National survey on perioperative cognitive dysfunction.

BACKGROUND: Perioperative cognitive dysfunction (PCD) is a very prevalent clinical syndrome due to the progressive aging of the surgical population.The aim of our study is to evaluate the clinical practice of Spanish anesthesiologists surveyed regarding this entity. MATERIAL AND METHODS: Prospective online survey conducted by the Neurosciences Section and distributed by SEDAR. RESULTS: 544 responses were obtained, with a participation rate of 17%. 54.4% of respondents never make a preoperative assessment of cognitive impairment, only 7.5% always do it. 79.6% lack an intraoperative management protocol for the patient at risk of PCD. In the anesthetic planning, only 23.3% of the patients was kept in mind. Eighty-nine percent considered regional anesthesia with or without sedation preferable to general anesthesia for the prevention of PCD. 88.8% considered benzodiazepines to present a high risk of PCD. 71.7% considered that anesthetic depth monitoring could prevent postoperative cognitive deficit. Routine evaluation of postoperative delirium is low, only 14%. More than 80% recognize that PCD is underdiagnosed. CONCLUSIONS: Among Spanish anesthesiologists surveyed, PCD is still a little known and underappreciated entity. It is necessary to raise awareness of the need to detect risk factors for PCD, as well as postoperative assessment and diagnosis. Therefore, the development of guidelines and protocols and the implementation of continuing education programs in which anesthesiologists should be key members of multidisciplinary teams in charge of perioperative care are suggested.

Assessment of cerebral blood flow velocities, brain midline shift and optic nerve sheath diameter by ultrasound in patients undergoing elective craniotomy: A prospective observational feasibility study.

BACKGROUND: Brain ultrasound allows measuring the cerebral flow velocity, brain midline shift and optic nerve sheath diameter. Literature is scarce in determining the feasibility to perioperatively perform these measurements altogether and the cerebrovascular behavior in patients scheduled for elective craniotomy. METHODS: We assessed bilateral cerebral flow velocities, composite index, brain midline shift and optic nerve sheath diameter by cerebral ultrasound in patients scheduled for elective craniotomy before anesthetic induction, at extubation, and at 6 and 24 h after. The aim was to assess the feasibility of brain ultrasound in patients for elective craniotomy and to describe the changes in cerebral flow velocities, brain midline shift and optic nerve sheath diameter from baseline values at different times in the postoperative period. RESULTS: Sixteen patients were included, of these two were excluded from analysis due to an inadequate sonographic window. There were no changes throughout the study regarding cerebral flow velocity, brain midline shift nor optic nerve sheath diameter assessments. All parameters were maintained in the physiological range without significant variations during the procedure. No perioperative complications were detected. CONCLUSIONS: The results of our study show the feasibility to perform a perioperative assessment of cerebral flow velocity, brain midline shift or optic nerve sheath diameter jointly and successfully to obtain additional information of baseline cerebral hemodynamics in patients scheduled for elective craniotomy and their postoperative changes during the first 24 h. Future studies with lager samples are needed to address the efficacy of cerebral ultrasound as a monitoring tool.

[Cerebrovascular accident with haemorrhagic transformation in a patient on antiplatelet treatment subjected to surgery of a hypophyseal macroadenoma]. / Accidente cerebrovascular con transformación hemorrágica en una paciente con tratamiento antiagregante intervenida de macroadenoma hipofisario.

The case is presented of a 51 year-old woman, proposed for endoscopic endonasal transsphenoidal resection of a hypophyseal macroadenoma diagnosed in the context of a stroke suffered 10 weeks before the date of the surgery. During this time, she had been treated with antiplatelet drugs, which were withdrawn 5 days before the surgery. The surgical procedure was performed without any incidents. On the second day after the surgery, the patient had an ischaemic infarction of the left cerebellar hemisphere, with signs of hydrocephaly and a posterior haemorrhagic transformation, with brain death 5 days after the operation. There are no definitive guidelines on the use of antiplatelet drugs in the perioperative period of neurosurgery. Also, there is no agreement as regards the waiting time between a cerebrovascular event and surgery, it appears that between 4 and 12 weeks would be the most advisable. The importance of an individual assessment of each patient before surgery is emphasised, as well as a review of the antiplatelet management of the patient with a risk of thrombosis in the context of neurosurgery, and their possible postoperative complications.

