Neurocritical Care: The Continued Evolution

Critical illnesses that are secondary to neurological disease processes are prevalent in intensive care units. Over the last 60 years, many of these illnesses have been better classified and, thanks in part to the growing specialty field of neurocritical care, we are now seeing a decline in disease-related mortality.¹  Neurocritical care is recognized as the only specialty service that positively influences patient outcomes.^2–4  As one of the most recently recognized critical care specialty services, neurocritical care is continuing to evolve.⁵  To continue this evolution and manage caring for this specialty’s complex patient population, experienced neurocritical care providers are needed. The American Academy of Neurology has identified advanced practice providers, such as nurse practitioners, as necessary to the continued growth of neurologic practice.⁶ 

As neurocritical care continues to evolve, so does the growing body of research and the continued progression of evidence-based patient management. The purpose of this symposium is to update readers on recent advances in the field of neurocritical care and demonstrate new strategies, new research, and new technology that will help provide the best care and improve outcomes. To help the reader understand the advances, many of the articles include a brief history.

Two of the articles in this symposium—Boling and Keinath; Burns and colleagues—echo topics that were addressed in AACN Advanced Critical Care 5 years ago.^7,8  By comparing the articles in this symposium with those in the previous one, the reader will see how management of subarachnoid hemorrhage and acute ischemic stroke has changed. Specifically, the use of endovascular treatment options has increased in subarachnoid hemorrhage and ischemic stroke. The 2 related articles in the current symposium describe new evidence that supports current practice.

As knowledge has increased about caring for patients in neurocritical care, so has need to facilitate patient transfer to tertiary care centers for specialty treatment. Because the use of critical care transport teams is relatively new, many health care professionals who work at tertiary care centers may not be aware of the processes involved in receiving a transfer from an outside hospital. Zayas addresses this issue by describing the laws, the transportation options, and the potential effects of transportation on patients. One of the features of neurocritical care that tertiary hospitals typically can offer that rural centers cannot is more advanced patient monitoring. Multimodal monitoring incorporates the use of several monitoring techniques to best manage such areas as intracranial pressure, cerebral blood flow, cerebral oxygen delivery, cerebral metabolism, central nervous system function, and electrophysiology in patients who are in neurocritical care. Peacock and Tomlinson’s review describes the use of these monitoring techniques, including many devices and monitoring parameters that have not yet become mainstream.

Even with the evolution of neurocritical care practice over the last 5 years, it is difficult to imagine what the field will look like 5 years from now. Those working in neurocritical care must understand best practice recommendations, the studies that shaped them, and the areas for ongoing or future investigation. McNett and colleagues astutely recognize this need and describe ongoing research studies that will find their way into our future practice.

Neurocritical care is a burgeoning field. Therefore, practitioners who work in neurocritical care must remain informed about the most current evidence-based practice and guidelines to continue to improve patient outcomes. Furthermore, providers should question anecdotal practice and demonstrate best care for patients by developing high quality studies. Advanced practice providers collectively should be at the forefront of the charge to provide high quality care. In this spirit, perhaps we can continue to decrease mortality and improve patient outcomes for those patients in neurocritical care.