Pulmonary Critical Care


Specialists in Neurocritical Care

 

The Cottage Neurocritical Care Program is a tertiary-level program that provides specialized neurovascular interventions and intensive care to patients from a wide section of California.

 

The Pulmonary Critical Care Team (left to right): Dr. Jeff Fried, Dr. Richard Belkin, Dr. Robert Wright, Dr. Ann Lee, Dr. Eric Schroeder, Dr. Jeffrey Sager and Dr. David Zisman. Not pictured: Dr. Jeffrey Kupperman, Dr. Ronald Ungerer and Dr. Marta Sovilj.

 

 

 

 

Patients requiring emergent care for subarachnoid hemorrhage and ischemic stroke are frequently flown by helicopter to Santa Barbara Cottage Hospital. Subsequent intensive care of these patients is a complex and multi-disciplinary process involving not only neurosurgeons, nurses and respiratory therapists but also the expertise of physicians trained in pulmonary and critical care medicine. These doctors, also known as intensivists, include Richard A. Belkin, MD, Jeffrey Fried, MD, Ann Lee, MD, Jeffrey S. Sager, MD, C. Eric Schroeder, MD, Robert S. Wright, MD, and David Zisman, MD. All are board certified in critical care medicine. The coordination of care by intensivists is integral to achieving excellent outcomes for critically ill neurological patients.

 

One of the major problems encountered by our team is subarachnoid hemorrhage. Subarachnoid hemorrhage is most frequently due to a rupture of a weakened blood vessel wall providing circulation to the brain. Such weaknesses are known as aneurysms. Other common causes include arteriovenous malformations and fibromuscular dysplasia. It is the role of the neurosurgeon or neurointerventionalist to stop the bleeding by specialized catheter procedures. Frequently, the aneurysm site is embolized with small coils that prevent further bleeding. In other instances, drugs are administered directly into the vessels to dissolve clots. At other times, the clot may actually be physically extracted. Time is of the essence for all these procedures. However, even with the most expedient and timely procedures, it is anticipated that the brain can become quite injured. The care of the patients after these initial procedures is key to their survival. The intensivists at Santa Barbara Cottage Hospital play a crucial role in their care.

 

Brain injury is accompanied by brain swelling. Because the skull is a rigid structure, the pressure from the swelling can further damage the brain. At our institution, therapeutic hypothermia is a key treatment to improving the neurocritical patients’ outcome. These patients are intentionally paralyzed with specialized medications and a cooling catheter is placed into a large vein. Because the patients are paralyzed, a mechanical ventilator is used to breathe for them through a tube placed in the trachea. Their body temperature is lowered and maintained for one or two weeks until brain swelling resolves. Much like an ice pack on a bruised extremity, this cooling can lessen damage to the brain. However, these maneuvers are complicated and have the potential to cause short-term problems such as pneumonia, severe lung injury known as acute respiratory distress syndrome (ARDS), electrolyte disorders and bleeding. Therapeutic hypothermia is also used to protect the brain from injury after certain types of cardiac arrest and is available at Santa Barbara Cottage Hospital.

 

The control of ventilation is essential in neurocritical care patients. Pulmonary intensivists work to achieve a delicate physiological equilibrium, balancing ventilation to achieve carbon dioxide (pCO2) levels that reduce brain swelling, while administering large amounts of fluid to maintain optimal blood pressure. The lungs can become injured from these fluid challenges because the patients are paralyzed and unable to mobilize and expectorate their own secretions. This sometimes leads to the competing priorities of protecting the brain vs. adequate ventilation and the health of the lungs. Consequently, pulmonary edema, a form of congestive heart failure, and ARDS are frequent complications. The pulmonary intensivists perform bronchoscopy to remove and culture secretions in order to determine appropriate antibiotic treatment for pneumonias. For pulmonary edema and ARDS, the intensivists use traditional as well as creative and alternative ventilation modalities to keep patients alive; such maneuvers are important to prevent complications such as collapsed lungs.

 

The pulmonary and critical care specialists collaborate with the neurosurgeons, neurologists, nurse practitioners, nurses, respiratory therapists, dietitians and other members of the healthcare team to coordinate daily care of the patients. During rounds, radiographs are reviewed and nutrition and other physiological needs such as bowel function are assessed so that the patient’s care is individualized to optimize his or her recovery.

 

Approaching a Crossroads

The care of neurocritical care patients by our pulmonary and critical care specialists is not only important, but it is relatively uncommon. While critical care physicians play a unique role and many studies have indicated that their expertise is important, it is estimated that only about 20 percent of the intensive care units in the United States are staffed with critical care specialists. The demand for critical care specialists is rising, yet the number of these trained specialists is not anticipated to keep up with demand. In fact, the Society of Critical Care Medicine estimates that by 2020 there will be a 35 percent shortfall of trained specialists nationally. As such, we have been fortunate at Cottage Hospital to have so many well-trained critical care specialists. However, the demand for their services is expected to increase as advancing technologies for the care of critically ill patients evolve. It will be important to have the services of these doctors available for the future.

 

 

To meet the specialists at Santa Barbara Neuroscience Institute at Cottage Health System, visit www.sbni.org. To refer a patient, please contact the transfer center at 1-888-MY-CAL-NEURO.

 


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