1 Javed Siddiqi Neurosurgery is, at the same time, the oldest form of surgery and the newest. We know that trephining, for instance, was done thousands of years ago and represents the earliest form of surgery. In recent decades, the addition of microsurgery techniques and the development of technology, including neuroimaging modalities and frameless stereotaxy, have revolutionized neurosurgery. Historically, the operative mortality was tremendously high for neurosurgical operations; now, with the exception of trauma, intraoperative mortality is extremely rare. The most serious morbidity and mortality our patients currently face are really in the postoperative phase, in the intensive care unit (ICU). The subtlety and finesse of ICU management significantly contributes to patient outcomes, with trauma being the most dramatic example. In the drive to be better physicians, neurosurgeons continue to evolve in their education. Whereas historically it was the anesthesiologist or internist who served as an intensivist for our patients in the ICU, a field of neurointensive care is evolving, with subspecialists who acknowledge that the nervous system is unique and cannot and should not be treated as an extrapolation of other organ systems. An increasing number of neurosurgery residency programs in North America are insisting on a thorough grounding for their residents in direct hands-on neurointensive care management of their patients. This emphasis is expanding the focus of neurosurgery education beyond the technical. Fluid and electrolyte management, blood pressure control, and ventilator management of the postoperative patient are clearly within the domain of the neurosurgeon today; and the intensive care of the neurosurgical patient has now become a genuine multidisciplinary effort in a way it never was only two decades ago (when the surgeon largely handed over the postoperative patient to the intensivist to manage). In neurointensive care, as in other areas of medicine, the stakes are high. Unfortunately, in this relatively new field of neurocritical care, most of the known treatments and interventions are based on convention, not on science. The field aspires to evidence-based medicine, but the severity of the patients’ conditions and the complexity of their diseases render rigorous scientific study very difficult. The number of prospective double-blind randomized studies that guide our clinical management in all medicine is limited; this is no less true in neurointensive care. In this early stage in the development of neurocritical care, all precepts are open to question, and there is ample room for chaos; it is also a time of great optimism, as we have much to learn from our patients. For those of us with a keen eye and a sharp mind, we find ourselves in a position to make significant contributions to the field. Walking into an ICU can be overwhelming for patients, families, and physicians. For the neurosurgeon taking care of his or her patients in the neurologic ICU, an understanding that the nervous system cannot be treated in isolation of the rest of the body is critical. Having said that, I must emphasize that we need to understand our role in the modern neurosurgical ICU (NICU) in the context of a multidisciplinary team. Within this team, it is no exaggeration to say that all neurosurgery patients in the ICU will be affected, to varying degrees, by one or more of six key problems. In this book, we offer a checklist to these key problems, as well as others that are faced in the NICU. The six most important areas for neurosurgical critical care are In this book, we hope to present some factors that are involved in the care of patients in the neurointensive care unit. The art of medicine has not been, and probably never will be, fully quantitated; accordingly, much of what is expressed in this work has not been proven scientifically. We hope to offer rationales of current management of neurosurgery patients in the ICU and raise questions about ongoing controversies that we will not settle here. Most importantly, we wish to make the point that neurosurgeons are ideally suited to deal with neurointensive care management of their own patients, in collaboration with colleagues from anesthesia, general surgery, internal medicine, and so on. Let’s become active participants in the care of our ICU patients, as opposed to passive observers.
Introduction to the Neurosurgical Intensive Care Unit
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