Many a times we are faced with situations where our relatives are being treated in the ICU. We are frightened, we are worried that our friend, relative, parent or child may die.
But half our worries will go away if we understand how an ICU works and how a neurology or neurosurgical ICU works. Let us understand how ICUs work and how patients after neurosurgery are taken care of in Neuro-ICU. Lets learn about ICUs and NICUs.
By Dr.Ravindra Patil
An Intensive Care Unit (ICU) is a specialized department of a hospital to provide intensive and specialized care for patients who are critically ill or have life-threatening conditions. Each bed has electric sockets nearby to power the ICU equipment. Piped gas outlets for oxygen, medical air and vacuum outlets are available nearby. The staff changes into scrub suits to prevent entry of outside dust in the ICU. Special footwear is always worn when entering the ICU. Caps and masks are worn by hospital staff as well as visitors. Visitors may have to wear gowns over their clothes. ICU work goes on 24×7.
The ICU team consists of various healthcare professionals like intensivists (physicians or anaesthetists specialized in critical care medicine), critical care nurses, respiratory therapists, pharmacists, nutritionists, physical therapists and patient care officers [PROs]. Collaboration among team members is essential to ensure coordinated care and optimize patient outcomes.
Some of the ICU equipment is: ventilators, monitors, syringe or infusion pumps, bedside ultrasound machines, trans-cranial Doppler, medical gas outlets, laryngoscopes, five-movement electrically operated beds and central air-conditioning. A patient transfer system for sliding the patient from the patient stretcher to the bed is often used to prevent pain to the patient and reduce difficulty of ICU staff. Defibrillators, Deep Vein Thrombosis [DVT] prevention pumps, air beds, built in weighing scales inpatient beds, glucometers, BP instruments, dialysis machines and nebulisers are other essential ICU biomedical items.
The NICU will have advanced devices like electroencephalography (EEG), intracranial pressure (ICP) monitoring and trans-cranial Doppler ultrasound. CT-Scan and MRI facilities must be nearby an NICU.
NICU patients may have undergone a Craniotomy surgery, head injury, tumour surgery, stroke or cerebral haemorrhage may be admitted and treated in the NICU.
Comatose patient means one who is unresponsive to external stimuli such as light, sound, or touch, makes no purposeful movements, no signs of awareness. The patient cannot be awakened.
There are many causes for the above, like, head injury, stroke, brain haemorrhage, metabolic disorders, intoxication, or prolonged hypoxia.
Treating such comatose patients before, during and after surgery is the subject of this blog. It is known as perioperative management.
It is the comprehensive care of patients before, during, and after a surgery. Let us break it into three parts:
It is first checked if the patient is ‘fit’ to be operated. It will mean a long list of blood tests, X-Ray, CT, MRI, Echo of the heart, give anaesthesia, checking for high BP, diabetes and existing infection. Then a physician gives his fitness. Many a times in brain surgery, the patient may not be ‘fit’ to be operated, yet surgery is done because the very condition which makes the patient ‘unfit for surgery’ will be cured with surgery. Being comatose is one such condition where the physician may say that the patient is ‘unfit for surgery’ but the neurosurgeon will treat that very condition with surgery. Patient is not given food, either orally or by a tube. This is called NBM or Nil By Mouth. Lastly, the patient is checked by the anaesthetist, ideally a day before and just before surgery. Surgery is undertaken only if the patient ‘passes’ all the above tests and criteria.
Means during surgery. Various lines [actually they are tubes] like intravenous, central venous, Foley’s catheter, ICP monitoring line, arterial line etc may be introduced to deliver medicines, remove urine, measure pressure or take blood samples will be inserted by the Anaesthesia team. Then the anaesthetist ‘induces’ the patient, meaning makes the patient unconscious and pain-free. The patient’s vital signs like BP, Pulse, Respiratory rate per minute, oxygen saturation by SpO2 and temperature are monitored. Any adverse changes in the vital signs will be immediately treated by the anaesthetist in consultation with the neurosurgeon. If there is unexpected blood loss, blood transfusions may be given.
This is the time to help the patient recover from his surgical wounds and also manage his/her general condition. Recovery from anaesthesia may take time in a comatose patient. Hence such patients need to be monitored very carefully. Their GCS [explained below] monitoring becomes crucial, along with their intake, output, their antibiotics, their blood coagulation, their intracranial pressure, their vital signs and their general conditions. A comatose patient needs to be moved to prevent pressure sores, but the neurosurgeon may refuse permission to move him, and such challenging situations are handled with frequent discussions amongst the super specialists.
All of the above together are called perioperative patient management.
The GCS score is an important tool for neurological monitoring. The Glasgow Coma Scale (GCS) is most commonly used in emergency rooms and ICUs by trained staff. The GCS is used to predict survival in hospitalized patients. It is the sum of the scores for three components: eye opening, verbal response, and motor response. The highest score is 15, and the lowest is 3. A score of 15 indicates that the patient is fully awake, responsive, and has no memory or thinking problems. The lower the score, the deeper the coma is.
The Glasgow Coma Scale (GCS) score of a comatose patient is usually 8 or less.
Intensive care management in the perioperative period revolves around vigilant neurological monitoring and prompt intervention. Continuous assessment of neurological status, including pupil reactivity, motor response and GCS. The above guide in decision-making about sedation levels, ventilator settings, and pharmacological interventions to optimize cerebral perfusion and prevent secondary insults to the body.
Perioperative management of comatose patients in the NICU demands a comprehensive and multidisciplinary approach which includes neurosurgical interventions, anaesthesia, critical care medicine, and Neuro-rehabilitation.
Many people are afraid of ICUs. Actually ICUs in good hospitals are the best places for curing patients. If a patient is intubated and is on ventilator, it doesn’t mean that the person is going to die. Intensive care specialists are stabilising the patient so that they can gradually reduce the air given by the ventilator, and the patient breathes on his/her own. This is done by ‘weaning’, where the oxygen supply to the patient is gradually reduced. This is how surgical comatose patients are treated in a good hospital.
Samarth Neuro and Superspeciality Hospital has 100+ beds & specializes in emergency surgery for neurological issues/disorders & diagnostics.
Samarth Neuro and Superspeciality Hospital
