FEATURED NEURO ICU PROGRAM
Neurocritical Care in Ecuador By Nelson J. Maldonado, MD, Manuel Jibaja, MD, Claudio Scherle, MD, and Jose I. Suarez, MD
Nelson J.
Maldonado, MD
Manuel Jibaja, MD
Claudio Scherle, MD Jose I. Suarez, MD
Quilotoa Volcano lagoon. Ecuador
Ecuador is a South
American country
straddling the equator
and crisscrossed by the
Andean Mountain Range.
It has a population of
14.5 million, and is
bordered by Colombia
to the North and Peru
to the South. Ecuador’s
largest two cities are Quito
(its capital), located at
9,500 feet above sea level,
and Guayaquil, located
at sea level. Ecuador’s
population is a melting
pot of people of European,
Amerindian, African, and
Middle Eastern descent.
Due to the ethnic diversity
of its people and the
various altitudes at which
they dwell, health care
professionals are faced
with unique medical conditions. Health care coverage is provided
by three different systems: private pre-paid services, pensionbased
Social Security, and government-paid programs to cover the
poorest inhabitants.
Advanced Hospital Care
The Hospital de Especialidades Eugenio Espejo (HEEE) is the
main public hospital in Quito with a capacity of 420 fully
staffed and licensed beds. HEEE is the main national referral
hospital for all specialties, and as such, a national pioneer in the
management of acute neurologic pathologies. In 2015, it became
the first hospital in the country to develop a stroke/step down
unit (SU), and so far it remains the only hospital to do so. HEEE
has developed via international collaborations a unique clinical
neurosciences department with fellowship-trained neurologists,
neurointensivists, neurosurgeons, neuro interventionists, and
physical medicine and rehabilitation specialists.
The SU is located on the eighth floor within the neurology general
unit. It has nine beds with continuous systemic monitoring
capabilities, which are centralized to a main nursing station.
We provide semi-intensive vigilance for patients with ischemic
stroke, ICH, subarachnoid hemorrhage, myasthenia gravis (MG),
status epileptics (SE), and guillain barre syndrome (GBS), among
others, as long as no mechanical ventilation is required following
established international protocols.
Our team is led by one neurointensivist and one vascular
neurologist and composed of internal medicine residents (as there
are no neurology residency programs in the country at the present
time), nurses, and physical therapists. The nurse-to-patient ratio
is 1:5. We have the capability to perform bedside evaluations
such as carotid and transcranial doppler ultrasound. However,
we are hampered by the lack of adequate and well-maintained
equipment, which limits the development of neurosonology. We
are constantly faced with challenges to perform timely ancillary
tests, such as echocardiograms, MRIs, and CT scans, mainly due
to equipment failure and a dearth of specialists to perform the
tests. In addition, HEEE is not equipped with continuous EEG
technology. Moreover, the medications available to control
elevated blood pressure, one of the main targets of management
in an SU, differ when compared to the U.S. or Europe. For
example, the only parenteral antihypertensive available is sodium
nitroprusside, and the only antiepileptic drugs are phenytoin and
valproate. We are capable, however, of administering IVIG for
acute inflammatory or autoimmune processes. Despite all these
challenges, we are happy to report that since November 2016, 131
stroke patients haven been evaluated in the SU, 89 of them with
acute ischemic stroke and 12 received IV r-TPA, and 29 with ICH.
The HEEE has had a mixed-type ICU since 1988. It began with
a capacity of six beds and has progressively increased to 23. The
ICU functions as an open unit (there are no closed units in the
country) and is a national referral center. On average, the annual
number of admissions is 900 patients, the median length of stay
is seven days, and the in-hospital mortality rate is 18.3 percent.
About 32 percent of admissions are patients with some type of
acute neurological pathology who require mechanical ventilation.
By order of frequency, the main neurological pathologies seen
in the ICU include brain tumors (about 150 patients yearly),
followed by severe traumatic brain injury (TBI)—70 patients, and
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