Neurocritical Care in the Resource Limited Setting of Nepal By Gentle Sunder Shrestha, MD The recent catastrophic earthquake of 7.8 The country faces a major burden of neurocritical illness like magnitude that struck Nepal on April 25, traumatic brain injury, stroke, epilepsy, and infectious diseases 2015 imposed a major humanitarian crisis like meningitis, encephalitis, and cerebral malaria. Neurocritical with over 8,500 deaths and over 14,000 care is at the stage of infancy in Nepal. There are only a few injuries. The weak healthcare system and the dedicated Neuro ICUs in the country. The Neuro ICUs are limited resources were easily overwhelmed being run as open or semi-closed units by neurosurgeons, by the major disaster. Much of the brunt of neurologists, and anesthesiologists. The Neuro ICUs do not major disaster victims was managed by a few meet the signifi cant disease burden. Therefore, the majority of referral hospitals in the major cities. Services neurologically ill patients are managed in general ICUs. were extended beyond the usual boundaries of emergency rooms and ICUs and beyond the usual times of Management is often suboptimal due to constrained resources, functioning of operating rooms. limited ability, and availability of invasive monitoring and lack of trained neurointensivists and full time intensivists. Invasive A signifi cant number of trauma victims had neurological monitoring such as intracranial pressure monitoring is available injuries. Relief and rescue operations were facilitated by extensive only in a few centers. Neuroradiological diagnostic facilities involvement of government and relief organizations across the are also limited. Due to lack of public awareness, poor referral boundaries of nations and continents. Various national and systems, challenging geography of the country, and the lack international groups of effective patient and organizations are transport systems, involved in fundraising critically ill neurologic and donations. The patients either do not need of proper disaster reach the few centers preparedness and with provision of effective training neurocritical care or they is underscored. reach those centers late. Collaborations with international The system for organizations management of patients and societies have with stroke is poorly strengthened the fi ght developed despite a against this natural signifi cant burden of disaster. disease. Nepal lacks dedicated stroke units. Nepal is a small South Thrombolytic therapy Asian nation with an is administered rarely, estimated population of only in some centers due 27.8 million. As per the World Bank data, it is classifi ed as a low in part to the expenses for the drugs. Most of the patients income nation with a gross national income (GNI) per capita of are managed conservatively. US $730 in the year 2013. The health care system of the nation is adversely affected by a high rate of poverty, illiteracy, and Nepal has only a limited number of certifi ed challenging geography. neurosurgeons. To date, there are only about 45 certifi ed neurosurgeons in the country. Only four There are about 500 ICU beds across the country, but most of tertiary level centers offer the post-MS, MCh training them are not well equipped. The majority of them are mixed course in Neurosurgery. The Nepalese Society of Neuro ICUs run as open units. The Nepalese Society of Critical Care Surgeons (NESON) was established in 2008 to promote Medicine (NSCCM) was founded in 2010 to promote the neurosurgical services in the country. Similarly, there development of critical care in Nepal. are only about a dozen certifi ed neurologists in the country. Three centers run postgraduate training courses The NSCCM plans to collaborate with the Ministry of Health in Neurology. Just this past year, the Nepalese Academy of Nepal to develop ICUs at district, zonal, and tertiary level of Neurology was formed to enhance the care of patients hospitals. The Nepal Critical Care Development Foundation with neurological illness. Critical care nursing training (NCCDF) was formed as a non-profi t organization to improve for Neuro ICU nurses is being conducted by Annapurna the status of critical care medicine in Nepal. One of the major Neurological Institute & Allied Sciences to enhance the barriers to the development of critical care medicine has been the nursing care of neurological critically ill patients. lack of trained manpower. A few tertiary level teaching hospitals have started three-year postgraduate programs in critical care Outcome research has demonstrated reduced mortality, medicine, but they are not expected to meet the demand for improved outcome, and reduced length of stay if intensivists in the country. Interested clinicians continue to go patients with traumatic brain injury and hemorrhagic abroad to get training. Short duration, competency-based training stroke are managed in dedicated Neuro ICUs by in critical care medicine is required to address the needs. neurointensivists. Considering the signifi cant burden of neurological critical illness in Nepal, it is about time 8
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