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

Encuesta nacional sobre la atención anestesiológica perioperatoria en el tratamiento endovascular del ictus isquémico agudo / National survey on perioperative anaesthetic management in the endovascular treatment of acute ischaemic stroke

Objetivo. Conocer la práctica clínica habitual de los anestesiólogos españoles en el manejo del tratamiento endovascular del infarto isquémico cerebral agudo (IIA). Materiales y métodos. Encuesta diseñada desde la Sección de Neurociencias de la SEDAR, enviada a todos los servicios de anestesiología en hospitales españoles con unidad de referencia de ictus, entre julio y noviembre de 2016. Resultados. De los 47 hospitales donde se realiza tratamiento endovascular del IIA, en 37 participa el servicio de anestesiología. Obtuvimos 30 respuestas, eliminándose 3 por duplicidad (tasa de respuesta del 72,9%). El 63% de los hospitales tiene cobertura asistencial para el tratamiento endovascular del IIA las 24 h del día. El anestesiólogo encargado es el de presencia física en el hospital en un 55,3%. Existe gran variabilidad interhospitalaria en la monitorización no estándar y el tipo de anestesia. El criterio más empleado para su elección, es una decisión consensuada entre anestesiólogo, neurólogo y neurorradiólogo (59,3%). El tiempo transcurrido desde el inicio de la técnica anestésica hasta la punción arterial en un 59,3% es de 10-15 min. En un 44,4%, se mantiene una presión arterial sistólica entre 140-180mmHg y diastólica <105mmHg. El control de la glucemia se realiza en un 81,5% de los hospitales. El 66,7% (18) lleva a cabo una heparinización endovenosa durante el procedimiento pero con un régimen muy variado. El 85,2% coincide en la educción y extubación del paciente al final del procedimiento en caso de deterioro neurológico leve o moderado sin complicaciones añadidas. Conclusiones. La gran variabilidad observada en el manejo anestésico y organización del tratamiento endovascular del IIA, pone de manifiesto la necesidad de crear unas pautas de actuación comunes entre los anestesiólogos de España (AU)

Objective. To assess the anaesthetic management of treatment for endovascular acute ischaemic stroke (AIS) in Spain. Materials and method. A survey was designed by the SEDAR Neuroscience Section and sent to the Spanish anaesthesiology departments with a primary stroke centre between July and November 2016. Results. Of the 47 hospitals where endovascular treatment of AIS is performed, 37 anaesthesiology departments participated. Thirty responses were obtained; three of which were eliminated due to duplication (response rate of 72.9%). Health coverage for AIS endovascular treatment was available 24hours a day in 63% of the hospitals. The anaesthesiologist in charge of the procedure was physically present in the hospital in 55.3%. There was large inter-hospital variability in non-standard monitoring and type of anaesthesia. The most important criterion for selecting type of anaesthesia was multidisciplinary choice made by the anaesthesiologist, neurologist and neuroradiologist (59.3%). The duration of time from arrival to arterial puncture was 10-15minutes in 59.2%. In 44.4%, systolic blood pressure was maintained between 140-180mmHg, and diastolic blood pressure<105mmHg. Glycaemic levels were taken in 81.5% of hospitals. Intravenous heparinisation was performed during the procedure in 66.7% with different patterns of action. In cases of moderate neurological deterioration with no added complications, 85.2% of the included hospitals awakened and extubated the patients. Conclusions. The wide variability observed in the anaesthetic management and the organization of the endovascular treatment of AIS demonstrates the need to create common guidelines for anaesthesiologists in Spain (AU)

National survey on perioperative anaesthetic management in the endovascular treatment of acute ischaemic stroke. / Encuesta nacional sobre la atención anestesiológica perioperatoria en el tratamiento endovascular del ictus isquémico agudo.

OBJECTIVE: To assess the anaesthetic management of treatment for endovascular acute ischaemic stroke (AIS) in Spain. MATERIALS AND METHOD: A survey was designed by the SEDAR Neuroscience Section and sent to the Spanish anaesthesiology departments with a primary stroke centre between July and November 2016. RESULTS: Of the 47 hospitals where endovascular treatment of AIS is performed, 37 anaesthesiology departments participated. Thirty responses were obtained; three of which were eliminated due to duplication (response rate of 72.9%). Health coverage for AIS endovascular treatment was available 24hours a day in 63% of the hospitals. The anaesthesiologist in charge of the procedure was physically present in the hospital in 55.3%. There was large inter-hospital variability in non-standard monitoring and type of anaesthesia. The most important criterion for selecting type of anaesthesia was multidisciplinary choice made by the anaesthesiologist, neurologist and neuroradiologist (59.3%). The duration of time from arrival to arterial puncture was 10-15minutes in 59.2%. In 44.4%, systolic blood pressure was maintained between 140-180mmHg, and diastolic blood pressure<105mmHg. Glycaemic levels were taken in 81.5% of hospitals. Intravenous heparinisation was performed during the procedure in 66.7% with different patterns of action. In cases of moderate neurological deterioration with no added complications, 85.2% of the included hospitals awakened and extubated the patients. CONCLUSIONS: The wide variability observed in the anaesthetic management and the organization of the endovascular treatment of AIS demonstrates the need to create common guidelines for anaesthesiologists in Spain.

