2013 textbook of neurointensive care

A. Joseph Layon
Andrea Gabrielli
William A. Friedman
Editors

Textbook of
Neurointensive Care
Second Edition

123


Textbook of Neurointensive Care



A. Joseph Layon • Andrea Gabrielli
William A. Friedman
Editors

Textbook of
Neurointensive Care

Second Edition


Editors
A. Joseph Layon, MD, FACP
Critical Care Medicine
Pulmonary and Critical Care Medicine
The Geisinger Health System

Danville
PA
USA

Andrea Gabrielli, MD, FCCM
Departments of Anesthesiology and Surgery
University of Florida College of Medicine
Gainesville
FL
USA

Temple University School of Medicine
Philadelphia
PA
USA

William A. Friedman, MD
Department of Neurological Surgery
University of Florida College of Medicine
Gainesville
FL
USA

ISBN 978-1-4471-5225-5
ISBN 978-1-4471-5226-2
DOI 10.1007/978-1-4471-5226-2
Springer London Heidelberg New York Dordrecht

(eBook)

Library of Congress Control Number: 2013945859
© Springer-Verlag London 2013
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
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To my family—Susana Picado, Maria Layon-Taylor, Nicolas Layon,
Daniel Layon—all in the service of our people and country. All of whom have
sacrificed.
To those who are in search of a home, family, country: may you find them.
To those who struggle to become: may you be.
—A. Joseph Layon
To my father Pietro and my mother Giuliana, now walking the family dog
between the clouds, for being my role models and the inspiration behind all

my efforts.
To my brother and friend Marco, the real smart guy of the family.
To my students, friends, and colleagues worldwide.
To our patients, our inspiration for compassionate care, our reason to try
harder.
—Andrea Gabrielli
To my many colleagues, friends, and patients who have taught me so much
about neurosurgery.
—William A. Friedman



Foreword to the Second Edition

During the 9 years since the publication of the first edition of this Textbook of Neurointensive
Care, considerable developments have evolved in the critical care of the neurologically injured
patient. This second edition captures such advances presented by more than 100 leading
authorities, offering a clear and comprehensive update. It represents a collective accomplishment of clinician scientists dedicated to providing such enormous material and thereby extensive knowledge in the care of the brain injured from the emergency department to the ICU, to
the operating room, and through the postoperative period. This edition is the only textbook
providing such a comprehensive offering throughout the continuum of care.
Such a continuum of critical care is exemplified throughout this second edition in its extensive chapters. A presentation of key concepts of brain physiology essential to the understanding of intracranial hypertension is offered in the chapter on elevated intracranial hypertension.
Despite recent advances in the treatment, diagnosis, and management of aneurysms and cerebral vasospasm, morbidity and mortality remain high and are addressed in the chapter on treatment of aneurysmal subarachnoid hemorrhage. The chapter on intracranial hemorrhage is an
essential presentation. Such hemorrhage remains formidable as patient outcome is still poor,
despite recent advances that have led to extensive research establishing evidence-based management. This chapter notes the disparate incidence of stroke in African-Americans and discusses possible risk factors in this population. Neuroradiologic imaging is discussed in a
substantial chapter, providing an understanding of how such images are created utilizing MRI
and CT modalities though technical presentation. The chapter on pharmacotherapy in the neurosurgical ICU is a further example of the comprehensive approach to such care extended by
this second edition. Knowledge of pharmacokinetics and pharmacodynamics of neuroactive
drugs is provided for the optimal management of neuroinjured patients. In addition to these
chapters, all the contributions provide evidenced-based data and algorithms for decision making and illustrate key points; multiple supporting references are provided for documentation
and reviews.

