- Email: [email protected]
Neurocritical care: an emerging discipline
In Context
I found the first chapter, “Personal”, to be the most successful. The subsequent chapters on “The brain’ and ‘The spine” are the author’s summary of these areas as they pertain to his experiences in neurosurgery; I very much feel that this part of the book is directed towards the non-medical reader. Subsequent chapters include Harris’ overseas medical travels as well as his roles in medical and other organisations that were mostly within the Edinburgh medical sphere. Chapter 7, titled “Miscellany”, is an odd potpourri of paragraphs on various ideas, experiences, and notions that the author has decided to include; for example, describing his golf partner, the experience of Mexican food in Texas, the Alabama National Guard, attempted suicide, and “an epidemic of ageing”. The book finally concludes with Harris’ description of “two artistic giants”, Rembrandt and Gustav Mahler. Admittedly, Rembrandt has relevance with regard to early anatomy in his
paintings and drawings. Mahler seems to be a more personal choice by the author. The figures, photographs, and drawings are excellent and relevant, and the glossary of surgical terms would also be very useful for the lay reader. All in all, the book is too variable in its themes to be a classic; part memoir, part lay-guide to neurosurgery. However, it is not overly long and the reader will be able to bypass sections that are of less interest to them. Harris’ family will no doubt be extremely proud of the end product. For those in the medical community who are interested in the history of post-war hospital medicine in the UK, there are some important passages, while the non-medical reader will find the educational passages illuminating.
Neil Kitchen [email protected]
Neurocritical care: an emerging discipline The care of critically ill patients with brain and spinal cord injuries has traditionally been provided through one of two approaches. Primary care has been delivered either by general intensivists, relying heavily on consultative input from neurosurgeons or neurologists (commonly adopted in Canada, Australia, and some European countries), or by neurosurgeons or neurologists, relying heavily on consultative support from other medical subspecialists (commonly adopted in the USA). Critical care is a dynamic and increasingly complex discipline, in which patients’ status can fluctuate greatly. Thus, this specialty is not well suited to rely heavily on “off-site” consultants, who might be at the bedside only once a day, and might lack experience in understanding the complicated interactions between organ systems. Recognition of these and other limitations has provided an impetus for the emergence of neurocritical care as a distinct discipline. Buoyed by observational research suggesting improved outcomes with the use of an organised, protocolbased approach to the management of brain-injured patients, more medical centres are introducing dedicated neurological intensive care units, with multidisciplinary care directed by neurointensivists. Specialised fellowship training is being increasingly offered. Although neurocritical care is covered to some degree in most general critical care textbooks, few are dedicated solely to the management of neurological patients. Neurocritical Care is the most recent reference to fill this niche. It is divided into four sections: principles of neurocritical care, with chapters focusing on neurophysiology, neuropharmacology, and essentials of “life support” in the context of neurological illness; neuromonitoring, with emphasis on intracranial pressure and cerebral perfusion; management of specific disorders (the largest section), with chapters devoted to www.thelancet.com/neurology Vol 9 July 2010
various forms of stroke, status epilepticus, neurotrauma, and CNS infections; and management of medical disorders in the neurocritical care unit. All the chapters are mostly written by authors working in the USA, primarily with neurology or neurosurgery as their base specialty. Neurocritical Care is sufficiently concise that it can easily be read in a few weeks, yet it is comprehensive enough to provide an inclusive overview of the field. Thus, this book is an excellent introductory resource, particularly for early neurocritical care training for residents or fellows, specialised neurointensive care unit nurses, and neurologists or neurosurgeons seeking a general synopsis. For experienced neurointensivists, many topics are not covered in sufficient depth for this book to be used as a comprehensive reference. For example, the sections on various forms of advanced neuromonitoring (eg, cerebral microdialysis, brain tissue oxygenation, and continuous electroencephalography) are placed into a single chapter. Readers are left wishing for more detail and for examples of how these techniques can be applied practically at the bedside. Similarly, there is little discussion of advanced neuroimaging concepts. However, even experienced neurointensivists could find themselves repeatedly referring to the sections on neuropharmacology and on ethical and legal considerations (although this chapter is only from a US perspective). For physicians with substantial experience in the general intensive care unit, who are looking for an overview of neurocritical care, the first three sections will be of great interest. However, much of the information in the fourth section, although smartly organised, can also be found in most internal medicine bedside handbooks.
