Neuroanaesthesia and Neuro Critical Care

About the department:

The department of Neuroanaesthesia and Neuro Critical Care at NIMHANS is in the forefront of dedicated patient care, quality research and high-level training in neuroanaesthesia and neurocritical care to meet the increasing requirements of the nation since its inception in 1950s. The department is equipped with the latest and best of the equipments (anaesthesia workstations, advanced critical care ventilators, multiparameter monitors, echocardiography, intraoperative neuromonitoring, anaesthesia information management systems, latest airway gadgets, drug delivery systems, temperature management systems, ultrasonography, brain function monitors such as transcranial doppler, brain oxygenation, intracranial pressure, etc) required for meeting the complex challenges in the neurosurgical operating rooms and intensive care units. The faculty are selected and promoted based on a rigorous assessment and selection criteria. Residents undergoing advanced training in this department are chosen based on a highly competitive All India online entrance test and undergo extensive training and evaluation during the course period. Over several decades, the department has grown both in stature and eminence and is recognised as one of the best centers for training and research in neuroanaesthesia and neurocritical care both in India and abroad.

Summary information on key activities/work of the department:

The department caters to the requirements of various departments like neurosurgery, neurology, neuroradiology, and psychiatry with emergency services provided on a 24 X 7 basis throughout the year. Anaesthesia services are provided for ten neurosurgical operating theatres, two Neurointensive care units with 29 beds to cater to critical care needs of neurosurgical, neuromedical and neurotrauma patients. Apart from this, anaesthesia services are provided for both diagnostic (MRI/CT/PET MRI/DSA) and interventional radiology procedures, gamma knife radiosurgery, and electroconvulsive therapy for psychiatric patients. Perioperative pain management is another key area where department contributes to patient care. The NIMHANS Pain Management Clinic started in October 2017 and interventional procedures are performed as per requirements. The Pre-Anaesthesia Consultation clinic runs from F7 OPD every day from 2 to 5 PM.

Vision: 

Treating patients with compassion, empathy and dedication at par with world standards.

Mission:

Aim to excel in all spheres of Neuroanaesthesia – clinical care, training, and research.

Objectives:

To provide compassionate and competent care with regards to preoperative, intraoperative and postoperative services, acute and chronic pain management, diagnostic and therapeutic procedures outside the operating room, and intensive care management.

Develop human resources in neuroanaesthesia and neuro critical care to fulfil the requirements of the nation. Develop policies and programs to fulfil the same in collaboration with other institutes, government, and professional organizations.

Active encouragement and support is being provided to the research projects. Collaboration with other institutes within the country and abroad is actively pursued. Several funded research projects are being conducted by members of the department. The department strives to be recognized as a centre for research in the field of neurosciences in the world.

What we do

Services offered:

Perioperative care in ten neurosurgery OTs (including 24 X 7 emergency OTs), management of neuromedical and neurosurgical (including neurotrauma) ICUs consisting of 29 beds, services to diagnostic and interventional neuroradiology department, and electroconvulsive therapy unit of psychiatry department, and acute and chronic pain management.

Anaesthesia care is provided for various neurosurgical procedures include brain tumors, intracranial aneurysms, arterio-venous malformations, revascularization procedures for stroke in young, craniosynostosis, meningomyelocele, paediatric tumors, epilepsy surgeries, cerebello-pontine angle lesions, neuroendoscopic procedures, spine pathologies, traumatic brain and spine injuries, functional neurosurgeries, neuro-rehabilitative surgeries, awake craniotomy procedures for surgeries in the eloquent areas of the brain and gamma knife radiosurgery procedures.

Anaesthetic services are provided for magnetic resonance, computed tomography and PET-MR imaging studies in paediatric patients and uncooperative adults, and in the Cath lab for diagnostic and interventional procedures like embolization of arterio-venous malformations, arterio-venous fistulae of brain and spine, vein of Galen malformation, endovascular coiling of aneurysms, WADA testing, diagnostic angiography and intra-arterial therapy for stroke and vasospasm, and carotid stenting.