This second edition is improved in its sectioning with the provision of an Introduction
(Part I) which presents fundamentals of neurocritical care issues of organization, quality
improvement, and the emerging ICU subspecialty of Neurointensive Care Medicine. Part II
addresses Neuroanatomy and Neurophysiology; Part III covers Neuromonitoring; Part IV
addresses in detail the Neuroinjured Patient; Part V details Special Situations such as traumatic
brain injury in the adult and as well as in the pediatric population, the treatment of spinal cord
injury, and the treatment of seizures; Part VI provides Situations of Special Interest such as
intraoperative neuroanesthesia, neurorehabilitation, and brain death and the management of
potential organ donation. This section also reviews the ongoing concerns of ethical issues in
the neurointensive care unit.
In 2003, the year prior to the publication of the first edition of the Textbook of Neurocritical
Care, the Joint Commission (JC, formerly JCAHO) launched the Primary Stroke Center
Certification Program. During the 9 years since the First Edition, more than 925 certified primary stroke centers have been established in 48 states, with comprehensive stroke centers now
being certified by JC in several states. The Get With The Guidelines-Stroke National Quality
Improvement and Registry Program of the American Heart/American Stroke Association has
vii


viii

Foreword to the Second Edition

grown rapidly over these 9 years. Over 1,400 hospitals are participating in this program. The
first edition of this textbook and its editors and authors have contributed immensely to the
quality and outcomes of stroke care of these programs. Interim and current developments so
comprehensively provided now in this second edition will further enhance such care. It is a
pleasure and privilege to continue to work with such accomplished investigators. This second
edition is a tribute and an essential contribution to the care of the neurologically injured.
Danville, PA, USA

Edgar J. Kenton III, MD, FAAN, FAHA


Preface to the Second Edition

We claimed, in the Preface to the First Edition of Textbook of Neurointensive Care, that in the
near future our hospitals would be composed of EDs, ICUs, and operating rooms. Studies of
hospitals seem to have borne this out. And while we still are not sure of the precise dimensions
and shape it will take, health care (maybe better put, health insurance) reform will impact our
work and work environment significantly. Even those of us who hoped for a reformed health
system when the First Edition went to press had no idea, even in our heart of hearts, that in
2013 we would see the beginnings—just that—of the reform of our health-care system.
In this context, we have attempted to change and improve our Textbook of Neurointensive
Care. In this second edition, there is more emphasis on evidence-based medicine—our jumpoff point, not our end point—and best practice. We have improved chapters on the organization
of neurocritical care (Chap. 1) and quality improvement (Chap. 2); enhanced chapters on neuromonitoring (Chaps. 7 and 8) and on the prehospital care of the neurologically injured patient
(Chap. 9); and added chapters on neuroendocrine function (Chap. 15), on hematological/
thrombotic issues (Chaps. 16 and 17), and on acute kidney injury and the neurologically
injured patient (Chap. 19). Additionally, there is an entire chapter (Chap. 36) on temperature
regulation. Finally, we have added a chapter on brain death and the management of the potential organ donor (Chap. 44).
The reader will note that we eliminated the section on “The Future of NeuroCritical Care.”
We are good, but not that good! We cannot see into the future any better than anyone else can!
We thank our contributors for their hard work. We are in debt to them in a manner that will
never be paid. And the same goes for our editor and publisher, Elizabeth Corra and Grant
Weston: they have the patience of saints.
Let us know what you think of this second edition. As always, the errors in this book belong
to the three editors.
Gainesville, FL, USA
Gainesville, FL, USA
Gainesville, FL, USA

A. Joseph Layon, MD, FACP
Andrea Gabrielli, MD, FCCM
William A. Friedman, MD

ix



Preface to the First Edition

Whether apocryphal or not, it is said that in the near future, hospitals will be composed of three
areas: the emergency department, the operating rooms, and the intensive care unit (ICU). The
rationale for such a statement is that managed care is driving medicine in the United States
toward outpatient care except in cases of very ill patients, who are admitted into the ICU. Our
experience is that the severity of illness of the patients we care for is greater every year. This is
as true in the general ICU population as it is in those individuals with neurologic disease.
Partly because of this increased severity of illness in patients with neurologic injury, we conceived the project that led to this book.
The book before you is unusual in several respects. It is a textbook, rather than a monograph,
of neurointensive care. We initiate the book with a solid review of neurophysiology and neuroanatomy, including anatomy as seen through the “eyes” of our radiology colleagues. We remind
the reader of the problems that our neurosurgical colleagues expect to see, even in a wellperformed procedure. The body of the book then follows, first with general topics and then with
specific disease states. Difficult ethical issues, including topics such as access to health care,
alterations of a do-not-resuscitate order in patients going to the operating room, withdrawal and
withholding of therapy, physician-assisted suicide, and brain death, are embraced and discussed.
We finish the book with clinically relevant research issues that are present on the horizon, beckoning us forward with the unfulfilled promises that make up their potential. The use of evidence-based medicine when such data exist, provision of protocols and algorithms, and honesty
when our best approximations and biases are the only data available have served as our credo.
As any authors should, we undertook this book with some hesitation. To write a book—any
book—means laying open, for the world to see, one’s biases, flaws, and inadequacies. This is
especially true when dealing with an area as broad and complex as treatment of the critically
ill patient with neurologic injuries. While others might have written a different book, we
undertook this project and offer it, with humility, to our colleagues.

