Overview of Neurocritical Care 2006: Synchronicity

June 2006 Overview of Neurocritical Care 2006: Synchronicity By Cherylee W. Chang MD The 4 th Annual Cleveland Clinic s Neurocritical Care Conference will join the Neurocritical Care Society s 4th Annual Meeting for a four-day symposium from November 2 to 5, 2006 in Baltimore, Maryland. The joint program, co-directed by Michael DeGeorgia, MD and Cherylee Chang, MD, is entitled: Neurocritical Care 2006: Synchronicity. The Cleveland Clinic Conference starts Thursday, November 2 and focuses the first 1-½ days on traditional cerebrovascular topics ranging from pathophysiology to the acute management of ischemic stroke. The afternoon session, entitled Tough Calls, includes an informative and didactic lecture series covering medical and ethical controversies, including the management of CNS vasculitis, antiphospholipid antibodies, asymptomatic stenosis and making the ultimate difficult decision of withdrawing aggressive management. The afternoon concludes with a review of the neurovascular imaging advances in CT, MR and PET. Thirteen hours of AMA PRA credit will be offered for these sessions. A two-hour, non-cme workshop will be conducted on Thursday evening entitled: Building the Future of Neurocritical Care sponsored by the Medicines Company. This course is geared toward residents, fellows and junior staff interested in developing research careers and organizing a neurocritical care service. The activities on Friday, November 3, open with an archaeological view of trepanation. This is followed by presentations exploring the medical and surgical management of malignant hemispheric stroke. During the afternoon, traditional critical care issues such as blood transfusion, fever evaluation, sedation and ventilator weaning will be discussed. The CME portion of the conference closes with the Cleveland Clinic Foundation lecture: What a Coincidence: Synchronicity and Intuition. This is a discussion of the development of computational models of higher-level cognition. The Annual Neurocritical Care meeting begins the evening of Friday, November 3, with perspectives from the pioneers of neurocritical care of the history and future of neurocritical care. The 1 ½-day meeting incorporates twomorning poster and four oral abstract sessions. Highlights of the first day include the presentation of concepts and current guidelines of cardiac arrest and hypothermia, mechanisms of brain edema and the caveats of cerebral perfusion pressure management following traumatic brain injury, the future of neuromonitoring, and anticoagulation in the neuro intensive care unit. The development of a novel coma scale will also be presented. The lunch-time business meeting is an opportunity for Michael Diringer, MD, the NCS president, and the Membership, Long- Range Planning, Fund-raising, Publication, Accreditation, and Certification committees to share updates, goals, and direction for the next year. continued on page 5 Inside This Issue President s Corner P. 2 By Michael N. Diringer MD Welcome to the Newsletter P. 3 By Romergryko G. Geocadin MD Clinical Trial Report P. 3 By Matthew A. Koenig MD Featured Program: University of Kansas NICU By John Terry MD P. 4 Call for Abstracts P. 5 By J. Claude Hemphill III MD

President s Corner NCS Leadership 2005-2006 Officers Michael N. Diringer MD, president Cherylee Chang MD, vice president Stephan A. Mayer MD, treasurer Gene Sung MD, secretary Directors Neeraj Badjatia MD J. Ricardo Carhuapoma MD J.J. (Buddy) Conners, III MD William M. Coplin MD Jeffrey Frank MD Romergryko G. Geocadin MD Carmelo Graffagnino MD Daryl R. Gress MD Walter Haupt MD J. Claude Hemphill MD Randall T. Higashida MD Jeffrey R. Kirsch MD Andrew Kofke MD Marc D. Malkoff MD Edward M. Manno MD Marek A. Mirski MD Guy Rordorf MD Owen B. Samuels MD Jose Suarez MD Paul M. Vespa MD Administrative Director Jay Gorham By Michael Diringer MD My fellow neurointensivists, The past two years have been busy and very productive for the Neurocritical Care Society. In November 2005 we held our first stand-alone meeting in Scottsdale, Arizona, and it was a tremendous success. Because of the hard work of many of our members, attendance grew, and the program was expanded and well received. This was an important first step in becoming an established independent society. Our Journal is now in its third year and is published six times a year. It was recently approved for MEDLINE, a goal rarely achieved by a publication as young as ours. We have Eelco Wijdicks and the editorial staff s tireless work, along with a large and growing number of submissions, to thank for this achievement. After decades of waiting, we are well on the road to certification. As a result of Stephan Mayer s bulldog persistence, the United Council of Neurological Subspecialties (UCNS) has approved our application for subspecialty. The UCNS Accreditation Council is working closely with us on requirements for fellowship programs and developing an exam. We now have a funded fellowship program. Through a generous grant from Novo Nordisk, Inc., we sponsor two two-year career development fellowships to support clinical research training