Optimización del manejo del paciente neuroquirúrgico en Medicina Intensiva / Optimization of the neurosurgical patient in Intensive Care

Los pacientes con patología neuroquirúrgica requieren frecuentemente el ingreso en unidades de cuidados intensivos tanto para su manejo en el postoperatorio inmediato como para el control de las complicaciones que puedan presentar. La patología neuroquirúrgica es amplia y requiere profilaxis, tratamiento y monitorización específica. El tratamiento del paciente neuroquirúrgico se basa en asegurar una correcta perfusión tisular cerebral, es decir, mantener un flujo sanguíneo suficiente para aportar energía al parénquima cerebral. Con el objetivo de optimizar el tratamiento y el manejo de estos pacientes, en los últimos años se han desarrollado y perfeccionado diferentes sistemas para monitorizar variables como la presión intracraneal, la actividad eléctrica cerebral (electroencefalografía), el flujo cerebral, la oxigenación del parénquima (presión tisular de oxígeno) o el metabolismo locorregional (microdiálisis). Esta revisión sintetiza el manejo general del paciente neuroquirúrgico así como el de las principales complicaciones que puede desarrollar durante el postoperatorio. Asimismo, se propone un algoritmo de actuación para facilitar la decisión de los profesionales responsables que incluye la neuromonitorización multimodal

Neurosurgical patients frequently require admission to intensive care units, either for postoperative management or for treating complications. Most neurosurgical diseases require specific monitoring and prophylaxis. The basic principle of neurosurgical patient management is to ensure correct brain tissue perfusion, i.e., maintaining a sufficient blood flow to supply energy and oxygen to the brain parenchyma. In the last few years, several systems have been developed and improved for monitoring variables such as intracranial pressure, cerebral electrical activity (electroencephalography), cerebral blood flow, parenchymal oxygenation (tissue oxygen pressure) or locoregional metabolism (microdialysis). The present study provides an overview of the general management of neurosurgical patients and the main complications that may occur during the postoperative period. An interventional algorithm is also proposed to facilitate physician decisions, with the inclusion of multimodal neuromonitoring

Optimization of the neurosurgical patient in Intensive Care. / Optimización del manejo del paciente neuroquirúrgico en Medicina Intensiva.

Neurosurgical patients frequently require admission to intensive care units, either for postoperative management or for treating complications. Most neurosurgical diseases require specific monitoring and prophylaxis. The basic principle of neurosurgical patient management is to ensure correct brain tissue perfusion, i.e., maintaining a sufficient blood flow to supply energy and oxygen to the brain parenchyma. In the last few years, several systems have been developed and improved for monitoring variables such as intracranial pressure, cerebral electrical activity (electroencephalography), cerebral blood flow, parenchymal oxygenation (tissue oxygen pressure) or locoregional metabolism (microdialysis). The present study provides an overview of the general management of neurosurgical patients and the main complications that may occur during the postoperative period. An interventional algorithm is also proposed to facilitate physician decisions, with the inclusion of multimodal neuromonitoring.

Criterios para la formación y capacitación en Neurorradiología Intervencionista-Neurointervencionismo, acordados por el Grupo Español de Neurorradiología Intervencionista (GENI), la Sociedad Española de Neurorradiología (SENR), el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la Sociedad Española de Neurología (SEN) y el grupo experto en enfermedades vasculares de la Sociedad Española de Neurocirugía (SENEC). Bases para la obtención de una Acreditación de Centros y Especialistas en Neurorradiología Intervencionista-Neurointervencionismo / Criteria for training and accreditation in Interventional Neuroradiology-Neurointervention, approved by the Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN), and the vascular disease specialists in the Spanish Society of Neurosurgery (SENEC). Requirements for accreditation in Interventional Neuroradiology-Neurointervention for institutions and specialists