Although we live in a society that lionizes—at least rhetorically—the individual and individual
exploits, work of any quality is of necessity the culmination of a collective effort. This is true in
the case of our textbook. Our coauthors are dedicated clinicians and scientists with whom we are
honored to be associated. They have worked diligently in the process of creation of this work. The
publishers and printers are remarkable people and true professionals who put up with our foibles
and ideas of cover art (we lost on that one). To Allan Ross, Executive Editor, Natasha Andjelkovic,
Senior Editor, and Peter McEllhenney, Assistant Editor, at Elsevier; Jesamyn Angelica; and Nancy
Lombardi at PM Gordon Associates, we offer our heartfelt thanks and appreciation. To Poppy
Meehan, the hand that guided the entire project, we can only say thank you.
While this is a work of many, we are responsible for any errors or other flaws. We hope you
find this text useful. Let us know what you think. There should, after all, be a second edition.
Danville, PA, USA
Gainesville, FL, USA
Gainesville, FL, USA

A. Joseph Layon, MD, FACP
Andrea Gabrielli, MD, FCCM
William A. Friedman, MD

xi



Contents

Part I

Introduction

1

Neurocritical Care Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sayona John and Thomas P. Bleck

3

2

Quality Improvement and Neurocritical Care . . . . . . . . . . . . . . . . . . . . . . . . . . .
Matthew F. Lawson, F. Kayser Enneking, and J.D. Mocco

9

3

Neurointensive Care Medicine as an Emerging ICU Subspecialty . . . . . . . . . .
Cherylee W.J. Chang

19

Part II

Neuroanatomy and Pathophysiology

4

Basic Neuroanatomy for the Neurointensivist . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hung Tzu Wen and Albert L. Rhoton Jr.

33

5

The Functional Organization of the Nervous System . . . . . . . . . . . . . . . . . . . . .
William A. Friedman

65

6

Introduction to Basic Neuropathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anthony T. Yachnis

89

Part III
7

8

Neuromonitoring

Noninvasive Monitoring in the Neurointensive Care Unit:
EEG, Oximetry, TCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Christoph N. Seubert, Jean E. Cibula, and Michael E. Mahla

109

Invasive Neurological and Multimodality Monitoring
in the NeuroICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Peter Le Roux

127

Part IV

The Neuroinjured Patient and Critical Care Medicine

9

Prehospital Care of the Neurologically Injured Patient . . . . . . . . . . . . . . . . . . .
Christine Van Dillen, David Meurer,
and Joseph A. Tyndall

149

10

Airway Management in the Neurointensive Care Unit . . . . . . . . . . . . . . . . . . . .
Thomas C. Mort, Jeffrey P. Keck Jr., and Leah Meisterling

167

11

Neurologic Injury and Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . .
Kevin W. Hatton

217

12

Blood Pressure Management After Central Nervous System Injury . . . . . . . . .
Fred Rincon, Jack C. Rose, and Stephan A. Mayer

241

xiii


xiv

Contents

13

Cardiac Implications of Neurological Disease . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cesare Iani, Ennio Montinaro, Novella Bonaffini, and Achille Gaspardone

255

14

Sedation and Analgesia in Neurointensive Care . . . . . . . . . . . . . . . . . . . . . . . . .
Federico A. Villa and Giuseppe Citerio

281

15

Endocrine Issues in Neurocritical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Steven B. Greenberg, Arthur J. Tokarczyk, Cameron Zahed,
and Douglas B. Coursin

293

16

Hematologic and Coagulation Implications of Neurologic Disease . . . . . . . . . .
Jan S. Moreb