in neurocritical care. The first two awardees will receive $85,000 support each year beginning this July. Our annual meeting has been shifted to the fall and expanded considerably. The meeting has been extended by two days to offer a CME accredited educational symposium in collaboration with the Cleveland Clinic Foundation. We are striving to improve communication. Thanks to Romer Geocadin, you are receiving this premier issue of our newsletter. We are also in the process of revamping our website to have more content. Finally, I would like to thank all of our members for their support. Snapshot of the 2006 Neurocritical Care Society Neurocritical Care Society 5841 Cedar Lake Road, Suite 204 Minneapolis, MN 55416 Phone: (952) 646-2034 Fax: (952) 545-6073 Website: www.neurocriticalcare.org Email: info@neurocriticalcare.org Newsletter Advertising Display or Classified Contact: info@neurocriticalcare.org (952) 646-2034 Number of members 350 300 250 200 150 100 50 0 64% Total members: 531 23% 1 7% 6% Physicians Fellows/Residents/Students Nurses Health Care Professionals Page 2

From the Editor Inaugural Neurocritical Care Society newsletter Quarterly Newsletter of the Neurocritical Care Society. June 2006 Volume 1- Number 1 Editor Romergryko G. Geocadin MD Editorial Board Stephan A. Mayer MD Matthew A. Koenig MD Ashok Devasenapathy MD Boby V. Maramottom MD Robert G. Kowalski Jay Gorham By Romergryko G. Geocadin MD The Neurocritical Care Society is launching Currents, the official newsletter of the society that will be published quarterly. The name Currents was chosen because it evokes belonging to the present time, steady onward movement, and flow of electrical charge. Currents embody a dynamic and effective communication tool. As a communication tool of the NCS, Currents will provide information on key activities of the society as it undertakes its mission to improve outcomes for patients with life-threatening neurological illnesses. Currents will be a venue for information exchange between the officers and members, with a regular column of the president and a letters-tothe-society section from the general membership. The newsletter will also contain regular features of neuro-intensive care programs from around the world, a clinical trials monitor, updates of educational and training programs and means to enhance clinical practice of neuro-intensive care. Currents will also disseminate information about meetings and educational programs related to neuro-intensive care. Currents encourages active participation from the members of the society and will consider format suggestions and article submissions. Advertisements from members and other interested parties will be considered for a fee. Please direct correspondence by e-mail to: info@neurocriticalcare.org or by regular mail to: Neurocritical Care Society 5841 Cedar Lake Road, Suite 204, Minneapolis, MN 55416, USA. The editorial group of Currents is composed of the following: Romergryko G. Geocadin, MD, Baltimore, MD (Editor); Stephan A. Mayer, MD, New York, NY; Robert G. Kowalski, Ireland; Matthew A. Koenig, MD, Baltimore, MD; Ashok Devasenapathy, MD, Hershey, PA; Boby V. Maramottom, MD, India; and Jay Gorham, Minneapolis, MN. Clinical Trials Monitor NETT to Coordinate Multi-Center Clinical Trials in Neurological Emergencies By Matthew A. Koenig, MD On April 28, the National Institute of Neurological Disorders and Stroke (NINDS) announced a request for applications (RFA-NS-06-009) for funding of clinical hubs for the newly-conceived Neurological Emergencies Treatment Trials (NETT) network. The NETT was established by the NINDS in order to foster multi-center clinical trials for emergency neurological and neurosurgical conditions. The goal of NETT is to create a research consortium of participating emergency departments, neurologists, neurosurgeons, and neurointensivists with a centralized infrastructure for trial design, funding, coordination, participant training, data collection, and statistical analysis. The NETT is expected to streamline the early stages of multi-center trial design by establishing a mechanism that can be utilized for future clinical trials, rather than requiring de novo coordination of centers for every new trial. This article is the first in a planned quarterly series spotlighting multi-center clinical trials in neurological emergencies and intensive care. The intent of this series is to aid collaboration between neurological intensive care investigators by raising awareness of planned and active clinical trials. Investigators interested in publicizing clinical trials are asked to contact me through the Neurocritical Care Society e-mail address info@neurocriticalcare.org. The NETT was initiated because of a deficiency in large clinical trials of neurological emergencies involving the collaboration of emergency physicians and specialists in neurological diseases. The objective of the NETT is to conduct 2 large phase III clinical trials for emergency treatment of neurological conditions, such as traumatic brain injury, stroke, and epilepsy, within the next 5 years. These trials will serve the dual purposes of advancing patient treatment