[Comparison of 3 combinations of 0.5% levobupivacaine and 1% mepivacaine in popliteal sciatic block in hallux valgus outpatient surgery]. / Comparación de 3 combinaciones de levobupivacaína al 0,5% y de mepivacaína al 1% en el bloqueo del nervio ciático poplíteo, en la cirugía ambulatoria del hallux valgus.

BACKGROUND: To compare 3 combinations of 0.5% levobupivacaine (L) and 1% mepivacaine (M) for popliteal block for hallux valgus surgery. METHODS: Prospective, double blind study of 120 patients undergoing unilateral hallux valgus outpatient surgery with posterior popliteal block with ultrasound-guided single injection. Patients were randomly allocated into three groups: G1: 20mL L+10mL M; G2: 10mL L+20mL M; and G3: 15mL L+15mL M. Recorded variables were: time of block, onset and reversal times for tibial and peroneal nerves block; postoperative pain until the 7(th) day by means of visual analogue scale (VAS), simple descriptive scale and the quality of nocturnal rest, complications, and patient satisfaction. ANOVA and chi2 were applied in the statistical analysis, with a P<0.05 considered significant. RESULTS: Groups were homogeneous for demographic and surgical characteristics. None of the patients required intraoperative complementary analgesia or anaesthesia. Block onset was significantly longer in G1 than in G2 and G3 (39.4±14.7 versus 32.2±16.5 and 33.2±12minutes). Recovery time from sensory and motor block was significantly longer in G1 than in G2 and G3 (29.5±9.3 versus 22.2±8.2 and 24.8±7.9hours). Postoperative pain level was below VAS 30 (1-100) in the three groups; none of the patients experienced severe pain. Maximum pain level appeared at 24h postoperatively. Patient satisfaction was high and there were no complications. CONCLUSIONS: Block onset time and anaesthetic efficacy was adequate in the three groups. The combination of 20mL levobupivacaine 0.5% with 10mL mepivacaine 1% provide a good alternative for a lasting postoperative analgesia.

Intraoperative warming and post-operative cognitive dysfunction after total knee replacement.

BACKGROUND: Post-operative cognitive dysfunction (POCD) can affect 30% of orthopedic surgery patients. We hypothesized that perioperative temperature has an impact on POCD. METHODS: We included 150 patients over 65 years of age scheduled for total knee replacement under spinal anesthesia. They were randomized to receive standard care (sheet cover) or active warming. Neurocognitive assessment (11 subtests) was performed pre-operatively and at day 4 (three subtests) and 3 months (10 subtests). A control group of 55 nonsurgical patients took the same tests at equivalent times. POCD was defined as an individual score decrease of more than 2 standard deviations (SDs) below the baseline on at least two subtests or 2 SDs in the combined z-score, in both cases using control-adjusted changes. RESULTS: Tympanic temperature declined below 35 °C in 88% of standard-care patients; 25.3% of warmed patients had a temperature ≥36 °C. On day 4, 3.2% of standard-care patients and 19.4% of warmed patients had POCD (P=0.0058). At 3 months, there were no between-group differences (standard care, 14.3%; warmed, 6.5%) (P=0.2440). CONCLUSIONS: Perioperative warming was associated with a higher incidence of cognitive dysfunction at 4 days after total knee replacement in patients >65 years of age.

[Experience with the proseal laryngeal mask in ventriculoperitoneal shunting]. / Experiencia con el uso de la mascarilla laríngea Proseal en pacientes sometidos a cirugía de derivación ventrículo peritoneal.