321

17

Venous Thromboembolism in the Neurologic Intensive Care Unit . . . . . . . . . .
Chamisa MacIndoe and David Garcia

343

18

Water and Electrolyte Management in Neurological Disease . . . . . . . . . . . . . . .
Maryam Rahman, Nathan Kohler, and Azra Bihorac

355

19

Acute Kidney Injury and Renal Replacement Therapy

in the Neurologically Injured Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abdo Asmar, Mourad M. Alsabbagh, Michiko Shimada,
Azra Bihorac, and A. Ahsan Ejaz

379

20

Nutrition in the Neurointensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Larissa D. Whitney, Lawrence J. Caruso, Peggy White, and A. Joseph Layon

391

21

Neurologic Implications of Critical Illness and Organ Dysfunction . . . . . . . . .
Aaron N. LacKamp and Robert D. Stevens

409

22

Central Nervous System Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lennox K. Archibald and Ronald G. Quisling

427

Part V

Special Situations

23

Diagnosis and Treatment of Altered Mental Status . . . . . . . . . . . . . . . . . . . . . . .
Bryan D. Riggeal, Candice S. Waked, and Michael S. Okun

24

Aneurysmal Subarachnoid Hemorrhage: Evidence-Based Medicine,
Diagnosis, Treatment, and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Matthew M. Kimball, Gregory J. Velat, J.D. Mocco, and Brian L. Hoh

541

Intracerebral Hemorrhage: Evidence-Based Medicine, Diagnosis,
Treatment, and Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chad W. Washington, Ahmed N. Hassan, and Gregory J. Zipfel

565

Arteriovenous Malformations: Evidence-Based Medicine, Diagnosis,
Treatment, and Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Muhammad M. Abd-El-Barr, Seth F. Oliveria, Brian L. Hoh, and J.D. Mocco

579

Traumatic Brain Injury: Evidence-Based Medicine, Diagnosis,
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Andres Fernandez, Kristine H. O’Phelan, and M. Ross Bullock

591

Pediatric Traumatic Brain Injury: Evidence-Based Medicine, Diagnosis,
Treatment, and Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kyle M. Fargen and David W. Pincus

601

Spinal Cord Injury: Evidence-Based Medicine, Diagnosis, Treatment,
and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alexander Taghva and Daniel J. Hoh

619

25

26

27

28

29

521


Contents

xv

30

Complex Spine Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daniel J. Hoh and R. Patrick Jacob

643

31

Spinal Cord Injury Rehabilitation and the ICU . . . . . . . . . . . . . . . . . . . . . . . . .
Janice M. Cohen and Alan K. Novick

667

32

Special Issues in Pediatric Neurocritical Care After Neurosurgery. . . . . . . . . .
Robert C. Tasker

681

33

Acute Ischemic Stroke: Therapy and Guidelines. . . . . . . . . . . . . . . . . . . . . . . . .
Vishnumurthy Shushrutha Hedna, Brian L. Hoh, and Michael F. Waters

693

34

Central Nervous System Neoplasia: Evidence-Based
Medicine, Diagnosis, Treatment, and Complications . . . . . . . . . . . . . . . . . . . . .
Erin M. Dunbar

707

35

Elevated Intracranial Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Shelly D. Timmons

729

36

Therapeutic Hypothermia in Neurocritical Care . . . . . . . . . . . . . . . . . . . . . . . .
Adam Schiavi and Romergryko G. Geocadin

743

37

Cerebral Resuscitation from Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clifton W. Callaway

755

38

Neuromuscular Disorders in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Arash Salardini and William J. Triggs

777

39

Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Robin L. Gilmore, Jean E. Cibula, Stephan Eisenschenk, and Steven N. Roper

799

Part VI

Situations of Special Interest

40

Neuroradiological Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jeffrey A. Bennett and Sandip Patel

817

41

Intraoperative Neuroanesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Elizabeth Brady Mahanna, Dietrich Gravenstein, Nikolaus Gravenstein,
and Steven A. Robicsek

843

42

Postoperative Neurosurgical Care: Recovery Room Misadventures
and Immediate Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mary A. Herman, Nikolaus Gravenstein, and Dietrich Gravenstein

863

43

Neurorehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rita Formisano, Eva Azicnuda, Umberto Bivona, Maria Paola Ciurli,
Andrea Gabrielli, and Sheila Catani

