The Neurocritical Care Society of India (NCSI) and the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) Joint Position Statement and Advisory on the Practice of Neurocritical Care during the COVID-19 Pandemic

Abstract

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) has rapidly spread across the world including India. Management of patients complicated with neurological illness requiring neurocritical care is challenging during this time. Patients with neurological disease may develop COVID-19 infection or there could be independent neurological manifestations of COVID-19. Critically ill neurological patients are more vulnerable to contracting SARS-CoV-2 infection. Also, neurological patients with comorbidities and multisystem involvement are at increased risk of adverse outcomes. Though SARS-CoV-2 predominantly affects the pulmonary system, it can complicate the assessment and management of neurological patients. With increasing COVID-19 numbers, the hospitalizations of both non-COVID and COVID-19 neurological patients will bring significant strain on the hospital and neurocritical care facilities. Streamlining work pattern, understanding the pathophysiology of COVID-19 and its impact on neurological function, establishing general and specific neurocritical care management strategies, ensuring protection and well-being of health care providers, and implementing effective infection control policies are key elements of efficient neurocritical care management during this pandemic. This joint position statement and advisory on the practice of neurocritical care during the COVID-19 pandemic by the Neurocritical Care Society of India and the Indian Society of Neuroanaesthesiology and Critical Care has been developed to guide clinicians providing care to the critically ill neurological patients in the neurocritical care unit during the current pandemic. As the situation from this novel disease is rapidly evolving, readers must constantly update themselves with newly emerging evidence to provide the best possible care to the critically ill neurological patients.

Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study

“…All patients received standard treatment as per the need of specific neurological diagnosis and the advisory on neurocritical care practice during the COVID-19 pandemic provided by the Neurocritical Care Society of India. 13 Out of 43 patients, 34 (79%) patients received steroids (dexamethasone) and 30 (69.8%) received anticoagulants for COVID-19 management. Unfractionated heparin (UFH) was administered to 21 (70%) patients and low-molecular- weight heparin (LMWH) to 9 (30%) patients.…”

Tracheostomy during COVID-19 Pandemic: Viewpoint

“…Tracheostomy is not indicated in patients requiring high fractions of inspired oxygen (FiO 2 ), have high ventilator requirements, and those who require prone positioning as part of their ventilatory strategy. 4,11 The benefits and risks of tracheostomy may vary on an individual basis and should be considered after analyzing the patient profile and discussion with family members. Considerations also vary depending on the center's requirements, stage of the pandemic at the place, and experience and expertise of the care provider team.…”

“…There have been raging debates with some meta-analysis alluding to early tracheostomy for prevention of ventilator-associated pneumonia and shortening of ICU stay, while others stating no significant difference in outcomes with regard to timing. 11 Even during the COVID-19 pandemic, early tracheostomy does not result in a shorter duration of invasive mechanical ventilation or improvement in hypoxia. If the patient meets weaning targets like FiO2 less than 40%, positive end-expiratory pressure (PEEP) < 8, PaO2/FiO2 > 200, and pressure support < 8 cmH 2 O, extubation could be reached between 7 and 14 days and tracheostomy should be postponed.…”

Implicaciones en Neuroanestesia durante la pandemia por COVID-19

“…Autopsias de pacientes con covid-19 que muestran hallazgos histopatológicos como edema cerebral y degeneración neuronal sugieren encefalopatía tóxica secundaria a hipoxemia que pudieran ser la etiología de la confusión. 8,11,17 Pacientes neurocríticos y neuroquirúrgicos siguen presentándose en los hospitales independientemente de la pandemia; sus comorbilidades y compromiso multisistémico aumentan el riesgo de resultados adversos 18 . A pesar que es difícil clasificar a los pacientes con trastornos neurológicos 19 , la mayoría de los centros han establecido protocolos y recomendaciones de manejo de pacientes neurocríticos y neuroquirúrgicos con estratificación, programación y reestructuración del servicio [20][21][22] , disminución de personal en áreas quirúrgicas y hospitalización, prevención de infección por transmisión nosocomial [23][24][25] y participación y difusión de investigación neuroquirúrgica referente a COVID-19.…”