OBJECTIVE: To describe the use, utility, safety, and effectiveness of the Proseal laryngeal mask for airway management in patients undergoing ventriculoperitonea shunting. PATIENTS AND METHODS: We retrospectively reviewed the records of all patients in whom the Proseal laryngeal mask was used during ventriculoperitoneal shunting between January 2006 and October 2009. Patient demographic characteristics, airway assessments, type of anesthesia, quality of ventilation, and perioperative complications were recorded. RESULTS: Of the 43 patients included, 8 (18.6%) had at least 1 difficult airway criterion. We were able to insert the Proseal laryngeal mask in all patients. Ventilation was optimal in 39 (91%) patients, with maintenance of end-expiratory carbon dioxide pressures between 35 and 40 mm Hg and airway pressures above 25 cm H2O throughout the procedures. Air leaks developed in 3 cases (7%) when the patient was placed in a lateral-cervical position for surgery; these patients required orotracheal intubation before surgery could begin. Mean duration of surgery was 53 minutes. Awakening occurred without incident in all cases. CONCLUSIONS: The Proseal laryngeal mask is useful for airway management in patients undergoing ventriculoperitoneal shunting. Due to the forced position of the neck, however, it may be necessary to reposition the mask or even proceed to orotracheal intubation in some cases. As is the case for other advanced uses, experience with the device is necessary. Material for managing a difficult airway should be on hand.

Whole-Genome Sequencing and De Novo Assembly of 61 Staphylococcus pseudintermedius Isolates from Healthy Dogs and Dogs with Pyoderma.

We have de novo assembled and polished 61 Staphylococcus pseudintermedius genome sequences with Nanopore-only long reads. Completeness was 99.25%. The average genome size was 2.70 Mbp, comprising 2,506 coding sequences, 19 complete rRNAs, 56 to 59 tRNAs, and 4 noncoding RNAs (ncRNAs), as well as CRISPR arrays.

[Ultrasound-guided single dose injection of 0.5% levobupivacaine or 0.5% ropivacaine for a popliteal fossa nerve block in unilateral hallux valgus surgery]. / Levobupivacaína 0.5% frente a ropivacaína 0.5% en el bloqueo poplíteo con dosis única de anestésico local por abordaje posterior dirigido por ecografía para cirugía de hallux valgus unilateral.

OBJECTIVE: To compare the perioperative analgesic efficacy of 0.5% levobupivacaine and 0.5% ropivacaine injected in a single dose to block the tibial and peroneal nerves for surgery using a posterior (popliteal fossa) approach. MATERIAL AND METHODS: Prospective randomized trial in patients undergoing hallux valgus surgery; anesthesia was provided by blocking nerves in the popliteal fossa with either 0.5% levobupivacaine or 0.5% ropivacaine. Variables studied were times until anesthetic block onset and reversal, need for additional sedation or peripheral block anesthetic, course of postoperative pain at 12, 24 and 48 hours and at 7 days, nighttime rest, need for additional analgesia, and patient satisfaction. RESULTS: Forty-six patients were enrolled. Times until onset of the sensory and motor blocks were similar in the 2 groups. For 57.1% of the patients, the sensory and motor block lasted 24 hours after surgery, with no between-group differences. The levobupivacaine group had less pain at rest 24 hours after surgery (mean [SD] visual analog scale score of 0.16 [0375] vs. 1.17 [1.88] in the ropivacaine group; P < .05). No patient reported severe pain or required additional analgesics. None were readmitted. More than 80% rested well at night. No between-group differences were observed. CONCLUSIONS: The use of a single dose of either levobupivacaine or ropivacaine to provide anesthesia for a popliteal approach to hallux valgus surgery is effective for controlling postoperative pain.

Narrative review of acute post-craniotomy pain. Concept and strategies for prevention and treatment of pain. / Revisión narrativa del dolor agudo poscraneotomía. Concepto y estrategias de prevención y tratamiento del dolor.

The aim of this narrative review is to confirm that acute pain after craniotomy is frequent and presents with moderate to severe intensity. We also highlight the importance of not only treating post-craniotomy pain, but also of preventing it in order to reduce the incidence of chronic pain. Physicians should be aware that conventional postoperative analgesics (non-steroidal anti-inflammatory, paracetamol, cyclooxygenase inhibitors 2, opioids) are not the only options available. Performing a scalp block prior to surgical incision or after surgery, the use of intraoperative dexmedetomidine, and the perioperative administration of pregabalin are just some alternatives that are gaining ground. The management of post-craniotomy pain should be based on perioperative multimodal analgesia in the framework of an "enhaced recovery after surgery" (ERAS) approach.