879

44

Brain Death and Management of the Potential Organ Donor . . . . . . . . . . . . . .
Kenneth E. Wood and A. Joseph Layon

895

45

Ethical Issues in the Neurointensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . .
William Allen

919

46

Pharmacotherapy in the Neurosurgical Intensive Care Unit . . . . . . . . . . . . . . .
Aimée C. LeClaire, Jennifer R. Bushwitz, and Steven A. Robicsek

941

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

965



Contributors

Muhammad M. Abd-El-Barr, MD, PhD Department of Neurosurgery,
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
William Allen, JD, MD Program for Bioethics, Law, and Medical Professionalism,
University of Florida College of Medicine, Gainesville, FL, USA
Mourad M. Alsabbagh, MD Division of Nephrology, Hypertension, and Transplantation,
University of Florida College of Medicine, Gainesville, FL, USA
Lennox K. Archibald, MD, PhD, FRCP Department of Medicine, College of Medicine,
University of Florida College of Medicine and the Malcom Randall VA Medical Center,
Gainesville, FL, USA
Abdo Asmar, MD Department of Clinical Science, University of Central Florida,
Orlando, FL, USA
Eva Azicnuda, PsyD IRCCS Sanata Lucia Foundation, Rome, Italy
Jeffrey A. Bennett, MD Department of Radiology, University of Florida College of Medicine,
Gainesville, FL, USA

Azra Bihorac, MD, PhD Division of Critical Care Medicine, Department of
Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
Umberto Bivona, PhD IRCCS Sanata Lucia Foundation, Rome, Italy
Thomas P. Bleck, MD, FCCM Department of Neurological Sciences, Neurosurgery,
Medicine, and Anesthesiology, Rush Medical College, Chicago, IL, USA
Novella Bonaffini, MD Department of Neurology and Stroke Unit,
Ospedale S. Eugenio-ASL RMC, Rome, Italy
M. Ross Bullock, MD, PhD Department of Neurosurgery, University of Miami/Jackson
Memorial Hospital, Miami, FL, USA
Jennifer R. Bushwitz, PharmD Department of Pharmacy Services,
Shands at the University of Florida, Gainesville, FL, USA
Clifton W. Callaway, MD, PhD Department of Emergency Medicine, University
of Pittsburgh, Pitssburgh, PA, USA
Lawrence J. Caruso, MD Department of Anesthesiology,
University of Florida College of Medicine, Gainesville, FL, USA
Sheila Catani, MD IRCCS Sanata Lucia Foundation, Rome, Italy
Cherylee W. J. Chang, MD, FACP, FCCM Department of Medicine and Surgery,
Neuroscience Institute/Neurocritical Care, The Queen’s Medical Center,
University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA

xvii


xviii

Jean E. Cibula, MD Department of Neurology, University of Florida College of Medicine,
Gainesville, FL, USA
Giuseppe Citerio, MD Neuro-Anesthesia and Neuro-Intensive Care Unit,
Department of Anesthesia and Critical Care, Ospedale San Gerardo, Monza, Italy
Maria Paola Ciurli, PsyD IRCCS Sanata Lucia Foundation, Rome, Italy

Janice M. Cohen, MD Department of Neuroscience/Physical Medicine and Rehabilitation,
Memorial Regional Hospital South/Memorial Healthcare System, Hollywood, FL, USA
Douglas B. Coursin, MD Department of Medicine, University of Wisconsin School
of Medicine and Public Health, Madison, WI, USA
Erin M. Dunbar, MD Department of Neurosurgery, University of Florida College
of Medicine, Gainesville, FL, USA
Stephan Eisenschenk, MD Department of Neurology, University of Florida College
of Medicine, Gainesville, FL, USA
A. Ahsan Ejaz, MD, FASN Division of Nephrology, Hypertension, and Transplantation,
University of Florida College of Medicine, Gainesville, FL, USA
F. Kayser Enneking, MD Department of Anesthesiology, University of Florida College
of Medicine, Shands Quality Committee, Shands at the University of Florida,
Gainesville, FL, USA
Kyle M. Fargen, MD, MPH Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Andres Fernandez, MD Division of Neurocritical Care, Department of Neurology,
Columbia University, New York, NY, USA
Rita Formisano, MD, PhD IRCCS Sanata Lucia Foundation, Rome, Italy
William A. Friedman, MD Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Andrea Gabrielli, MD, FCCM Department of Anesthesiology Surgery, University
of Florida College of Medicine, Gainesville, FL, USA
David Garcia, MD Department of Hematology, University of New Mexico,
Albuquerque, NM, USA
Achille Gaspardone, MPhil, MD, FESC, FACC, EAPCI Division of Cardiology,
Department of Medicine, Ospedale S. Eugenio-ASL RMC, Rome, Italy
Romergryko G. Geocadin, MD ACCM-Neurology, Johns Hopkins University and
Hospital, Baltimore, MD, USA
Robin L. Gilmore, MD Department of Neurology, Maury Regional Medical Center,
Columbia, TN, USA