Introducción: El desarrollo de las técnicas endovasculares ha colocado a la Neurorradiología Intervencionista-Neurointervencionismo (NRI-NI) como una alternativa de primera elección para el tratamiento de gran parte de las enfermedades vasculares del sistema nervioso central. Al no disponer de programas formativos en NRI-NI normalizados, las sociedades científicas de los países desarrollados han creado estándares de formación y acreditación para la práctica segura de estos procedimientos. Desarrollo: En España, estamos a la espera del desarrollo legislativo de las Áreas de Capacitación Específicas que establecerán el modelo formativo oficial para los especialistas que deseen formarse en NRI-NI. Hasta que llegue ese momento, se hace pertinente disponer de unos estándares que definan los mínimos deseables para el periodo formativo en NRI-NI al que puedan acceder especialistas no solo de la Radiología, sino también de la Neurocirugía, y la Neurología, así como los requisitos exigibles a los hospitales que realizan esta actividad y quieran impartir dicha formación. Conclusiones: Para poner en práctica la acreditación de centros formativos y la acreditación de los centros formadores y especialistas formados en NRI-NI, el Grupo Español de Neurorradiología Intervencionista (GENI), la Sociedad Española de Neurorradiología (SENR), el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la Sociedad Española de Neurología (SEN) y el grupo experto en enfermedades vasculares de la Sociedad Española de Neurocirugía (SENEC), han aprobado el contenido de este documento de consenso y crearán un comité acreditador

Background: The development of endovascular techniques has put Interventional Neuroradiology (INR) as the first-option treatment in the majority of vascular diseases of the central nervous system. Scientific societies in developed countries have created standard procedures for training and accreditation for a safe practice in these procedures. Discussion: In Spain, we are waiting for the development of the legislation on the accreditation for specialists which will establish the official formative model to achieve an accreditation in INR. Until this moment comes, it is necessary to establish standards that define desirable minimums for the formative period in INR. Radiology specialists as well as neurologists and neurosurgeons will have access to INR accreditation. Specific requirements for the hospitals that wish to offer this technique and training should also be defined. Conclusion: The Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN) and the Spanish Society of Neurosurgery (SENEC) have approved the content of this document and will create a committee in order to put into practice the accreditation of formative centres and INR specialists

Criteria for training and accreditation in Interventional Neuroradiology-Neurointervention, approved by the Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN), and the vascular disease specialists in the Spanish Society of Neurosurgery (SENEC). Requirements for accreditation in Interventional Neuroradiology-Neurointervention for institutions and specialists. / Criterios para la formación y capacitación en Neurorradiología Intervencionista-Neurointervencionismo, acordados por el Grupo Español de Neurorradiología Intervencionista (GENI), la Sociedad Española de Neurorradiología (SENR), el Grupo de Estudio de Enfermedades Cerebrovasculares (GEECV) de la Sociedad Española de Neurología (SEN) y el grupo experto en enfermedades vasculares de la Sociedad Española de Neurocirugía (SENEC). Bases para la obtención de una Acreditación de Centros y Especialistas en Neurorradiología Intervencionista-Neurointervencionismo.

BACKGROUND: The development of endovascular techniques has put Interventional Neuroradiology (INR) as the first-option treatment in the majority of vascular diseases of the central nervous system. Scientific societies in developed countries have created standard procedures for training and accreditation for a safe practice in these procedures. DISCUSSION: In Spain, we are waiting for the development of the legislation on the accreditation for specialists which will establish the official formative model to achieve an accreditation in INR. Until this moment comes, it is necessary to establish standards that define desirable minimums for the formative period in INR. Radiology specialists as well as neurologists and neurosurgeons will have access to INR accreditation. Specific requirements for the hospitals that wish to offer this technique and training should also be defined. CONCLUSION: The Spanish Group of Interventional Neuroradiology (GENI), the Spanish Society of Neuroradiology (SENR), the Spanish Group of Cerebrovascular Diseases (GEECV), the Spanish Society of Neurology (SEN) and the Spanish Society of Neurosurgery (SENEC) have approved the content of this document and will create a committee in order to put into practice the accreditation of formative centres and INR specialists.

The treatment of hypercholesterolemic children: efficacy and safety of a combination of red yeast rice extract and policosanols.

