Manejo de la presión arterial en pacientes neuroquirúrgicos y neurocríticos / Management of blood pressure in neurosurgical and neurocritical patients

Las diferencias etiológicas y fisiopatológicas entre las entidades que pueden requerir una intervención neuroquirúrgica o el establecimiento de cuidados neurocríticos hace imposible hablar del control de la presión arterial en el paciente neurocrítico o neuroquirúrgico de un modo genérico. Con este razonamiento en mente, decidimos revisar por separado el control de la presión arterial en algunas de las entidades patológicas a las que más frecuentemente nos enfrentamos en la práctica clínica. Los temas revisados son: traumatismo craneoencefálico, ictus isquémico agudo, cirugía de los aneurismas intracraneales, cirugía de las malformaciones arteriovenosas cerebrales, cirugía tumoral encefálica, cirugía medular y cuidados de la lesión medular aguda

The etiological and pathophysiological differences between diseases that may require a neurosurgical intervention or the establishment of neurocritical care make it impossible to talk about the control of blood pressure in the neurocritical or neurosurgical patient in a generic manner. With this reasoning in mind, we decided to review separately the control of blood pressure in some of the pathologies we most frequently faced in clinical practice. The topics reviewed are: cranial brain trauma, acute ischemic stroke, intracranial aneurysm surgery, cerebral arteriovenous malformation surgery, brain tumor surgery, spinal cord surgery and acute spinal cord injury

Los primeros 10 años de la Sección de Neurociencias de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor / The first ten years of the Department of Neurosciences Spanish Journal of Anesthesiology and Critical Care

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Guía de práctica clínica sobre tromboprofilaxis y manejo de los fármacos anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos / Clinical practice guideline on thromboprophylaxis and management of anticoagulant and antiplatelet drugs in neurosurgical and neurocritical patients

No disponible

Encuesta nacional sobre la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos / National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients

Objetivos. Conocer la práctica clínica de los anestesiólogos españoles en la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos. Material y métodos. Encuesta diseñada desde la Sección de Neurociencia de la Sociedad Española de Anestesiología y Reanimación, con 22 preguntas, difundida y contestada en formato electrónico, disponible entre junio y octubre de 2012. Resultados. De los 73 centros hospitalarios con servicio de Neurocirugía incluidos en el Catálogo Nacional de Hospitales, se recibió respuesta válida a la encuesta on line por parte de 41 anestesiólogos de 37 centros (tasa de respuesta del 50,7%). Se consideró una respuesta de cada centro. Solo el 27% de los centros respondedores disponían de un protocolo escrito específico para el manejo de estos pacientes. La tromboprofilaxis mecánica se utilizó hasta en un 80%, aunque de forma variable, y la farmacológica en un 75% de los centros. La enoxaparina fue la heparina de bajo peso molecular más utilizada en pacientes sometidos a craneotomía (78%). En la mitad de los centros respondedores se realizaron craneotomías manteniendo el tratamiento con ácido acetilsalicílico en los pacientes con antecedentes de cardiopatía isquémica, stent coronario y antiagregación dual. Conclusiones. La tromboprofilaxis mecánica es más utilizada que la farmacológica en la población neuroquirúrgica de nuestro país. El manejo de los pacientes tratados previamente con anticoagulantes presenta una marcada variabilidad clínica entre los diferentes hospitales, mientras que el tratamiento con antiagregantes se modifica en función de si se trata de profilaxis primaria o secundaria (AU)

Objectives. To determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. Material and methods. An online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. Results. Of the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in a half of the centres. Conclusions. Mechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription (AU)

National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients.

OBJECTIVES: To determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. MATERIAL AND METHODS: An online survey with 22 questions, with one or multiple options, launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available between June and October 2012. RESULTS: Of the 73 hospitals included in the National Hospitals Catalogue, a valid response to the online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%). Only one response per site was used. A specific protocol was available in 27% of these centres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetylsalicylic acid treatment in patients with coronary stents and double anti-platelet treatment in a half of the centres. CONCLUSIONS: Mechanical thromboprophylaxis is used more frequently than the pharmacological approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of patients under previous anticoagulant treatment was highly heterogeneous among hospitals included in this survey. Previous antiplatelet treatment is modified depending on primary or secondary prescription.

Consideraciones preoperatorias y manejo neuroanestesiológico intraoperatorio / Preoperative considerations and intraoperative neuroanesthesiologic management

El manejo anestésico de los pacientes sometidos a procedimientos neuroquirúrgicos de fosa posterior presenta una serie de características particulares que deben ser conocidas por el anestesiólogo. Los cambios fisiopatológicos secundarios a la posición del paciente durante la cirugía, la relevancia del adecuado posicionamiento para facilitar el abordaje quirúrgico, la menor tolerancia a los cambios de elastancia de la región infratentorial, las escasas opciones terapéuticas ante un episodio de edema- hinchazón intraoperatorio y la presencia de complicaciones como la embolia aérea venosa condicionan la actuación intraoperatoria. Este primer apartado de las guías recoge las principales evidencias disponibles en la bibliografía respecto al abordaje preoperatorio e intraoperatorio de estos pacientes (AU)