Dietrich Gravenstein, MD Department of Anesthesiology, University of Florida College
of Medicine, Gainesville, FL, USA
Nikolaus Gravenstein, MD Departments of Anesthesiology and Neurological Surgery,
University of Florida College of Medicine, Gainesville, FL, USA
Department of Periodontology, University of Florida College of Dentistry,
Gainesville, FL, USA
Steven B. Greenberg, MD Department of Anesthesiology, NorthShore University
HealthSystem, University of Chicago, Evanston, IL, USA

Contributors


Contributors

xix

Ahmed N. Hassan, MD Department of Neurology/Neurocritical Care,
Washington University School of Medicine, St. Louis, MI, USA
Kevin W. Hatton, MD Division of Critical Care Medicine, Department of Anesthesiology,
University of Kentucky, Lexington, KY, USA
Vishnumurthy Shushrutha Hedna, MD Department of Neurology, University of Florida
College of Medicine, Gainesville, FL, USA
Mary A. Herman, MD, PhD Department of Anesthesiology, University of Florida College
of Medicine, Gainesville, FL, USA
Brian L. Hoh, MD, FACS, FAHA, FAANS Department of Neurological Surgery,
University of Florida College of Medicine, Gainesville, FL, USA
Daniel J. Hoh, MD Department of Neurological Surgery, University of Florida College
of Medicine, Gainesville, FL, USA
Cesare Iani, MD Department of Neurology and Stroke Unit, Ospedale S. Eugenio-ASL
RMC, Rome, Italy

R. Patrick Jacob, MD Department of Neurological Surgery, University of Florida College
of Medicine, Gainesville, FL, USA
Sayona John, MD Department of Neurology, Rush University Medical Center,
Chicago, IL, USA
Jeffrey P. Keck Jr., MD Virginia Commonwealth University, Richmond, VA, USA
Departments of Anesthesia and Critical Care, Pikeville Medical Center, Pikeville, KY, USA
Matthew M. Kimball, MD Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Nathan Kohler, MD, PhD Department of Radiology, Florida Hospital, Orlando, FL, USA
Aaron N. LacKamp, MD Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Baltimore, MD, USA
Matthew F. Lawson, MD Tallahassee Neurological Clinic, Tallahassee, FL, USA
A. Joseph Layon, MD, FACP Critical Care Medicine, Pulmonary and Critical Care
Medicine, The Geisinger Health System, Danville, PA, USA
Temple University School of Medicine, Philadelphia, PA, USA
Aimée C. LeClaire, PharmD, BCPS Clinical Pharmacy Services, Critical Care Clinical
Pharmacy Services, Department of Pharmacy Services, Shands at the University of Florida,
Gainesville, FL, USA
Peter Le Roux, MD Department of Neurosurgery, University of Pennsylvania,
Philadelphia, PA, USA
Chamisa MacIndoe, DO Department of Neurosurgery, University of New Mexico,
Albuquerque, NM, USA
Elizabeth Brady Mahanna, MD Division of Critical Care Medicine, Department of
Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
Michael E. Mahla, MD Division of Neuroanesthesia, Department of Anesthesiology,
University of Florida College of Medicine, Gainesville, FL, USA
Stephan A. Mayer, MD, FCCM Neurocritical Care Division, Columbia University Medical
Center, New York, NY, USA

