INTERNATIONAL

Neuroanesthesia in Denmark

Dr. Juul
Niels Juul, MD

Niels Juul, MD
Department of Neuroanesthesia, Aarhus University Hospital
Aarhus, Denmark

Stig Dyrskog, MD, PhD
Department of Neurointensive Care, Aarhus University Hospital
Aarhus, Denmark

Karsten Bülow, MD
Department of Neuroanesthesia, Odense University Hospital
Odense C, Denmark

Christine Sølling, MD, PhD
Department of Neuroanesthesia, Rigshospitalet, Copenhagen University
Capital Region, Denmark

Denmark has 5.8 million inhabitants dispersed over 43,000 km2. Health care is free, public-funded, and administered by five Regions. The Regions manage 26 hospitals; four university hospitals have neurosurgery and neuroanesthesiology departments in conjunction with a level 1 trauma center.

Neurosurgery is a relatively small specialty with approximately 60 active specialists; in addition, nine neurointerventional radiologists work at the four university hospitals mentioned above. Approximately 70 anesthesiologists hold consultancies in neuroanesthesiology at one of the four university hospitals. About 20 small private clinics provide minor spinal surgery (herniated discs, simple fusions, etc.) but are not authorized to perform more complex or intracranial procedures.

In Danish health care, the specialty of anesthesiology covers perioperative medicine, intensive care medicine, prehospital and emergency medicine, acute and chronic pain treatment, and palliative medicine. Vocational training for anesthesiology is a five-year program, with a comprehensive curriculum comprising three-month to one-year rotations between departments, mandatory courses, competency testing, 360° assessments, written exercises, and a mandatory research project. Training on neuroanesthesiology and neurointensive care is covered during a three-month stay at one of the four departments. However, there is no specialist exam conducted for that.

After board authorization, many continue to work in more than one area of anesthesiology, e.g., in both perioperative and intensive care medicine or in prehospital and perioperative medicine. The Scandinavian Society of Anesthesiology and Intensive Care Medicine hosts various sub-specialization programs such as critical emergency medicine, perioperative medicine, pediatric anesthesia, obstetric anesthesia, cardiovascular and thoracic anesthesia, intensive care medicine, and pain education, but a program in neuroanesthesia is not available. At the Danish national level, a specialist education in neuroanesthesiology is also not been introduced. Recently, one university hospital has started an ICPNT-accredited fellowship program on neuroanesthesia; the three other departments are also in the process.

Neurosurgery in Denmark has a high standard. Neuronavigation is an integrated part of all intracranial procedures and intraoperative monitoring with evoked potentials is used frequently. Intraoperative MRI, including MRI-guided laser ablation of tumors and epileptic foci, has been introduced recently. Awake craniotomies are performed at most of the centers and pediatric intracranial surgeries are done at two centers. Stroke plays an increasing role in our daily practice, from diagnosis to treatment; endovascular thrombectomy is performed at all centers in Denmark. Neurointervention is evolving rapidly, and new advanced procedures are being introduced on a regular basis in the angio-suites.

Nurse anesthetists are an integral part of anesthesia services in all Scandinavian countries. All anesthesia procedures for intracranial surgery and neurointervention are performed or overseen by anesthesiologists with experience in neuroanesthesia. The four university hospitals have dedicated neurointensive care departments, which are staffed by neuroanesthesiologists; in three centers, the same anesthesiologists cover both neuroanesthesia and neurointensive care. In addition, all centers have in-house specialists on duty around the clock.

Neurointensive care is an integral part of the intensive care medicine curriculum in Scandinavia. The neuro-ICUs perform advanced multimodal brain monitoring, with some variation in choice of modality between centers.

Research in neuroanesthesiology at Aarhus focuses on the choice of anesthesia and hemodynamic management during endovascular thrombectomy, cerebral hemodynamic effects of vasopressor agents. Research in spinal cord injury includes intraspinal pressure monitoring, and the center will participate in the international study on ‘Duroplasty for Injured Cervical Spinal Cord with Uncontrolled Swelling (DISCUS).' An animal model of spinal cord injury in pigs is under development.

A large study in subarachnoid hemorrhage has received approval and financial support, which is in progress. Rigshospitalet, Copenhagen, hosts Denmark's (so far) only professorship in neuroanesthesiology and neurointensive care. Current research at the department includes perioperative management of neurosurgical patients using the Early Recovery After Surgery (ERAS) approach, perioperative pathophysiology focusing on tumor craniotomy, multimodal neuromonitoring in the neuro-ICU for clinical decision and understanding the pathophysiology of acute brain injury.

In Odense, there is a long tradition for research in microdialysis, with ongoing studies in progress. Interdisciplinary groups work with the development of neuromonitoring and the department contributes to multicenter studies. Currently, significant data research in SAH patients is undertaken. A national group for multimodal neuromonitoring in neurointensive care has recently been established, with representatives from all four university hospitals.

In general, Denmark is perceived to offer a good work-life balance for neuroanesthesiologists. Doctors from abroad are welcome provided their board authorization is approved and they learn to speak Danish.

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