Current Status of Neurocritical Care in India
By Dheeraj Khurana, MD1; Kiran Jangra, MD2; and Gagandeep Singh, MD, DM3
1. Department of Neurology, Postgraduate Institute of Medical
Education and Research
2. Department of Neuroanesthesia, Postgraduate Institute of
Medical Education and Research
3. Department of Neurology, Dayanand Medical College
& Hospital, Ludhiana
Neurocritical care is a vast specialty that covers various
subspecialities, including neurology, neurosurgery, neuroanaesthesiology
and interventional neuroradiology. In India, this
field is most developed in the major cities while it is still emerging
in various other cities and underprivileged areas. The rising
incidence of neurotrauma and stroke and advances in neurosurgical
techniques warrant the need for more neurocritical care setups.
The current population of India is over 1.2 billion and still
on rise by approximately 18 million per year. The origins of
critical care in India can be traced back to the early 1960s when
a formal society of critical care, the Indian Society of Critical
Care Medicine (ISCCM), was created in 1993. In 1951, eminent
neurosurgeons and neurologists founded the Neurological
Society of India (NSI). This society annually organizes various
conferences (including Neurological Surgeons’ Society of India)
and neurocritical care workshops.
In 1992, Indian neurologists initiated the Indian Academy of
Neurology.1 In February 1995, Professor H. H. Dash, head of
neuroanaesthesiology at All India Institute of Medical Sciences
(AIIMS), New Delhi, organized the first International Symposium
on Neuroanaesthesia and Critical Care where anaesthesiologists
interested in neuroanaesthesia could interact with many
distinguished international faculty. Subsequently, in 1996, a
Neuroanaesthesiology Society of India akin to the international
body, the Society of Neuroanesthesiology and Critical Care
(SNACC), was convened. During that meeting, NSI also initiated
its support to the program.
In February 1999, a focused group of neuroanaesthesiologists
formed the Indian Society of Neuroanaesthesiology and Critical
Care (ISNACC). Since then, the annual conference is a regular
feature and is hosted in different cities of India every year. Around
a decade later, in 2009, The Indian Neuroanaesthesiology and
Critical Care Trust was formed.
Since then, the society has grown and affiliated with international
societies such as Asian Society for Neuroanesthesiology and
Critical Care (ASNACC) and SNACC. Hosting the second
ASNACC Conference along with ISNACC - 2011 at New Delhi
under the leadership of Dr. H. H. Dash, was a testimony to that.
Neurosonology has also taken off in India with the recently
formed Neurosonology Society of India (2014), which also has
annual meetings as well as conducts an annual neurosonology
certification examination.
In most centers, neurocritical care is instituted in general ICUs.
An internet-based survey conducted by Amin in 2013 revealed
that out of the 162 respondents, 59 (36.42 percent) had exclusive
neurocritical care units.2 There may be approximately 100 to 125
neurosurgical ICUs in India, but their distribution is not uniform
throughout the country. Recently (in 2017), AIIMS has initiated a
one year fellowship in neurocritical care.
There are eight stroke registries in various states in India that
have stroke surveillance systems, based on the WHO STEPS
guidelines. The Indian Council of Medical Research (ICMR) had
tried to integrate these registries, but it is still under development.
Although, as per a 2013 publication, approximately 35 stroke
units exist in India3, which include a multidisciplinary team
comprising of medical, nursing, physiotherapy, occupational
therapy, speech therapy and social work staff. Currently, the
number of stroke units has increased and a conservative estimate
would put them close to over 50. The ICMR has recently
sanctioned the Indian Stroke Clinical Trials (INSTRUCT) network
to conduct clinical trials for advancement of stroke treatments in
India (www.instructnetwork.in).
Various monitoring modalities are being used in neurocritical care
units including ICP monitoring (intraventricular/optic nerve sheath
diameter), Transcranial Doppler, EEG and EEG based monitors,
and, in a few research institutes, microdialysis (Figure 1).
Commercially available
systems for ICP
monitoring are rarely
used, and only in a few
centers, as these are
extremely expensive for
the Indian setting.4 The
most commonly used
modality for ICP
monitoring is the intraventricular drain, but it is associated with
high incidence of nosocomial meningitis.
Neurocritical care is currently a requirement, especially in the
emerging stroke programs since most of these centers, such as
AIIMS, Postgraduate Institute of Medical Education and Research
(PGIMER) and National Institute of Mental Health & Neuro
Sciences (NIMHAS) are routinely carrying out endovascular
therapy. Dedicated neurointensive care can improve the outcome
of neurological and neurosurgical patients undergoing various
procedures.
Recently, a few centers in India have started various training
courses in neurocritical care, such as a two year training course of
postdoctoral fellowship in neuroanaesthesia and critical care and
a one year postdoctoral fellowship in neurocritical care at AIIMS
New Delhi and NIMHANS Bangalore. There is an increasing
need of establishing more neurointensive care units in India.
Neurointensive care training, workshops and seminars are being
increasingly organized to train caregivers.
References
1. Ganapathy K. Neurosurgery in India: an overview. World
Neurosurg 2013; 79:621-8.
2. Amin P. Indian critical care discussion group survey. Indian
J Crit Care Med, Forthcoming 2014.
3. Pandian J D, Sudhan P. Stroke Epidemiology and Stroke
Care Services in India. J Stroke 2013;15:128-34.
4. Joseph M. Intracranial pressure monitoring in a resourceconstrained
environment: a technical note. Neurol
India 2003;51:333-5.
Dheeraj Khurana,
MD
Kiran Jangra, MD Gagandeep Singh,
MD, DM
7
/www.instructnetwork.in