and testing the feasibility of the NETT consortium for future trials. The consortium will ultimately be composed of 11 regional clinical hubs that will coordinate research activities at 2-10 emergency departments and involve the participation of 18-25 emergency physicians, neurologists, neurosurgeons, and neurointensivists. The hubs are envisioned as academic centers capable of overseeing patient enrollment at each of the regional spokes. Depending on the trial design, patients may either be enrolled on-site at the spoke hospital or transferred to the hub for enrollment. Funding for the clinical coordination center will be provided through an NIH U01 grant (RFA-NS-06-002) that will commit up to $5 million over 5 years. Separate funding through an NIH U01 (RFA-NS-06-008) grant will support a statistical and data management center with up to $500,000 per year for 5 years. The 11 hubs will be funded through an NIH U10 cooperative research grant (RFA-NS-06-009) for up to $200,000 per year for 5 years. continued on page 5 Page 3

Neuro-Intensive Care Featured Program: University of Kansas Medical Center NICU By John Terry MD We, at the University of Kansas Medical Center Neuroscience Intensive Care Unit (NICU), appreciate the opportunity to describe our progress in this inaugural issue of the Neurocritical care society newsletter. I have been the Director of the NICU for approximately one year. I currently do not have a fellow but I have rotating residents in the ICU. The NICU is a combined Neurosurgery/Neurology ICU that includes seven ICU beds and eight step-down beds. The average daily census is eight and average length of stay is 2.85 days. Six of the seven rooms have large windows providing patient exposure to normal circadian light variation. Three rooms are wired for networked continuous EEG monitoring with remote access capability. The unit also includes a conference room for family discussions, and office space. The NICU is located one floor below the operating rooms and CT scanners and one floor above the emergency department. As the only neuro-intensivist at KU, I perform or supervise all the necessary procedures in the Neuro-ICU such as arterial lines, central lines, PA catheters, endotracheal tubes, fiberoptic ICP monitors, and ventricular catheters. Most intracranial pressure (ICP) monitoring involves external ventricular drains. However, fiber optic monitoring devices are also used in patients suspected of having increased intracranial pressure. We use prophylactic antibiotics for indwelling intracranial devices and are in the process of developing a method to track ICP monitoring devices. We have 30 NICU nurses, all of whom are certified in the NIH stroke scale and have worked in the unit for an average of five years. Twenty eight percent of the nurses have CCRN or CNRN certification. Our NICU nurse manager has 19 years of neuroscience nursing experience and has been in her current To encourage exchange of ideas and enhance the practice of neuro-intensive care, Currents will feature the different types of clinical practices in neurocritical care: academic, private or mixed practice; closed/open unit designs; unique variation in practices as defined by local or national standards and other interesting programs related to neurocritical care. Please direct all inquiries regarding this section to Ashok Devasenapathy, MD, at: info@neurocriticalcare.org. position for six years. We have implemented multidisciplinary rounds, a standardized template for computer printed daily notes, and preprinted order sets. The order sets include standard admission orders, acute stroke evaluation orders, tpa dose calculation and administration orders, stroke admission orders, and stroke etiology evaluation orders. Several other order sets are under development. We utilize protocols for temperature modulation, insulin infusion and goaldirected therapy of sepsis. Our ICU quality data from calendar year 2005 showed significant promise. Ventilator-associated Medical staff of the University of Kansas NICU pneumonia rates decreased from 17.0 to 1.6 infections/ ventilator days despite an overall increase in ventilator utilization. Central line associated bloodstream infections were reduced from 9.4 to 0 infections/device days. During the same time period, the mortality index (observed deaths/expected deaths based on UHC methodology) for ischemic stroke decreased by 58% and hemorrhage stroke (ICH+SAH) decreased 17%. Much of the work over the past year has been focused in organizing a Stroke Program which was recently certified as a JCAHO stroke center. A cadre of 16 NICU nurses received over eight hours of continuing education regarding stroke. These nurses participate in our acute stroke response team with one of them carrying a stroke pager daily. Because of their 24/7 in-house availability and the proximity of the NICU to the emergency department, the average response time for stroke team arrival at the bedside is 4.0 minutes. This nurse involvement also enhances continuity of care as patients receiving intravenous or endovascular interventions. We also have full interventional neuroradiologic support and approximately 