Patients managed in the neurosurgical ICU include post-neurosurgical patients and traumatic brain and spine injury patients. The patients managed in the neuromedical ICU include but are not limited to those with status epilepticus, myasthenia gravis, acute and chronic inflammatory demyelinating polyneuropathies, neuroinfections and stroke.

Anaesthesia is provided for modified electroconvulsive therapy for patients with medically refractory schizophrenia, major depression, mania, and other severe psychiatric disorders.

Acute postoperative pain management and interventional procedures for chronic pain conditions such as trigeminal neuralgia, chronic back pain, etc.

Pain management clinic

Venue: F7, 1st Floor OPD complex

Time: 2:30 PM to 4:30 PM on working Thursdays

Service objective: Assessment and management of acute and chronic pain

Patient information:

Patients are generally referred to the Pain Clinic by one of the primary specialities. Patients should come with a referral letter and file when they visit us. No prior appointment is available at present and all visits are walk-in by referrals. If necessary, after evaluation, patients are referred to other specialists for opinion and management. The aim is to provide comprehensive multi-disciplinary care for patients with chronic pain.

The service provided include assessment and diagnosis and, medical and non-surgical (percutaneous interventional) management. The focus is to provide care based on patient’s needs, pathology and preference and enable early return to activities of daily living. Interventions are performed in the Cath lab or Operating room, usually on forenoon of working Saturdays.

Pain management:

Varieties of medicines are used alone or in combination to manage pain after detailed evaluation. If medical management along with physical therapy and psychological support fail to effectively reduce pain, these patients are offered interventional treatment options. Most interventions are performed under ultrasonography or fluoroscopy guidance to enhance success and reduce side effects. The following interventional treatment procedures are currently undertaken:

• Epidural steroid injections
• Radiofrequency ablation
• Nerve blocks
• Targeted epidural blood patch
• Trigger point injections
• Ganglion block

The common painful conditions managed by our clinic include neck and back pain including that radiates to arm and leg from causes such as degenerated or herniated disc and facet arthralgia, neuropathic pain and neuralgias (post-herpetic, ilio-inguinal, trigeminal, occipital, meralgia, etc), carpal tunnel syndrome, frozen shoulder, hemifacial pain, CRPS, peripheral neuropathies (diabetic neuropathy, etc), fibromyalgia and post-stroke pain. At present we do not cater to cancer pain.

Pre-Anaesthesia Consultation Clinic

Venue: F7 OPD first floor OPD complex

Days and Time: Every working day from 2 to 5 PM

Service objective: Preoperative evaluation, optimization and advice for patients undergoing procedures under anaesthesia

Patient information:

Every patient undergoing surgery, radiological procedure or electroconvulsive therapy or diagnostic procedures such as MRI, angiography under anaesthesia should be evaluated for fitness for anaesthesia and assessment of perioperative risk. This helps in better understanding of patient condition and information sharing with patient and family. Cross consultation may be suggested for further assessment and preparation. During this consultation, history will be taken regarding current problem, previous medical conditions, and general physical examination of different organs including heart, lungs, airway etc. will be performed. Appropriate laboratory and imaging investigations will be suggested and if done, will be reviewed to document baseline status.  Preanesthetic advice will be provided regarding consent, risk explanation, transfusion, airway and pain management, ICU care, fasting, etc. Any queries from the patient/family will be addressed.

Patient care

Intensive Care Units

Department of Neuro-anaesthesia and Neurocritical care manages the neurocritical care unit (NCCU) at NIMHANS with the vision of excellence in patient care, education, research, and leadership. The mission of the NCCU is to provide quality health care services. At present, there are three NCCUs at NIMHANS. The critical care units are open in nature. The NCCU specializes in the comprehensive critical care of all critically ill adult and paediatric neurological and neurosurgical patients. NIMHANS is a tertiary referral centre, and hence the NCCU manages most complex patients. The scope of Neurocritical care clinical services includes the provision of emergency medical interventions and resuscitation, provision of close observation and continuous multi-system monitoring and provision of mechanical ventilation for patients.  NCCUs provide an environment conducive to the continuous quality improvement of the medical, nursing, and other healthcare professional staff.

