8) Activation of neurocritical care education after academic
affiliation between NCS and JNE in 2013, including the first
Emergency Neurological Life Support (ENLS) course as part
of the International Joint Symposium on neurocritical care
While high-fidelity simulation is an effective means of neurologic
education for critical care trainees, with improvement in both
medical knowledge and trainee confidence (Braksick SA, et al.
Neurocrit Care 26: 96-102, 2017), neurocritical care education
in Japan is still the leading approach used in high-fidelity
simulation education. However, an existing problem in the
neurocritical care education in Japan is the evidence-practice gaps
such as the infrequent use of hypertonic saline for raised ICP
and unavailability of intravenous lorazepam for epileptic seizure.
The following is a representative example of a scenario-based
2. Neurocritical Care Hands-on Seminar Certified by the JSICM
(Satoshi Egawa, Yasuhiro Kuroda)
Fortunately, the importance of neurocritical care has recently
been recognized in Japan. However, no neurocritical care training
program is available to date. Thus, we developed the neurocritical
care Hands-on Seminar as a training module in the JSICM.
This seminar aims to identify the various methods of maintaining
cerebral oxygen demand and supply balance to prevent secondary
brain injury. The seminar starts with a short lecture about the
concept. Eventually, participants join four hands-on scenario
booths (40 minutes per booth): post-cardiac arrest syndrome
(PCAS), subarachnoid hemorrhage (SAH), traumatic brain injury
(TBI), and status epilepticus (SE).
Troubleshooting of TTM
Management of shivering
a EEG (from ver. 1.5)
Procedure to insert ICP monitor
Management of DCI
Training of TCCFI (from ver. 1.5)
Management of SE
EEG interpretation based on
ACNS* and modified Salzburg
AW (from ver. 2)
How to conduct neurological examination to
six to eight trainees / scenario the intubated patient !?
PCAS : Post Cardiac Arrest syndrome, TTM : Targeted Temperature Management, aEEG : Amplitude-integrated
Electroencephalogram, TBI : Traumatic Brain Injury, ICP : Intracranial Pressure, SAH : Subarachnoid hemorrhage, DCI : Delayed
cerebral ischemia, TCCFI : transcranial color coded flow imaging, SE : Sates Epilepticus, *ACNS : American Clinical
Neurophysiology Society’s Standardized Critical Care EEG Terminology: 2012 version, AW : Acute non-traumatic weakness
At the PCAS booth, the trainees learn how to intervene in the
situation using TTM. We emphasize the importance of managing
patients’ shivering in order to keep the balance between cerebral
oxygen demand and supply.
At the SAH booth, students learn the neurocritical care
management of patients in the perioperative period. This scenario
shows how the progress in patients’ condition contributes to the
delay in cerebral ischemia (DCI) and how to provide the support
needed. Among those are emergent fluid management and
inducing hypertension. These recommended interventions are
based on NCS and American Heart Association guidelines.
At the TBI booth, the trainees learn to manage ICP in a scenariobased
simulation. The training starts with an actual insertion of
ICP monitor to the simulator. With this, the trainees learn the
importance of sedation, proper head positioning, and end tidal
CO2 monitoring using a simulator. Moreover, hyperventilation
therapy as a management for malignant intracranial hypertension
and the correct administration of osmotic diuretics and hypertonic
saline are taught.
At the SE booth, the management of SE, refractory SE (RSE),
and super RSE showing an actual cEEG monitoring with a video
(international 10–20 system) is introduced. Moreover, trainees
learn how to assess the cEEG based on the American Clinical
Neurophysiology Society’s Standardized Critical Care EEG
Terminology (2012 version). The main objective of cEEG is to
diagnose NCSE using the modified Salzburg consensus criteria.
Since February 2017, the evaluation of cEEG was initially done
thrice in Japan. Now, we are planning to revise this method and
adopt the use of transcranial color-coded flow imaging. Finally,
this seminar will consist of five booths. The fifth booth will
include training on the acute non-traumatic weakness (AW).
Up to the present, we continue to receive positive comments from
the Japanese intensivists who participated in our seminar. Because
of this, we will make efforts to promote neurocritical care in Japan.
Masao Nagayama Professor, Department of Neurology,
International University of Health and
Welfare School of Medicine
Secretary-General, Japan Resuscitation Council
Hitoshi Kobata Director, Osaka Mishima Emergency
Critical Care Center
Satoshi Egawa Neurocritical Care Unit, Asakadai Central
Yasuhiro Kuroda Professor, Department of Emergency,
Disaster, and Critical Care Medicine,
Faculty of Medicine, Kagawa University