[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.

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

Objetivos: Conocer por medio de una encuesta la actuación de los anestesiólogos españoles en el manejo perioperatorio de los pacientes intervenidos neuroquirúrgicamente de enfermedades de fosa posterior del cráneo. Material y métodos: Se remitió a los servicios de anestesiología de hospitales con servicio de neurocirugía un cuestionario con un planteamiento cerrado sobre la participación de los anestesiólogos en el tratamiento perioperatorio de los pacientes sometidos a cirugía de fosa posterior. Resultados: De los 73 hospitales nacionales públicos que disponen de servicio de neurocirugía, completaron el formulario 42 (57,5%). En 36 centros se realiza la cirugía de fosa posterior con el paciente en sedestación, aunque se emplea con menor frecuencia que el decúbito lateral o el decúbito prono. La monitorización neurológica específica es escasa, así como el empleo del Doppler precordial y/o transcraneal para la detección de embolia vascular aérea. La técnica anestésica más empleada en estos procedimientos es la intravenosa. En menos del 10% de los centros se emplea óxido nitroso, y en un 15% se evitan los bloqueadores neuromusculares cuando se usa monitorización neurofisiológica intraoperatoria. Los problemas cardiovasculares durante la cirugía se refieren como muy frecuentes en el 29% de los centros, mientras que en el postoperatorio las complicaciones referidas como más habituales son los déficit de pares craneales, el edema de vía aérea (23%) y los vómitos postoperatorios (47%). Conclusiones: Los resultados obtenidos de la encuesta muestran que en las cirugías de fosa posterior la sedestación se utiliza menos que el decúbito prono y que apenas se usa monitorización neurofisiológica intraoperatoria(AU)

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 deficit, 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(AU)

[Protective measures against cerebral ischemia following subarachnoid hemorrhage: Part 1]. / Medidas protectoras frente a la isquemia cerebral tras hemorragia subaracnoidea (I).

BACKGROUND AND OBJECTIVES: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage contributes significantly to morbidity and mortality. Many studies on the various treatments aimed at preventing cerebral vasospasm have been carried out, but evidence of efficacy is limited. Our aim was to review the literature on the various therapies for which there is scientific evidence of protection against cerebral vasospasm following aneurysmal subarachnoid hemorrhage. METHODS: MEDLINE search (1950 to the october 2009) and review of articles found on the prevention of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. The search was restricted to articles in English, French, and Spanish. The keywords were cerebral vasospasm, subarachnoid hemorrhage, therapy, nimodipine, triple H, clazosentan, statins, and magnesium in addition to the word forms derived from them. We also searched manually for references cited in the selected articles. A title was included if it was a randomized controlled trial, meta-analysis, nonrandomized clinical trial, descriptive study, observational study with statistical analysis, opinion article, or expert review. RESULTS: Part 1 analyzed treatment with calcium antagonists and triple-H therapy (hypertension, hemodilution, and hypervolemia). Part 2 analyzed new therapies such as clazosentan, magnesium, and statins. A total of 597 titles were located; 283 were initially selected. The 61 articles finally selected for review were of the following types: 2 opinion articles, 21 randomized controlled trials, 22 expert review articles, 3 meta-analyses, 4 nonrandomized clinical trials, 1 descriptive study, and 5 observational studies with statistical analysis. Three studies (2 meta-analyses and 1 randomized controlled trial) demonstrated that nimodipine use confers benefits (reduced morbidity and mortality) for patients with aneurysmatic subarachnoid hemorrhage. Statistically significant clinical benefits could not be demonstrated for the other drugs (clazosentan, statins, and magnesium). CONCLUSIONS: Insufficient evidence is available to support the use of the triple-H therapy, clazosentan, statins, or magnesium sulfate for the prevention of cerebral vasospasm following subarachnoid hemorrhage. Nimodipine is the only preventative treatment that can be recommended.