The anesthesiological management of patients undergoing neurosurgery of the posterior fossa has a series of characteristics that should be known by anesthesiologists. Intraoperative management is guided by a series of factors that include the physiopathological changes secondary to the patient’s position during surgery, the importance of appropriate patient positioning to facilitate the surgical approach, the lower tolerance to changes in the elastance of the infratentorial region, the limited therapeutic options in episodes of intraoperative edema-swelling, and the presence of complications such as a venous air embolism. This first contribution to the guidelines discusses the main evidence available in the literature on the pre- and intraoperative approach to these patients (AU)

Consideraciones y conducta neuroanestesiológica postoperatoria / Postoperative neuroanesthesiologic considerations and management

La cirugía de fosa posterior y/o región craneorraquídea presenta una elevada tasa de morbimortalidad postoperatoria, escasamente descrita en la literatura científica. El propósito de esta revisión es describir las evidencias disponibles en la bibliografía respecto a las complicaciones asociadas y su manejo neuroanestesiológico y/o neurocrítico; así como resaltar los factores predisponentes que pueden influir en el incremento de la tasa de complicaciones.El conocimiento de las complicaciones relacionadas con la patología neuroquirúrgica de la fosa posterior, puede ayudar a su prevención o a la instauración de un tratamiento adecuado que permita minimizar sus consecuencias. Con este objetivo, en las diferentes bases de datos bibliográficos se realizó una búsqueda sistemática, en castellano e inglés, con los artículos comprendidos entre 1966 y 2012. Además se revisaron los manuscritos que se consideraron relevantes en las pesquisas bibliográficas identificadas. La emesis y el dolor postoperatorio son las complicaciones postoperatorias más frecuentemente descritas, seguida por el edema de la lengua y/o vía aérea, la afectación de pares craneales y la aparición de fístula de líquido cefalorraquídeo durante el postoperatorio. El resto de complicaciones fueron referidas como poco frecuentes. La cirugía de fosa posterior y craneorraquídea cervical posterior tiene mayor morbilidad y mortalidad que la cirugía del compartimento supratentorial. Además de las complicaciones de toda craneotomía, la cirugía infratentorial presenta complicaciones específicas. El trabajo en equipo entre todas las especialidades y estamentos implicados en la atención al paciente es fundamental para disminuir la morbimortalidad asociada a estos procedimientos (AU)

Surgery of the posterior fossa and/or craniospinal region has a high rate of postoperative morbidity and mortality, which has rarely been described in the scientific literature. This review aims to describe the available evidence in the literature on the complications associated with this type of surgery and its neuroanesthesiological and/or neurocritical management, as well as to highlight the predisposing factors that can increase the complications rate. Knowledge of the complications related to neurosurgical disorders of the posterior fossa could aid in their prevention or help in the selection of appropriate treatment that would minimize their consequences. A systematic literature search was made in Spanish and English for articles published between 1966 and 2012 in various databases. Articles considered important in the identified literature were reviewed. The most frequently described postoperative complications were vomiting and postoperative pain, followed by edema of the tongue and/or airway, involvement of the cranial nerves, and the development of cerebrospinal fluid fistulas. The remaining complications were reported as being uncommon. Posterior fossa and posterior cervical surgery produces higher morbidity and mortality than surgery of the supratentorial space. In addition to the complications involved in all craniotomies, infratentorial surgery has specific complications. Team work among all the specialties and staff involved in the care of these patients is essential to reduce the morbidity and mortality associated with these procedures (AU)

[Questionnaire on the anaesthesiology treatment of patients subjected to posterior fossa neurosurgery]. / Encuesta sobre el tratamiento anestesiológico de los pacientes sometidos a neurocirugía de fosa posterior.

OBJECTIVES: To find out, by means of a questionnaire, the procedures used by Spanish anaesthetists in peri-operative management of patients subjected to neurosurgery of the posterior cranial fossa. MATERIAL AND METHODS: A closed-question type questionnaire was sent to Anaesthesiology Departments with a Neurosurgery Department on the participation of anaesthetists in the peri-operative treatment of patients subjected posterior fossa surgery. RESULTS: The questionnaire was completed by 42 (57.5%) of the 73 national public hospitals with a Neurosurgery Department. The posterior fossa surgery was performed in the sitting position in 36 hospitals, although it was less frequently used than the lateral decubitus or prone decubitus position. There was little specific neurological monitoring, as well as little use of precordial and/or transcranial Doppler for detecting vascular air embolism. Nitrous oxide was used in less than 10% of the centres, and 15% avoided neuromuscular block when neurophysiological monitoring was used during the surgery. Cardiovascular problems were mentioned as being the most frequent in 29% of the centres, while in the post-operative period the most common complications were, cranial nerve déficit, airway oedema (23%), and post-operative vomiting (47%). CONCLUSIONS: The results obtained from the questionnaire showed that the sitting position was less used than the prone position in posterior fossa surgery, and that neurophysiological monitoring is during surgery is hardly used.