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Neurocritical Care in Resource-limited Settings

Shrestha, Gentle S. MD, FACC, EDIC, FCCP, FNCS; Lamsal, Ritesh MD, DM

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Journal of Neurosurgical Anesthesiology: October 2020 - Volume 32 - Issue 4 - p 285-286
doi: 10.1097/ANA.0000000000000720
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Neurocritical care is a specialized branch of medicine dealing with critically ill neurological patients. Neurocritical care links critical care medicine, neurology, and neurosurgery to provide comprehensive management of patients with complex and life-threatening neurological diseases. Conditions such as traumatic brain injury, stroke, and central nervous system infection place a significant burden on global health care delivery systems, and particularly on neurocritical care. Patients with neurocritical illness constitute 20% to 25% of the severely ill patients who require critical care.1

Neurocritical care provided in dedicated neurocritical care units led by neurointensivists is associated with improved clinical outcomes compared with more traditional management.2,3 There are several possible reasons for these improved outcomes, including dedicated physicians and nurses, protocolized management, stricter adherence to neurocritical care protocols, and widespread use of neuromonitoring and neuroimaging tools. In the developed world, neurocritical care is fast-emerging from a niche specialty restricted to a few large academic institutions to a widely available specialty supported by health care workers from diverse fields providing specialized care for critically ill neurological patients.4 However, in low-income countries, neurocritical care is still rudimentary; it is seldom recognized as a separate specialty even in large academic institutes, and training opportunities are either extremely limited or nonexistent.

PROBLEMS IN RESOURCE-CHALLENGED SETTINGS

The need for neurocritical care is high in low-income countries. However, many institutions cannot provide standard neurocritical care, as it requires sophisticated technology that is costly and labor-intensive. Low-income countries also lack neurocritical care providers, proper infrastructure, adequate resources, and specialized training. There is a glaring disparity between the need for and the availability of neurocritical care facilities in low-income countries.

Traditionally, infectious diseases like meningitis, encephalitis, and cerebral malaria were considered to be the predominant causes of neurocritical illnesses in resource-limited countries.5 However, with changing lifestyles, longer lifespan, rising comorbidities such as diabetes and hypertension, greater tobacco-use, and increasing road-traffic accidents, the burden from illnesses common in high-income countries, including stroke, traumatic brain injury, and age-related neurodegenerative conditions, is rising. This problem is compounded because neurocritical care is not prioritized by local health care systems; most people living in low-income countries cannot access or afford the neurocritical care services that do exist. Prehospital systems are also underdeveloped, and technologies for diagnostics, monitoring, and therapeutics are lacking. There is a shortage of neurocritical care beds, and common neurocritical care modalities such as continuous electroencephalography, intracranial pressure monitoring, measurement of cerebral hemodynamics, cerebral oxygenation, and cerebral microdialysis are rarely available. Moreover, as medical research is primitive, there is a paucity of locally derived evidence, meaning that it is difficult to identify effective strategies tailored to resource-limited settings. The ongoing coronavirus disease (COVID-19) pandemic has stretched health care systems around the world, as scarce critical care resources, including manpower, have been diverted to manage patients in COVID-19 facilities. This is particularly the case in resource-limited settings where the current pandemic has led to neurocritical care being relegated to an even lower priority than previously.

MITIGATING EXISTING PROBLEMS

Neurocritical care strategies investigated, tested, and used in high-income countries cannot be extended to resource-limited settings. For example, the standard recommendations6 for general organization and infrastructure of neurocritical care units, physician and nurse staffing levels, respiratory therapy services, availability of neurocritical care equipment, and research are not feasible in resource-limited settings.

Although many existing problems cannot be mitigated in a short period, there must be an effort to develop locally sustainable strategies that target “low-cost and high-yield” neurocritical care (Table 1). In light of the COVID-19 pandemic, it is important not only to focus on neurocritical care capacity-building but, at the same time, develop contingency plans to deal with natural disasters and pandemics. There must also be greater emphasis on prevention of neurocritical illnesses by adopting measures such as increasing road-traffic safety awareness and better management of underlying disease conditions like hypertension and diabetes. Improving emergency department care of patients with neurological illnesses, including triaging, is a cost-effective strategy to reduce the burden on neurocritical care services and improve patient outcomes. Without a robust emergency response team, the clinical outcomes of time-sensitive neurological emergencies like acute ischemic stroke or status epilepticus cannot be improved. Improving telemedicine facilities may be extremely helpful for the timely diagnosis and referral of patients from remote areas where specialist services may be difficult to access. There is also an urgent need to expand existing training programs and establish new ones for all health care providers working in neurocritical care. Major academic institutes should take the initiative to design a curriculum to train neurocritical care nurses, increase fellowship programs for young physicians, and develop programs to foster training and skill-sets of neurointensivists. Various professional societies in the fields of critical care, anesthesiology, neurology, neurosurgery, and internal medicine should facilitate educational exchange between neurocritical care health care professionals. There is evidence that professional educational initiatives and short-term focused courses can significantly improve the practice and decision-making of physicians over a sustained period.7 A concerted effort from physicians working in neurocritical care to perform high-quality research to better understand local disease patterns and treatment responses is also clearly needed. Finally, in resource-limited settings, a few private institutions may currently be the only centers that deliver high-quality neurocritical care.5 A greater public-private partnership may be instrumental in allowing access to neurocritical care services by underprivileged members of society.

TABLE 1 - Facilitating Delivery of Neurocritical Care in Resource-limited Settings
Proposed strategies
 Strengthen preventive measures to minimize the burden of neurocritical illness
 Appropriate organization and infrastructure resources
 Capacity building with contingencies to deal with natural disasters and pandemics
 Focus on the basics
 Multidisciplinary approach
 Promote telemedicine services
 Promote training and education programs in neurocritical care
 Quality research focused on local needs’ assessment and cost-effectiveness analysis
 Collaborative efforts

THE SILVER LINING

Despite the numerous problems that afflict low-income countries, there is a silver lining. Even though the burden of neurocritical illnesses is higher in resource-limited settings, the affected population is generally younger than in high-income countries, with the potential for better neurological outcomes if timely care is provided. Of note, there are very few proven interventions with Level 1 evidence for improving outcomes in patients with neurocritical illnesses.8 So, instead of overzealously trying to meet the standards set by international guidelines, it is important for those working in low-income countries to get the basics right. These include timely detection of neurological-emergencies, maintaining the airway and ensuring adequate oxygenation and ventilation, optimizing blood pressure, maintaining good nutrition, stringent infection-control measures, good nursing care, and avoiding complications like deep-vein thrombosis. Inexpensive and ubiquitous drugs such as aspirin can easily be provided for patients with acute ischemic stroke in places with limited resources.9 Although the availability of sophisticated equipment and drugs can also make some difference, it is more meaningful to have a well-trained and dedicated neurocritical care team. In resource-limited settings, it is most important for neurocritical care units to set and achieve attainable goals.

Gentle S. Shrestha, MD, FACC, EDIC, FCCP, FNCS

Ritesh Lamsal, MD, DM
Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

REFERENCES

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