Neurocritical Care Edited by Michel T Torbey Cambridge, 2009. Pp 440. £35. $65. ISBN 978-0-521-67689-2
Andreas Kramer [email protected]
661
I found the first chapter, “Personal”, to be the most successful. The subsequent chapters on “The brain’ and ‘The spine” are the author’s summary of these areas as they pertain to his experiences in neurosurgery; I very much feel that this part of the book is directed towards the non-medical reader. Subsequent chapters include Harris’ overseas medical travels as well as his roles in medical and other organisations that were mostly within the Edinburgh medical sphere. Chapter 7, titled “Miscellany”, is an odd potpourri of paragraphs on various ideas, experiences, and notions that the author has decided to include; for example, describing his golf partner, the experience of Mexican food in Texas, the Alabama National Guard, attempted suicide, and “an epidemic of ageing”. The book finally concludes with Harris’ description of “two artistic giants”, Rembrandt and Gustav Mahler. Admittedly, Rembrandt has relevance with regard to early anatomy in his
paintings and drawings. Mahler seems to be a more personal choice by the author. The figures, photographs, and drawings are excellent and relevant, and the glossary of surgical terms would also be very useful for the lay reader. All in all, the book is too variable in its themes to be a classic; part memoir, part lay-guide to neurosurgery. However, it is not overly long and the reader will be able to bypass sections that are of less interest to them. Harris’ family will no doubt be extremely proud of the end product. For those in the medical community who are interested in the history of post-war hospital medicine in the UK, there are some important passages, while the non-medical reader will find the educational passages illuminating.
Neil Kitchen [email protected]
Neurocritical care: an emerging discipline The care of critically ill patients with brain and spinal cord injuries has traditionally been provided through one of two approaches. Primary care has been delivered either by general intensivists, relying heavily on consultative input from neurosurgeons or neurologists (commonly adopted in Canada, Australia, and some European countries), or by neurosurgeons or neurologists, relying heavily on consultative support from other medical subspecialists (commonly adopted in the USA). Critical care is a dynamic and increasingly complex discipline, in which patients’ status can fluctuate greatly. Thus, this specialty is not well suited to rely heavily on “off-site” consultants, who might be at the bedside only once a day, and might lack experience in understanding the complicated interactions between organ systems. Recognition of these and other limitations has provided an impetus for the emergence of neurocritical care as a distinct discipline. Buoyed by observational research suggesting improved outcomes with the use of an organised, protocolbased approach to the management of brain-injured patients, more medical centres are introducing dedicated neurological intensive care units, with multidisciplinary care directed by neurointensivists. Specialised fellowship training is being increasingly offered. Although neurocritical care is covered to some degree in most general critical care textbooks, few are dedicated solely to the management of neurological patients. Neurocritical Care is the most recent reference to fill this niche. It is divided into four sections: principles of neurocritical care, with chapters focusing on neurophysiology, neuropharmacology, and essentials of “life support” in the context of neurological illness; neuromonitoring, with emphasis on intracranial pressure and cerebral perfusion; management of specific disorders (the largest section), with chapters devoted to www.thelancet.com/neurology Vol 9 July 2010
various forms of stroke, status epilepticus, neurotrauma, and CNS infections; and management of medical disorders in the neurocritical care unit. All the chapters are mostly written by authors working in the USA, primarily with neurology or neurosurgery as their base specialty. Neurocritical Care is sufficiently concise that it can easily be read in a few weeks, yet it is comprehensive enough to provide an inclusive overview of the field. Thus, this book is an excellent introductory resource, particularly for early neurocritical care training for residents or fellows, specialised neurointensive care unit nurses, and neurologists or neurosurgeons seeking a general synopsis. For experienced neurointensivists, many topics are not covered in sufficient depth for this book to be used as a comprehensive reference. For example, the sections on various forms of advanced neuromonitoring (eg, cerebral microdialysis, brain tissue oxygenation, and continuous electroencephalography) are placed into a single chapter. Readers are left wishing for more detail and for examples of how these techniques can be applied practically at the bedside. Similarly, there is little discussion of advanced neuroimaging concepts. However, even experienced neurointensivists could find themselves repeatedly referring to the sections on neuropharmacology and on ethical and legal considerations (although this chapter is only from a US perspective). For physicians with substantial experience in the general intensive care unit, who are looking for an overview of neurocritical care, the first three sections will be of great interest. However, much of the information in the fourth section, although smartly organised, can also be found in most internal medicine bedside handbooks.
Neurocritical Care Edited by Michel T Torbey Cambridge, 2009. Pp 440. £35. $65. ISBN 978-0-521-67689-2
Andreas Kramer [email protected]
661