As a primary teaching institution, the education of future physicians is at the pivot of our mission. The NIMHANS Neurocritical care fellowship program is of the highest quality with excellent teaching program in the country. Towards that objective, NCCU offers tertiary, referral-based intensive care for patients with serious, challenging, and life-threatening diseases of the central and peripheral nervous system. The NCCU provides complete intensive care management to more than 1200 patients with neurosurgical, neurological pathologies every year. The unit’s state-of-the-art equipments and technology, and individualized care plans ensure the patients of optimal recovery from life-threatening critical illness.

Courses conducted by the department:

• DM Neuroanaesthesia – 3 years – Seven seats per year
• PDF Neuroanaesthesia – 1 year – Six seats per year
• PDF Neurocritical Care – 1 year – Two seats per year
• BSc Anaesthesia Technology – 3 +1 year (Internship) – Ten seats per year

Training to other students provided:

Training Nursing students, DM/Mch Residents from other departments of the institution during rotation postings. Postgraduate trainees from other colleges (MD/DA/DNB/DrNB) in neuroanaesthesia for one month. Short term training (3 to 6 months) in neuroanaesthesia from deputed from WHO/government institutes or professional bodies.

Contact (department):

Department of Neuroanaesthesia and Neurocritical Care, 3rd Floor, Neurosciences faculty centre, NIMHANS, Bangalore 560029

Current Faculty and staff

Sl. No.	Photograph of Faculty	Name of the Faculty and Designation in the department	Areas of Research
1		Dr. Sriganesh K Professor & HOD	Perioperative outcomes Acute and chronic Pain Evidence based clinical practice
2		Prof. V. Bhadrinarayan Professor	Head Injury Supratentorial tumors
3		Prof. K. R. Madhusudan Reddy Professor	Neuroendoscopy Pituitary tumors
4		Prof. V. J. Ramesh Professor	Neuromonitoring Head Injury Outcomes of intensive care
5		Prof. M. Radhakrishnan Professor	Neuromonitoring
6		Dr. V Sudhir Professor	Head Injury
7		Dr. Gopalakrishna. K. N Professor	Evoked potentials monitoring POCUS (Point of care ultrasonography)
8		Dr. Sonia Bansal Additional Professor	Head Injury and Neurocritical care Anaesthesia for Electroconvulsive therapy Acute and chronic Pain
9		Dr. Rohini Surve Additional Professor	Neurointensive care Functional MRI
10		Dr. Suparna Bhardwaj Additional Professor	Intraoperative Neurophysiological Monitoring Multimodality Monitoring of the brain
11		Dr. Dhritiman Chakrabarti Associate Professor	Biostatistics and Research Methodology Neuromonitoring
12		Dr. Shwethashri K R Associate Professor	Pediatric Neuroanaesthesia Acute and chronic pain Intensive care
13		Dr. Bharath S Associate Professor	Perioperative haemodynamics Neuromonitoring Neurointensive care
14		Dr. Rajeeb Kumar Mishra Associate Professor	Subarachnoid hemorrhage Neuromonitoring Neurocritical care
15		Dr. Shwetha S Naik Associate Professor	Intensive care unit Fluid management in neurological patients
16		Dr. Sangeetha R P Associate Professor	Perioperative outcomes Neuromonitoring Acute brain injury

Technical Staff:

Mr. Manjunath RN

Mr. John P Andrew

Mr. Divakar C

Ms. Anusha Subakumar

Mr. Nune Videya

Mr. Hemanth Kumar

Mr. Samuel Jackson

Ms Shilpa (on contract)

Ms. Hindu (on contract)

Ms. Labya (on contract)

Ms. Annusheen (on contract)

Ms. Sumisha (on contract)

Ms. Keerthana (on contract)

Administrative staff:

Mr. Prince

Ms. Hema (Contract)

Supporting staff:

Mr. Shivakumar LH

Mr. Vijay (Contract)

Infrastructure / Equipment / Facilities: 