Postoperative circuits in patients undergoing elective craniotomy. A narrative review. / Circuitos postoperatorios en los pacientes sometidos a craneotomía programada. Revisión narrativa.

In 2017, the Neurosciences section of the Spanish Society of Anaesthesiology, Critical Care and Pain Therapy published a national survey on postoperative care and treatment circuits in neurosurgery. The survey showed that practices vary widely, depending on the centre, the anaesthesiologist and the pathology of the patient. There is currently no standard postoperative circuit for cranial neurosurgical procedures in Spanish hospitals, and there is sufficient evidence to show that not all patients undergoing elective craniotomy should be routinely admitted to a postsurgical critical care unit. The aim of this study is to perform a narrative review of postoperative circuits in elective craniotomy in order to standardise clinical practice in the light of published studies. For this purpose, we searched MEDLINE (PubMed) to retrieve studies published in the last ten years, up to November 2019, using the keywords neurosurgery and postoperative care, craniotomyand postoperative care.

[Survey of anesthesiologists' practice in treating spontaneous aneurysmal subarachnoid hemorrhage]. / Encuesta sobre la práctica y actuación de los anestesiólogos ante una hemorragia subaracnoidea aneurismática de origen no traumático.

OBJECTIVES: To evaluate the participation of Spanish anesthesiology departments in the management of patients hospitalized for spontaneous aneurysmal subarachnoid hemorrhage. MATERIAL AND METHODS: Chiefs of anesthesiology departments of hospitals listed in the Spanish National Catalog of Hospitals of the Ministry of Health and Consumer Affairs were sent a questionnaire with 30 items covering protocols for the management of patients with spontaneous aneurysmal subarachnoid hemorrhage. Items asked about the participation of anesthesiologists during both admission and the perioperative period. RESULTS: The questionnaire was sent to 132 hospitals, of which 18 (13.6%) responded. Forty-six percent of anesthesiology departments do not participate in the initial resuscitation. Only 4 reported having a protocol for treating these patients. The initial diagnosis was reportedly made by cranial computed tomography in all cases. Endovascular treatment was the most common procedure reported (66%) and it was given within the first 48 hours (66%). Basic monitoring was used more than nervous system monitoring. Total intravenous anesthesia was used for craniotomy in 53% of the hospitals and for endovascular treatment in 64%. Complications reported most often were vasospasm (100%) and hydrocephalus (69%). CONCLUSIONS: Even though few questionnaires were returned, the results reveal scarce use of protocols for the treatment of spontaneous aneurysmal subarachnoid hemorrhage by anesthesiologists. It was also evident that the participation of anesthesiology department staff in the treatment of this condition takes place almost exclusively in the intraoperative period and that the use of nervous system monitoring is scarce. Endovascular treatment is increasing in our practice settings.

[Anesthesia considerations for deep-brain stimulation in a patient with type-2 pantothenate kinase deficiency (Hallervorden-Spatz disease)]. / Consideraciones anestésicas en una paciente con déficit de pantotenato cinasa tipo 2 (enfermedad de Hallervorden-Spatz) para estimulación cerebral profunda.

Neurodegeneration associated with pantothenate kinase deficiency is an autosomal recessive condition caused by mutations in the pantothenate kinase 2 gene (PANK2). Clinical characteristics include progressive motor impairment and dementia. Medical treatment is limited and the dystonia tends to be refractory, making stereotactic surgery with placement of deep-brain electrodes an option that is being adopted with greater frequency in these patients. We report the case of a 32-year-old woman with severe dystonia associated with PANK2 protein deficiency. The patient was scheduled for stereotactic bilateral placement of electrodes in the medial globus pallidus, guided by computed tomography and under general anesthesia, to treat the debilitating dystonia and generalized stiffness associated with her condition. Anesthesia was maintained with propofol, rocuronium and remifentanil in perfusion during the intervention, which was uneventful. After the procedure, the patient was transferred to the intensive care unit and sedation was provided with remifentanil to allow slow, gradual emergence from anesthesia. The patient was discharged from hospital after placement of the implanted pulse generator, and subsequent follow-up showed improvement of the dystonia.