xx

Leah Meisterling, DO, MBA Surgical Intensive Care Unit, Hartford Hospital, Hartford,
CT, USA
Department of Anesthesiology, University of Connecticut School of Medicine,
Farmington, CT, USA
David Meurer, MD Department of Emergency Medicine,
University of Florida College of Medicine, Gainesville, FL, USA
J.D. Mocco, MD, MS, FAANS, FAHA Department of Neurosurgery, Vanderbilt University
Medical Center, Nashville, TN, USA
Ennio Montinaro, MD Department of Neurology and Stroke Unit,
Ospedale S. Eugenio-ASL RMC, Rome, Italy
Jan S. Moreb, MD Division of Hematology and Oncology, Department of Medicine,
University of Florida College of Medicine, Gainesville, FL, USA
Thomas C. Mort, MD Department of Anesthesiology and Critical Care Medicine,
Hartford Hospital, University of Connecticut, Glastonbury, CT, USA
Alan K. Novick, MD Department of Neuroscience/Physical Medicine and Rehabilitation,
Memorial Regional Hospital South/Memorial Healthcare System, Hollywood, FL, USA
Michael S. Okun, MD Department of Neurology, University of Florida College
of Medicine, Gainesville, FL, USA
Seth F. Oliveria, MD, PhD Department of Neurological Surgery,
University of Florida College of Medicine, Gainesville, FL, USA
Kristine H. O’Phelan, MD Neurocritical Care Division, Department of Neurology,
University of Miami Miller School of Medicine, Miami, FL, USA
Sandip Patel, MD Department of Radiology, University of Florida College of Medicine,
Gainesville, FL, USA
David W. Pincus, MD, PhD Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Ronald G. Quisling, MD Department of Radiology, Neuroradiology Section,
University of Florida College of Medicine, Gainesville, FL, USA

Maryam Rahman, MD, MS Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Albert L. Rhoton Jr., MD Department of Neurological Surgery, University of Florida
College of Medicine, Gainesville, FL, USA
Bryan D. Riggeal, MD Rockdale Neurology Associates, Conyers, GA, USA
Fred Rincon, MD, MSc, MBE, FACP, FCCP, FCCM Department of Neurosurgery,
Thomas Jefferson University, Philadelphia, PA, USA
Steven A. Robicsek, MD, PhD Department of Anesthesiology,
University of Florida College of Medicine, Gainesville, FL, USA
Steven N. Roper, MD Department of Neurological Surgery, University of Florida College
of Medicine, Gainesville, FL, USA
Jack C. Rose, MD Department of Neurosciences, California Pacific Medical Center,
San Francisco, CA, USA

Contributors


Contributors

xxi

Arash Salardini, BSc, MBBS Department of Radiology, University of Florida College
of Medicine, Gainesville, FL, USA
Adam Schiavi, PhD, MD Division of Neuroanesthesia and Neurosciences Critical Care,
Anesthesiology and Critical Care Medicine, Johns Hopkins University and Hospital,
Baltimore, MD, USA
ACCM-Neurology, Johns Hopkins University and Hospital, Baltimore, MD, USA
Christoph N. Seubert, MD, PhD Division of Neuroanesthesia, Department of
Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
Intraoperative Neurophysiologic Monitoring Laboratory, Shands Hospital,

Gainesville, FL, USA
Michiko Shimada, MD, PhD Division of Cardiology, Respiratory Medicine,
and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki City, Japan
Robert D. Stevens, MD Department of Anesthesiology, Critical Care Medicine, Neurology,
and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Alexander Taghva, MD Department of Neurological Surgery, Ohio State University,
Columbus, OH, USA
Robert C. Tasker, MA, MBBS, MD Division of Critical Care Medicine, Department
of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital,
Boston, MA, USA
Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
Shelly D. Timmons, MD, PhD, FACS, FAANS Department of Neurological Surgery,
Geisinger Health System, Danville, PA, USA
Arthur J. Tokarczyk, MD Department of Anesthesiology, NorthShore University
HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL, USA
William J. Triggs, MD Department of Neurology, University of Florida College
of Medicine, Gainesville, FL, USA
Joseph A. Tyndall, MD, MPH Department of Emergency Medicine, University of Florida
College of Medicine, Gainesville, FL, USA
Christine Van Dillen, MD Department of Emergency Medicine, University of Florida
College of Medicine, Gainesville, FL, USA
Gregory J. Velat, MD Department of Neurosurgery, Lee Memorial Hospital,
Fort Myers, FL, USA
Federico A. Villa, MD Neuro-Anesthesia and Neuro-Intensive Care Unit,
Department of Anesthesia and Critical Care, Ospedale San Gerardo, Monza, Italy
Candice S. Waked, DO Department of Neurology, Emory University, Atlanta, GA, USA
Chad W. Washington, MS, MPHS, MD Department of Neurological Surgery,
Washington University in St. Louis, St. Louis, MO, USA
Michael F. Waters, MD, PhD Department of Neurology, McKnight Brain Institute,
University of Florida College of Medicine, Gainesville, FL, USA