Medidas protectoras frente a la isquemia cerebral tras hemorragia subaracnoidea (I) / Protective measures against cerebral ischemia following subarachnoid hemorrhage: part 1

Objetivos: La presencia de vasoespasmo cerebral tras hemorragia subaracnoidea aneurismática contribuye a la importante morbimortalidad de esta entidad. Por ello, se han desarrollado múltiples estudios con diferentes tratamientos dirigidos a su prevención, aunque la evidencia sobre su eficacia es limitada. Nuestro objetivo fue realizar una revisión bibliográfica de las diferentes terapias con evidencia científica para la prevención del vasoespasmo cerebral posthemorragia subaracnoidea aneurismática. Métodos: Búsqueda en MEDLINE (desde 1950 hasta octubre 2009) y revisión bibliográfica de las publicaciones halladas sobre prevención del vasoespasmo cerebral posthemorragia subaracnoidea aneurismática. Se restringió la búsqueda a artículos en inglés, francés y español. Se emplearon las palabras clave [cerebral vasospasm, subarachnoid hemorrhage, therapy, nimodipine, triple h, clazosentan, statins, magnesium] y sus combinaciones. Además se llevó a cabo una búsqueda manual en las referencias de los artículos seleccionados. Se incluyeron artículos que reunieran las siguientes condiciones: estudios controlados aleatorizados, metaanálisis, estudios clínicos no aleatorizados, estudios descriptivos, estudios analíticos observacionales, artículos de opinión y revisión. Resultados: La parte 1 analiza el tratamiento con calcioantagonistas y la triple terapia (hipertensión, hemodilución e hipervolemia) y la parte 2 analiza nuevas terapias como son el clazosentán, el magnesio y las estatinas. Hallamos 597 referencias de las cuales 283 fueron seleccionadas. Se incluyeron finalmente 61, las cuales se distribuyeron en 2 artículos de opinión, 21 estudios controlados aleatorizados, 22 artículos de revisión, 3 metaanálisis, 4 estudios clínicos no aleatorizados, 1 estudio descriptivo y 5 estudios analíticos observacionales. Tres estudios (2 metaanálisis y un estudio controlado aleatorizado) demostraron un beneficio en términos de morbimortalidad del uso del nimodipino en pacientes con hemorragia subaracnoidea aneurismática. Por el contrario en el análisis del resto de fármacos (clazosentán, estatinas y magnesio) no se objetivó un beneficio clínico estadísticamente significativo. Conclusiones: En la actualidad no hay suficiente evidencia para apoyar la utilización de triple terapia, clazosentán, estatinas y sulfato de magnesio para la prevención del vasoespasmo cerebral posthemorragia subaracnoidea aneurismática. El único tratamiento preventivo recomendado es el nimodipino(AU)

Background and objectives: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage contributes significantly to morbidity and mortality. Many studies on the various treatments aimed at preventing cerebral vasospasm have been carried out, but evidence of efficacy is limited. Our aim was to review the literature on the various therapies for which there is scientific evidence of protection against cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Methods: MEDLINE search (1950 to the october 2009) and review of articles found on the prevention of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. The search was restricted to articles in English, French, and Spanish. The keywords were cerebral vasospasm, subarachnoid hemorrhage, therapy, nimodipine, triple H, clazosentan, statins, and magnesium in addition to the word forms derived from them. We also searched manually for references cited in the selected articles. A title was included if it was a randomized controlled trial, meta-analysis, nonrandomized clinical trial, descriptive study, observational study with statistical analysis, opinion article, or expert review. Results: Part 1 analyzed treatment with calcium antagonists and triple-H therapy (hypertension, hemodilution, and hypervolemia). Part 2 analyzed new therapies such as clazosentan, magnesium, and statins. A total of 597 titles were located; 283 were initially selected. The 61 articles finally selected for review were of the following types: 2 opinion articles, 21 randomized controlled trials, 22 expert review articles, 3 meta-analyses, 4 nonrandomized clinical trials, 1 descriptive study, and 5 observational studies with statistical analysis. Three studies (2 meta-analyses and 1 randomized controlled trial) demonstrated that nimodipine use confers benefits (reduced morbidity and mortality) for patients with aneurysmatic subarachnoid hemorrhage. Statistically significant clinical benefits ould not be demonstrated for the other drugs (clazosentan, statins, and magnesium). Conclusions: Insufficient evidence is available to support the use of the triple-H therapy, clazosentan, statins, or magnesium sulfate for the prevention of cerebral vasospasm following subarachnoid hemorrhage. Nimodipine is the only preventative treatment that can be recommended(AU)

Medidas protectoras frente a la isquemia cerebral tras hemorragia subaracnoidea (II) / No disponible

No disponible