[Importance of monitoring neuroendoscopic intracranial pressure during anesthesia for neuroendoscopic surgery: review of 101 cases]. / Importancia de la monitorización de la "presión intracraneal dentro del neuroendoscopio" durante el tratamiento anestésico de la cirugía neuroendoscópica. Experiencia en 101 casos.

OBJECTIVE: The aim of this study was to describe monitoring, anesthetic management, and risk factors for complications in neuroendoscopic surgery. PATIENTS AND METHODS: Patients who underwent neuroendoscopy between 1994 and 2003 under general anesthesia, with monitoring of intracranial pressure from inside the neuroendoscope, were studied retrospectively. In some patients, the blood flow rate in the middle cerebral artery was monitored using transcranial Doppler ultrasound. Information was collected related to surgical procedure and the development of complications. RESULTS: Of 101 patients included in the study, transcranial Doppler ultrasound images were available for 20. In 75 patients neuroendoscopic intracranial pressure exceeded 20 mm Hg. Forty-five percent of the patients with available transcranial Doppler ultrasound images showed episodes of reduced diastolic flow rate in the middle cerebral artery during ventricular irrigation. Hemodynamic instability was associated with higher neuroendoscopic intracranial pressures (P < .05). An increase of more than 30 mm Hg in neuroendoscopic intracranial pressure was associated with more postoperative complications, the most common of which was delayed awakening. Procedures that were more complicated than a simple ventriculostomy were performed in 58% of the cases. Mean (SD) neuroendoscopic intracranial pressures in such cases were higher (50.5 [30.9] mm Hg vs 31.8 [25.1 mm Hg] in the simpler procedures) and the postoperative complication rate was higher (P = .003). CONCLUSIONS: Neuroendoscopic surgery can causes increases in neuroendoscopic intracranial pressure that are associated with disturbances in cerebral blood flow and complications. This situation demonstrates the importance of monitoring intracranial pressure and cerebral blood flow.

[Problem/case-based learning compared to lectures for acquiring knowledge of air embolism in continuing medical education]. / Clase magistral versus aprendizaje basado en caso/problema para la enseñanza del embolismo aéreo en formación médica continuada.

OBJECTIVE: The efficacy of continuing medical education in anesthesiology has been examined very little. This study compared the efficacy of a lecture on air embolism to that of a class that used a problem/case-based learning approach. MATERIAL AND METHODS: Prospective, randomized study enrolling 52 experienced anesthesiologists participating in a professional development course. Twenty-six anesthesiologists attended a lecture on air embolism in anesthesia and 25 attended a problem-based class. The objectives were the same for both groups and had been defined previously. The participants' knowledge was evaluated before and after the instruction with tests based on 2 cases dealing with the same knowledge areas: risk factors and symptoms, diagnosis, monitoring, and treatment. RESULTS: No significant between-group differences were found for any of the knowledge areas before or after the classes. After instruction, participants who listened to the lecture improved their scores for knowledge of monitoring (P = .03) and treatment (P = .001). Participants in the problem-based learning group also improved their scores for knowledge of treatment (P = .003). CONCLUSIONS: No between-group differences in participants' knowledge outcomes were detected; improvements were minimal. The study design allowed the knowledge acquired to be evaluated objectively.

[Neuroanesthetic practice in Catalonia. Results of a survey done on 2003]. / Intervenciones neuroquirúrgicas en Cataluña. Resultados de una encuesta anestésica durante 2003.

