India (NCSI ) and will spearhead the development of Neurocritical Care along with ISNACC and other societies. Meanwhile, the Indian Society of Critical Care Medicine (ISCCM ) has also grown as a major society spearheading critical care in India. With ISNACC, it is mainly the Neuroanesthesiologist who primarily are associated with Neurosciences institutes to lead the development of Sub Specialty Neurocritical care.
Neurocritical care necessitates a significant degree of resources and investment – both financial as well as in terms of human resources. In India, the practice of neurocritical care varies according to the setup. In major cities, private hospitals and government institutes provide dedicated critical care services. However, such facilities are not available in remote places, and patients are usually referred to cities for specialized care. With the introduction of fellowship programs, many trained physicians would be available to fill this healthcare gap. Neurocritical care is provided by both private hospitals managed by Societies, Trusts, or Companies and Government Institutions that offer ICU care services with high standards of patient care. In Private hospitals, Patients are charged for the services (self or by Insurance / Schemes) rendered, unlike the Government Institutes where the government bears the expenditure, and the patients are treated at no cost or for negligible fees.
Another major factor limiting the delivery of quality neurocritical care in India is the lack of a standardized national training program for the neurointensivists. Apart from institutes such as AIIMS, New Delhi, and NIMHANS, Bengaluru, who have developed their training programs, ISNACC initiated a one-year postdoctoral fellowships program in neurocritical care. However, few hospitals accredited by ISNACC now run this program. Such one-year postdoctoral fellowship courses may be better suited to physicians from neurology, neurosurgery, or neuroanesthesiology background with experience in general critical care who aim to hone their skills in the management of such critically ill patients. Recently, with the initiatives from ISNACC, another Government statutory body, the National Board of Examinations, New Delhi, started another 3-years postdoctoral course DrNB (Neuro Anaesthesia and Critical Care), in institutions with adequate logistic support (2018). This training helps fill the rapidly increasing need for adequately trained neurointensivists throughout the country. However, there is heterogeneity in physicians’ training (Table 1).
Table 1: Training in Neurocritical Care along with Neuroanesthesia in India
|ISNACC affiliated PDF in Neurocritical Care (1 year)||
|Government of India (GOI) affiliated PDF Neurocritical Care (1 Year)||
|DM Neuroanesthesiology & Critical Care (3 Years)
(GOI Institutions except the * marked)
|DrNB Neuro Anaesthesia & Critical Care (3 Years)
(Conducted by the National Board of Examinations, New Delhi, an organization under GOI)
(With permission from the webpage of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC): www.isnacc.org)
Apart from this, several other short-term training courses (1-3 days) are carried out under the aegis of scientific bodies such as ISNACC and NCS. These courses include Acute Neurological Life Support (ANLS), Acute Neuro Care (ANC by ISNACC), and Emergency Neurological Life Support (ENLS by NCS). These courses are conducted periodically across India by trained professionals. These foundation courses aim to help practicing clinicians stay updated with the latest pieces of evidence, and provide quality care to this fragile patient population. A greater understanding of the field of neurocritical care has led to the promotion of sub-sections such as the neurocritical subsections under the aegis of the Indian Society of Critical Care Medicine (ISCCM) and Indian Academy of Neurology (IAN) and the formation of new associations like the Society of Neurocritical Care (SNCC) and the Neurocritical Care Society of India (NCSI), in recent times. Hopefully, these societies will pave the way for trained neurointensivists to take charge of NCCUs across India.
However, the real need of the hour is the implementation of training standards across the country in order to ensure that the physicians are well trained with core competencies. Ensuring this will help mitigate the heterogeneity seen in training standards and foster more comprehensive and healthy research as well as training culture. In addition, such training programs may help alleviate the increasing demand for neurocritical care in India.
POSSIBLE DEVELOPMENTS IN FUTURE
Simulation in Neurocritical Care
Simulation offers students the chance to learn through experience in a controlled and safe manner, with ample time for reflection as well as remediation. As a result, it may lead to a reduced incidence of erroneous diagnoses, faster interventions, and improved collaborative skills, which may be crucial in patients with neurological injuries, where ‘time is brain’(6). Task training tools, manikin-based simulators, and computer-based simulators have been used to aid medical students in acquiring technical and procedural skills. Limiting factors in simulation-based learning are the high cost and lack of trained faculty, but cost-effectiveness may be achieved by limiting the number of subsequent complications(7).
Technological Advancements and Artificial Intelligence
Neurocritical care practice relies on identifying subtle changes in the neurological status of patients. Findings such as fever, hyperglycemia, and hypotension need to be interpreted and managed differently in patients with neurological injuries(8). Since continuous monitoring of subtle clinical signs may lead to missed or delayed diagnoses, investment in technology in neurointensive care is vital, making neurocritical care a resource-intensive specialty. If identified early, salvaging areas of potentially reversible neurological injury may be feasible, leading to reduced morbidity and neurological deficits on discharge. Monitoring modalities such as continuous electroencephalography (EEG), near-infrared spectroscopy (NIRS), transcranial doppler (TCD), cerebral microdialysis, jugular venous oximetry, brain tissue oxygen tension, etc. while of limited use in the general ICU setting, assume important roles in neurointensive care units(9). These monitoring modalities may help guide clinicians in the assessment of brain injury, potential for recovery of function, and prognostication(10).
Another exciting new development in the field of intensive care medicine is the increasing application of machine learning and artificial intelligence (AI). Multimodality monitoring in the neurocritical care unit has led to an abundance of data, which may lend itself to analysis and algorithmic decision-making based on predictive models. Closed-loop systems may monitor patient parameters and treat patients directly based on the same parameters, making real-time adjustments without human input (11). In neurologically injured patients, AI has already been used in an attempt to predict future intracranial pressure (ICP) values and assess ICP variability. Exciting potential applications for this technology could include closed-loop systems which could manage spikes in ICP or manage the administration of antiepileptic drugs in patients with seizures based on their EEG in real-time. Such models may help minimize the inherent delay associated with diagnosis and initiation of therapy in patients with time-sensitive pathologies and may help optimize patient outcomes. Though multimodality neuromonitoring has been found to be helpful in patient targeted treatment, it comes with a considerable cost, infrastructure, and data analysis and is challenging to practice in this country. However, few hospitals do have monitors like transcranial Doppler, cerebral oximetry, intracranial pressure, and microdialysis, and they are used in isolation rather than together.
Neurocritical care is a fascinating branch of medicine that is still in its infancy in India. Across the world, it has developed from a small group of physicians in the 1980s to an established subspecialty that now includes neurologists, neurosurgeons, neuroanesthesiologists, and intensivists. As newer and improved modalities of diagnosis are being developed, it has been seen that trained individuals with an understanding of cerebral physiology are crucial. NCCUs are coming up in most major medical centers across India, and studies have demonstrated improved outcomes when neurologically ill patients are cared for by specially trained staff. A growth of neurocritical care training programs in India has to parallel and complement the rapidly growing demand for specialists in this field. Scientific bodies such as ISNACC have played an important role in the growth of fellowship programs all over India and, in the future, will continue to contribute to the growth of the specialty.
In the future, a larger number of teaching institutions in India will aim to adopt a 3-year curriculum with balanced clinical as well as academic training in neurointensive care. Training in critical care ultrasound, simulation-based training of procedures, and training residents in quality control and safety should hopefully become an integral part of the curriculum in India.
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