BACKGROUND AND AIMS: The prevention of cardiovascular risk, as occurs in lipoprotein disorders, is required since childhood. Aim of the study was to evaluate, in a group of children affected by primary dyslipidemia, the efficacy, tolerability and safety of a short-term treatment with a dietary supplement containing red yeast rice extract and policosanols. METHODS AND RESULTS: 40 children affected by heterozygous Familial Hypercholesterolemia (FH) (n=24) and Familial Combined Hyperlipidemia (FCH) (n=16), aged 8-16 years, were enrolled in a double-blind, randomized, placebo-controlled, cross-over trial. After a 4-week run-in period with only dietary advice, children received a dietary supplement containing 200mg red yeast rice extract, corresponding to 3mg of monacolins, and 10mg policosanols once-daily and placebo for 8 weeks, separated by a 4-week washout period. Lipid profile was assessed after each treatment period. The dietary supplement, compared with the placebo, significantly reduced total cholesterol by 18.5% (p<0.001), LDL-C levels by 25.1% (p<0.001), and apolipoprotein B by 25.3% (p<0.001) when patients were considered as a whole group. Similar results were obtained when FH and FCH were considered separately and no significant difference between groups was detected. No significant differences were observed in HDL-C and apolipoprotein A-I levels. No adverse effects were detected when liver and muscular enzymes (AST, ALT, and CK) were determined. CONCLUSIONS: The treatment with a dietary supplement containing red yeast rice extract and policosanols has been for the first time successfully employed in hypercholesterolemic children. Results indicate this strategy as an effective, safe and well tolerated in a short-term trial.

Primary hyperlipidemias in children: effect of plant sterol supplementation on plasma lipids and markers of cholesterol synthesis and absorption.

Plant sterols lower serum cholesterol concentration. Available data have confirmed the lipid-lowering efficacy in adults, while there is a relative dearth of data in children and almost exclusively restricted to subjects with familial hypercholesterolemia (FH). Aim of the present study was to evaluate the efficacy, tolerability and safety of plant sterol supplementation in children with different forms of primary hyperlipidemias. The effect of plant sterol consumption on plasma lipids was evaluated in 32 children with heterozygous FH, 13 children with Familial Combined Hyperlipidemia (FCH) and 13 children with Undefined Hypercholesterolemia (UH) in a 12-week open-label intervention study using plant sterol-enriched yoghurt. Plasma lipids and apolipoproteins were measured by routine methods. Markers of cholesterol synthesis (lathosterol) and absorption (campesterol and sitosterol) were measured by GC-MS. Tolerability and adherence to recommended regimen was very high. A significant reduction was observed in LDL-cholesterol in the three groups (10.7, 14.2 and 16.0% in FH, FCH and UH, respectively). Lathosterol concentrations were unchanged, reflecting a lack of increased synthesis of cholesterol. Of the two absorption markers, only sitosterol showed a slight but significant increase. Daily consumption of plant sterol dairy products favorably changes lipid profile by reducing LDL-cholesterol. To our knowledge, this is the first report of the use of plant sterols-enriched foods in treating children with primary hyperlipidemia such as FCH and UH, likely to be the most frequent form also in the young age in the western populations.

Identification and management of dyslipidemic children.

Atherosclerotic cardiovascular disease is a leading cause of morbidity and premature mortality in Western countries and dyslipidemia is a recognized major cardiovascular risk factor. Evidences demonstrate that the atherosclerotic process begins early in childhood. Children showing dyslipidemia, as well as other cardiovascular risk factors, including hypertension, overweight/obesity and diabetes mellitus, are defined at high risk. To identify these children a selective screening between 2 to 10 years of age is necessary. This program must be performed to those children showing a familiarity for primary dyslipidemia and/or precocious cardiovascular events. These subjects need to undergo lipid biochemical analysis and assessment of other emergent risk factors (as ApoB, ApoA-I and their ratio). Given that total cholesterol and low-density lipoprotein cholesterol (LDL-C) concentrations vary by age and sex, the use of percentile values according to these parameters is now recommended. In these high-risk subjects the first step to lower LDL-C under the value of 130 mg/dL is represented by an appropriate physical activities and Step II diet. This entails further reduction of saturated fatty acid intake to less than 7% of daily calories and of cholesterol to less than 200 mg/day (since two years of age). When diet therapy is insufficient to lower LDL-C to the acceptable concentration, the use of non-pharmacologic agents (soluble fibers, plant stanols, sterols) is suggested. The third approach, for children showing persistent elevated LDL-C >95(th) percentile, is represented by drugs, that are allowed only in children older than eight years.