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Intensive care neurology and the autonomic nervous system
  1. Ian Bone,
  2. Geraint Fuller
  1. Correspondence to:
 Professor I Bone, Department of Neurology, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TS, UK; 

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Specialists often feel somewhat uneasy when they step outside their area of expertise. When seeing a patient with a neurological problem on the intensive care unit (ICU) the neurologist is both inside (the patient has a neurological problem after all) and outside their expertise (just look at the ventilators). This tension has led to the development of a subspecialty of neurologists expert in both these areas—the growing subspecialty of critical care neurology. This subspecialty is currently very small in the UK though well established in the rest of Europe and North America. This supplement explores this subspecialty further.

We start by considering patients with primarily neurological problems who need the ICU. A collaboration between a neurologist, Robin Howard, and neuro-intensivist, Nicholas Hirsch first consider, along with Dimitri Kullmann, the identification of those that need admission to the ICU, when and why, and then, with Jeremy Radcliffe, explore the general medical management in the ICU. We then move onto the “ICU referrals”. Saif Razvi and Ian Bone discuss how to assess patients on ICU who have gone on to develop neurological problems. Ventilation is not only used in the ICU and the role of long term ventilation for neurogenic respiratory failure is discussed by Robin Howard and Craig Davidson.

The disquiet of leaving familiar neurological country and going into the territory held by other specialties can be felt with patients with problems of autonomic function. Many autonomic problems have primarily cardiovascular, rather than neurological, symptoms and signs. However, the autonomic nervous system is undoubtedly within the neurological domain and Chris Mathias leads us firstly through the assessment and then the management of patients with autonomic disorders.

While swallowing is not an essential part of ICU neurology and not controlled by the autonomic nervous system, it is not entirely inappropriate to consider it here. Swallowing problems, and the protection from aspiration, are often an important consideration in patients for whom ICU care is being considered. Swallowing, like autonomic function, is not effectively assessed with conventional neurological examination. Tom Hughes discusses the neurology of swallowing.