Hung Tzu Wen, MD Department of Neurosurgery, Hospital das Clinicas,
College of Medicine, University of São Paulo, São Paulo, Brazil
Peggy White, MD Department of Anesthesiology, University of Florida
College of Medicine, Gainesville, FL, USA


xxii

Larissa D. Whitney, PA-C, BS, MS Department of Critical Care Medicine, Geisinger
Medical Center, Danville, PA, USA
Kenneth E. Wood, DO Department of Critical Care Medicine, The Geisinger Medical
Center, Danville, PA, USA
Anthony T. Yachnis, MD Department of Pathology and Laboratory Medicine,
University of Florida College of Medicine, Gainesville, FL, USA
Cameron Zahed, MD, MS Department of Anesthesiology, Internal Medicine, and Critical
Care, University of Wisconsin Hospital and Clinics, Madison, WI, USA
Gregory J. Zipfel, MD Department of Neurosurgery, Barnes-Jewish Hospital,
St. Louis, MO, USA

Contributors


Part I
Introduction


1

Neurocritical Care Organization
Sayona John and Thomas P. Bleck

Contents

Abstract

Neurocritical Care Organization gives a brief introduction
into the history, need, and development of Neuro ICUs.
This chapter describes the different models of ICUs that
currently exist and the pros and cons of these models. It
also describes staffing models for physicians and physician extenders. A special note has been made of workflows in an ICU and quality metrics of importance.

History and Evolution of Intensive Care Medicine...................

3

Neurocritical Care as a Subspecialty .........................................

4

Need for Specialized Units...........................................................

4

Intensive Care Unit Organization...............................................

4

ICU Physician Staffing ................................................................

5

Physician Extenders .....................................................................

5

Workflow in an ICU .....................................................................

5

Keywords

Quality Metrics in an ICU...........................................................

5

References .....................................................................................

7

ICU • Neurocritical care • ICU staffing • ICU quality
metrics • Unit organization • Physician extenders

History and Evolution of Intensive
Care Medicine

S. John, MD (*)
Department of Neurology, Rush University Medical Center,
1725 West Harrison, Chicago, IL 60521, USA
e-mail:
T.P. Bleck, MD, FCCM

Department of Neurological Sciences, Neurosurgery,
Medicine, and Anesthesiology, Rush Medical College,
600 S Paulina Street, 544AF, Chicago, IL 60612, USA
e-mail:
A.J. Layon et al. (eds.), Textbook of Neurointensive Care,
DOI 10.1007/978-1-4471-5226-2_1, © Springer-Verlag London 2013

Intensive care medicine is the science and the art of detecting
and managing critically ill patients while preventing further
deterioration, in order to achieve the best possible outcomes.
Intensive care medicine emerged as a specialty in the 1950s
with its beginnings in Copenhagen during the poliomyelitis
epidemic, where patients with respiratory failure were artificially ventilated [1].
The ICU is commonly located in proximity to other acute
areas in the hospital such as the emergency room and the
operating rooms as most situations in the ICU are critically
time dependent. This also permits optimization of the timing
of admissions to the ICU and safe, effective discharge of
patients to a less intensive area of the hospital for the continued monitoring of resolving organ dysfunction [2].
The concept of levels of care was defined by a National
Institute of Health (NIH) consensus conference of critical care medicine at the Bethesda Conference in 1983 [3].
Based on differences in staffing, available technology, and
professional organizational structure of ICUs, the Bethesda
Conference proposed the division of intensive care facilities
into four groups: intensive care, high care, medium care, and
3