Neuroanesthesiology and Neurocritical Care in the Netherlands
|Markus Klimek, MD, PhD, DEAA, EDIC|
|Anthony Absalom, MBChB, FRCA, MD (UCT)|
Markus Klimek, MD, PhD, DEAA, EDIC
Associate Professor, Department of Anesthesiology
Erasmus University Medical Center, Rotterdam, The Netherlands
Past-chair, Neuroanesthesia Section, Dutch Association of Anesthetists
Anthony Absalom, MBChB, FRCA, MD (UCT)
Full Professor, Department of Anesthesiology
University of Groningen, Groningen, The Netherlands
Chair, Neuroanesthesia Section, Dutch Association of Anesthetists
Driven by economic pressure and facilitated by the short distances, The Netherlands has undergone a period of fusion and concentration of health care facilities and centralization of tertiary and complex care. Finally, this has led to high volume hospitals with high volume teams providing a very high standard of care.
In The Netherlands, there are currently about 150 neurosurgeons who perform all major (intracranial and spinal) neurosurgical procedures for 17 million inhabitants in only 13 hospitals (eight university hospitals and five major general hospitals). With one exception, these hospitals are established as Level-1-Trauma Centers, too. Patients from the Caribbean part of The Netherlands can only undergo minor neurosurgical interventions on the islands. Due to close cooperation, they can be treated for emergency procedures in Colombia, but patients requiring scheduled major procedures are frequently treated in the European part of The Netherlands.
During their training, anesthesiology residents undergo theory and practical training in neuroanesthesia. It enables them to manage acute neurosurgical problems safely, which they might also have to manage in smaller hospitals, apart from the critical intervention or transfer to one of the 13 major facilities. At present, there is no official fellowship program on neuroanesthesia available. However, during their residency training, the trainees can request six months of focused neuroanesthesia training. It would expose them to special procedures such as awake craniotomy, neuromodulation procedures, including deep brain stimulation (DBS) surgery, neurovascular interventions, and intraoperative neuromonitoring for spinal surgeries.
Within the Dutch Society of Anesthesiology (2000 member anesthesiologists), there is a sub-section on "Neuroanesthesiology" with about 40 members. These colleagues primarily work within the 13 hospitals as dedicated neuroanesthetists, which means they spend a significant portion of the clinical time working in the neurosurgical operating rooms (ORs). It is also common practice that the neurosurgeons plan challenging cases in close cooperation with these dedicated colleagues to provide optimum care.
Although most of the apex centers now have dedicated neuroanesthesiologists, the caseload overnight and on weekends is generally insufficient to justify a separate on-call team for the neuroanesthesia. During the Dutch Society of Anesthesiology Annual Meetings, the neuroanesthesia section is allocated time for scientific and CME sessions, which is are usually used to address neuroanesthesia and perioperative neuroscience topics of interest to non-neuroanesthesiologists.
One of the most influential intraarterial thrombectomy (IAT) trials for acute ischemic stroke, the MR CLEAN study, was performed in The Netherlands, with the involvement of anesthesiologists from Amsterdam. Like in other countries, the resultant strong evidence of benefit has led to a burgeoning caseload of interventional neuroradiology procedures, with particular growth in the demand for IAT procedures. In most hospitals, these cases are usually challenging, given the time constraints and the absence of a specific on-call team for neurointerventional and neurosurgical emergencies. There are variations among centers in the proportions of patients undergoing IAT procedures under local anesthesia (LA), with or without sedation, and general anesthesia (GA). With recent randomized trials showing equivalent results for GA compared to sedation, and a recent study showing worse outcomes for LA only, the pendulum may likely swing back towards GA when it is logistically feasible.
Several centers have functional neurosurgery programs for awake tumor resection. The most common indications are the presence of low-grade gliomas in speech or motor areas. Still, the indications are being expanded to some extent, and a Dutch multicenter trial of awake surgery for high-grade tumors is underway (SAFE-trial). Functional neurosurgery for patients with intractable epilepsy is performed in only one center (University Medical Center Utrecht).
DBS implantation services are provided at most of the major centers. Previously these operations were mainly performed for Parkinson's Disease refractory to medical treatment. As in other countries, the indications have been broadened to include other movement disorders such as dystonia, torticollis and blepharospasm, and essential tremors. There are also plans to extend the indications to treatment-resistant depression, obsessive-compulsive disorder, and obesity.
Intraoperative neuromonitoring (IONM) is performed in most, but not all, of the major centers. In the past, an active national multidisciplinary IONM workgroup facilitated the exchange of ideas, expertise, and research. The indications for IONM included skull base surgery, complex spinal instrumentation procedures, excision of intradural spinal tumors, and awake craniotomy.
The imaging possibilities of all major centers are high-end. Tractography, 3-D-reconstructions of the cerebral vascular anatomy, and 5-ALA (5-aminolevulinic acid) fluorescence-guidance for resections of adult malignant gliomas are all available if needed. Indocyanine green (ICG) is frequently used for aneurysm or AVM surgery; the presence of hybrid operating rooms (ORs) enables intraoperative MRIs or angiographies. Finally, there are also recent developments in functional ultrasound (fUS), which is increasingly used by neurosurgeons during intracranial and spinal surgery, mainly in an experimental setting, but with promising results.
Four of the university hospitals serve as the bases for the country's four-helicopter emergency medical service (HEMS) teams. HEMS teams are routinely dispatched for level-1 trauma cases. As each team primarily includes an anesthesiologist with trauma management experience, rapid and expert anesthetic care is available for most cases of severe traumatic brain injury (TBI). There is currently an active consortium (the Brain Protect consortium) that is analyzing and publishing the results of data from patients with severe TBI collected prospectively by nine major trauma centers involved in the case of these patients.
Neurocritical care is organized in a working group managed mainly by the Dutch Societies of Neurology and Intensive Care and with the involvement of anesthetists and neurosurgeons. Most ICUs where neurosurgical patients are treated have a closed format setting (ICU as an independent department within the hospital) and have staff with a multidisciplinary background such as anesthesiologists, internal medicine physicians, and neurologists.
Dedicated neuro-ICUs are uncommon; however, neurological high-dependency units and stroke units with non-ventilated patients are well-established. The multidisciplinary cooperation is close and effective, not only on clinical but also on a scientific level, which is visible in annual meetings of the working group addressing running trials and future trends. Major research topics of brain-trauma research with anesthesia interest are neurotrauma care and delirium prevention and management.
For general aspects on the Netherlands and the Dutch Health Care System, please see:
An open-access article on functional ultrasound during awake brain surgery with many excellent figures.