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Neorocritical care centres could save lives

10 May 2005

The lives of tens of thousands of people with brain injuries could be saved, with a better quality recovery, at less cost, through the introduction of specialised neurocritical care centres, according to a leading British anaesthetist.

There is now clear evidence that such specialist centres could significantly improve the quality of survival, Professor David Menon said in Auckland today.

Neurocritical care is intensive or critical care of patients whose primary problem is in the nervous system, most commonly the brain. Common causes of such disease include head trauma, stroke, brain haemorrhage, meningitis, and diseases of the nerves and muscles.

Professor Menon, Professor of Anaesthesia at Cambridge University, was speaking at the Annual Scientific Meeting (ASM) of the Australian and New Zealand College of Anaesthetists (ANZCA), being attended by 1,000 anaesthetists, intensivists and pain medicine specialists from around the world. The theme of the meeting is "Improving Outcomes".

He said that research in recent years had increasingly demonstrated the efficacy of specialist neurocritical treatment, particularly in the field of acute brain injury.

Standard guidelines had been developed by several expert bodies in the late 1990s, after an assessment of the various treatment options then in use.

The US Brain Trauma Foundation had later estimated that, based on these guidelines, 20,000 lives could be saved each year in the USA alone, and clear benefits had been demonstrated since under protocols broadly based on the American guidelines.

"More recently (2002/03) there have been numerous reports of significant improvements in outcome from evidence based management of severe head injury, compared with historical controls," Professor Menon said.
"According to two relevant studies, there were clear improvements in the proportion of patients experiencing favourable outcomes - from 40.4 per cent to 59.6 per cent in severe head injury, and from 40 per cent to 84 per cent in all head injured patients.
"These data suggest that good quality neurocritical care has its most consistent impact not on survival but on the more desirable goal of quality of survival.
"It is also clear that these results are best achieved by professional intensivists," Professor Menon said.

Arguments for neurocritical specialisation included the fact that clinical teams who frequently cared for patients with acute brain injury were more likely to have knowledge of secondary damage, and would better understand the pathophysiology they treat. As well, specialisation often attracted greater volumes of patients and a greater case-load was very likely to improve expertise in the area, as it did in others.

While the examples listed above referred to specialist stand-alone neurocritical care units, it was entirely possible for high quality neurocritical care to be delivered in some dedicated "general" intensive care units.

"Neurocritical care is not a label - it is a way of life which recognises the special needs of the acutely ill neurological patient and uses the available knowledge to maximise outcomes in this group," Professor Menon said.
"The availability of high quality intensive care in this context is an investment that pays for itself many times over in improved outcome and reduced costs for rehabilitation and support services during the later stages of the illness.
"For example, good intensive care can mean the difference between a head injured teenager being dead or alive, bed-bound or mobile in a wheelchair, and suffering from severe learning difficulties or leading a near normal life," he said.

Professor Menon said there already were a number of specialised neurocritical care units in the USA, the UK and Europe that concentrated on brain and associated injury or illness.


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