60% of the aneurysms presenting to our hospital are coiled. Future plans for the unit include: an addition of six beds capable of flexing up or down based on patient acuity; hospital acquisition of more efficient devices for temperature modulation and implementation of a house-wide hypothermia protocol for post cardiac arrest treatment; completion of the IRB review process to begin participation in the ATACH trial for intracerebral hemorrhage; and the development of a neurocritical care and stroke fellowship. Dr. John Terry is an Associate Professor in Neurology and Neurosurgery at the University of Kansas School of Medicine. He completed his medical education at the University of Kansas School of Medicine. His postgraduate medical training includes a neurology residency at University of Texas-Southwestern in Dallas, Tx and a neurocritical care fellowship at Johns Hopkins Hospital in Baltimore, MD. Page 4

Fourth Annual Neurocritical Care Society Meeting Continued from page 1 The last-day activities will start with a daybreak session that will review the benefits and limitations of various acute revascularization modalities sponsored by Concentric Medical, Inc. This will be followed by the conclusion of the meeting with a discussion of the diverse national and international organizational models of neurocritical care. The meeting registration website will be available soon. A preliminary meeting agenda is available at www.neurocriticalcare.org. For those who wish to stay at the meeting hotel, a block of rooms is being held at the Baltimore Marriott Waterfront. A special room rate of $199.00 is available and can be reserved by contacting reservations at:- -------------------------- www.stayatmarriott.com/neurocriticalcare/. This four-day Synchronicity conference brings together the efforts of the Neurocritical Care Society and the Cleveland Clinic to provide an educational forum for an invigorating interchange of ideas, practice and areas for future study. The variety of topics promises an interesting and thought-provoking meeting. We hope that you will join us in Baltimore, November 2-5, 2006! Important Upcoming Dates Abstract Deadline: 2006 NCS Meeting June 30, 2006 European Federation of Neurological Societies Sept. 2-5, 2006 Glasgow, UK University of Virginia Department of Neurology 3 rd Annual Practical Critical Care conference Society of Neurosurgical Anesthesia and Critical Care 34 th Annual Meeting 4 th Annual Cleveland Clinic Neurocritical Care & Stroke Conference Sept. 14-15, 2006 Oct. 12-13, 2006 Nov. 2-3, 2006 Charlottesville, VA Chicago, IL Baltimore, MD 4 th Annual Neurocritical Care Society Meeting Nov. 4-5, 2006 Baltimore, MD Society of Critical Care Medicine 36 th Critical Care Congress American Association of Neurological Surgeons Annual Meeting Feb. 16-21, 2007 April 14-19, 2007 Orlando, FL Washington, D.C. NETT network Continued from page 3 In the proposed timeline, the first six fiscal months will be devoted to awarding grants for the clinical coordinating center, statistical and data management center, and 11 research hubs. The application deadline for the clinical coordinating center has passed and the deadline for the statistical and data management center and research hubs is June 28, 2006. Applications can be accessed through the NIH website at http://grants1.nih.gov/grants/index.cfm. The second 6 fiscal months will involve further clinical trial design, IRB approval of trial protocols at the hub and spoke sites, trial-specific training, and database design. The trials are currently scheduled to begin in the second fiscal year and will be carried out for up to four years. The NETT project is coordinated through the Clinical Trials section of the NINDS by Dr. Robin Conwit, MD (e-mail: conwitr@ninds.nih.gov). Call for Abstracts By J. Claude Hemphill III MD, MAS Abstracts are currently being accepted for the 2006 Neurocritical Care Society meeting! Abstracts relevant to either clinical or basic aspects of neurocritical care are encouraged. Submission is done electronically via the society website at http://www.neurocriticalcare.org. Submissions close on June 30, 2006, 12 midnight PST. Presenters will be notified of abstract acceptance by September 1, 2006 and accepted abstracts will be published in a future issue of the official journal of the society, Neurocritical Care. Last year's scientific meeting was extremely successful with over 80 accepted abstracts presented during four platform and two poster sessions. We expect an interesting meeting again this year! Don't forget that an award will be given at the 2006 meeting for the outstanding abstract submitted by a junior member of the society (student, resident, or fellow). Information on award eligibility will be available with abstract submission. Encourage your fellows and residents to submit! Additionally, while we strongly encourage presentation of new work, material which has been previously presented elsewhere will be eligible for submission and presentation at the 2006 meeting. Presenters are strongly encouraged to submit completed manuscripts for first review to Neurocritical Care. Go to the website and submit! Page 5