• State of the art multi-function patient monitors for 10 OTs, 4 Radiology units, ECT unit and 2 ICUs.
• Advanced anaesthesia workstations and ICU ventilators
• Anaesthesia information management system
• Portable multifunction ultrasound machine for central venous cannulation and nerve blocks, rapid diagnostic ultrasonography in emergency, transthoracic and transoesophageal echocardiography, transcranial Doppler sonography, peripheral vascular doppler for diagnosis of DVT
• Heart rate variability (HRV) monitors for autonomic nervous system function assessment.
• Invasive and non-invasive cardiac output monitors including hypotension predictability index.
• Near infrared spectroscopy (NIRS) and jugular venous catheter for assessment of cerebral oxygenation.
• Bedside integrated electroencephalography monitors for assessment of seizures in ICU and OT.
• Depth of anaesthesia monitors like Bispectral index and spectral entropy
• Target controlled infusion pumps, MRI compatible anaesthesia workstation, patient monitors and drug delivery systems
• Patient temperature management system, point of care coagulation monitoring systems.
• Patient transport ventilators and monitors, defibrillators.
• Many video laryngoscopes including Air traq, Mcgrath, CMAC. etc.
• Intubating laryngeal mask airway, light wand and fibreoptic scopes for difficult airway management.
• Percutaneous tracheostomy services, bedside cardiac enzyme evaluation.
• Intraoperative evoked potentials monitor.
• Bedside pain assessment – Analgesia nociception index (ANI), Surgical Pleth Index.

Patient information: 

FAQs, Facts about anaesthesia, Intensive care

Milestones:

1977- Establishment of modified ECT

1978 – Establishment of Respiratory unit

1998 – One year Post-Doctoral Fellowship course in Neuroanaesthesia started

2004 – Organised national conference of Neuroanaesthesia and neurocritical care (ISNACC-2004)

2006 – Establishment of Liquid oxygen plant

2010 – Commencement of three year BSc Anaesthesia Technology course

2011 – Commencement of three year DM Neuroanaesthesia course

2014- Commencement of one year PDF in Neurocritical care course

2016 – Organised national annual conference of Neuroanaesthesia and neurocritical care (ISNACC-2016)

2017 – Starting of intraoperative MRI OT complex, and pain management clinic in OPD

2018- Pre-Anaesthesia Consultation Clinic OPD

2020 – Organized 2^nd National Annual Conference of the Neurocritical Care Society of India

 Malathi Memorial Oration at ISNACC:

The department of Neuroanaesthesia and Neuro Critical Care constituted an oration in the name of Dr Malathi, the first HOD of the department, to be delivered every year during the annual ISNACC conference. The list of awardees is as below:

Sl No	Awardee	Year
1	Dr Adrian Gelb	2004
2	Dr Ravi Mahajan	2005
3	Dr David Smith	2006
4	Dr James Cottrell	2007
5	Dr Piyush Patel	2008
6	Dr Pirjo Manninen	2009
7	Dr Michael J Souter	2010
8	Dr Takefumi Sakabe	2011
9	Dr Monica S Vavilala	2012
10	Dr Yoram Shapira	2013
11	Dr Kawaguchi	2014
12	Dr Arun K Gupta	2015
13	Dr Sergio Bergese	2016
14	Dr. M. T. V. Chan	2017
15	Dr Anton Koht, USA	2018
16	Dr Federico Bilotta, Italy	2019
17	Dr Jose Sorez, USA	2020
18	Dr David Menon	2021
19	Dr Claude Hemophill	2022
20	Dr Emery Brown, USA	2023

Professor G S Umamaheswara Rao Oration at NCSI:

The department of Neuroanaesthesia and Neuro Critical Care constituted an oration in the name Professor G S Umamaheswara Rao, past HOD of the department and Dean and Director of NIMHANS, to be delivered every year during the annual national Neuro Critical Care Society of India (NCSI) conference. The list of awardees is as below:

Sl No	Awardee	Year
1	Dr Louis Puybasset, France	2021
2	Dr Nicola Latronico, Italy	2022
3	Dr Massimo Lamperti, Abu Dhabi	2023

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