INTRODUCTION: Health system planning requires the precise knowledge of the activity performed. We present the neuroanesthesic activity results in Catalonia during 2003. METHODS: A prospective and cross-sectional survey was performed for 14 randomised days during 2003. All hospitals practicing anaesthesia in Catalonia took part in the survey. Data on characteristics of patients, anaesthetic techniques and type of procedure were included. RESULTS: 6909 neuroanesthetic procedures performed in Catalonia in 2003 (95% IC 6022-7847), a 1.28% of total surgical activity. A 74% of procedures were done in the public hospitals and a 26% in private hospitals. Patients mean age was 48 years old (95% IC 45.5-50.6). Scheduled procedures were 79.7%. The most frequent interventions were: Spine surgery 40.1 %; craniotomies for tumour resection 24.1%, for haemorrhage o trauma 7.2% and for aneurysms or AVM surgery 2.3%; ventricular shunts 2.6%. Mean duration of craneotomies for tumour resection was 287 -/+95 min. All patients were distributed postoperatively in a conventional recovery room (55.8 %), in a monitored care unit (19.2%) or in an intensive care unit (24.9 %). Craniotomy patients were admitted to an intensive care unit (41.6%), a monitored care unit (33.7%) or a conventional recovery room (24.7%). CONCLUSIONS: About seven thousand Neurosurgical procedures were performed in Catalonia in 2003, in public (73.6%) and private (26.4%) hospitals. Spine surgery and craniotomies for tumour resection were the most frequently performed interventions. Craniotomy patients were mainly submitted to an ICU or a Monitored care unit.

National survey on postoperative care and treatment circuits in neurosurgery. / Encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía.

INTRODUCTION: The analysis of surgical processes should be a standard of health systems. We describe the circuit of care and postoperative treatment for neurosurgical interventions in the centres of our country. MATERIAL AND METHODS: From June to October 2014, a survey dealing with perioperative treatments and postoperative circuits after neurosurgical procedures was sent to the chiefs of Anaesthesiology of 73 Spanish hospitals with neurosurgery and members of the Neuroscience Section of SEDAR. RESULTS: We obtained 45 responses from 30 centres (41.09%). Sixty percent of anaesthesiologists perform preventive locoregional analgesic treatment. Pain intensity is systematically assessed by 78%. Paracetamol, non-steroidal anti-inflammatory and morphine combinations are the most commonly used. A percentage of 51.1 are aware of the incidence of postoperative nausea after craniotomy and 86.7% consider multimodal prophylaxis to be necessary. Dexamethasone is given as antiemetic (88.9%) and/or anti-oedema treatment (68.9%). A percentage of 44.4 of anaesthesiologists routinely administer anticonvulsive prophylaxis in patients with supratentorial tumours (levetiracetam, 88.9%), and 73.3% of anaesthesiologists have postoperative surveillance protocols. The anaesthesiologist (73.3%) decides the patient's destination, which is usually ICU (83.3%) or PACU (50%). Postoperative neurological monitoring varied according to the type of intervention, although strength and sensitivity were explored in between 70-80%. CONCLUSIONS: There is great variability in the responses, probably attributable to the absence of guidelines, different structures and hospital equipment, type of surgery and qualified personnel. We need consensual protocols to standardize the treatment and the degree of monitoring needed during the postoperative period.

[Behaviour of near-infrared cerebral oximetry readings during percutaneous carotid angioplasty]. / Valoración del comportamiento de la oximetría cerebral por infrarrojos durante la angioplastia percutánea de carótida interna.

BACKGROUND: Transluminal percutaneous carotid angioplasty and stenting (CAS) carries a risk of cerebral ischemia, hemorrhage, or edema due to relative hyperemia and hemodynamic instability during and after the procedure. Noninvasive monitoring of near-infrared regional cerebral oxygen saturation (SrO2) offers an indirect way to estimate cerebral blood flow. OBJECTIVE: To evaluate the behaviour of SrO2 during CAS and the usefulness of this variable for continuous monitoring of cerebral blood flow variation and neurological status. MATERIAL AND METHODS: Prospective study of 25 patients scheduled for unilateral CAS under monitored anesthesia care. SrO, and other hemodynamic and clinical data were recorded. A change in SrO2 (deltaSrO2) of 15% or more in comparison with the baseline value and lasting more than 30 seconds was considered clinically significant. Neurological complications in the first 24 hours were also registered. RESULTS: Baseline SrO, ranged from 51% to 75%. With administration of papaverine SrO2 values increased by a mean (SD) of 5.6% (6%) (P<.05 vs baseline). They decreased during angioplasty, -2.5% (5.7%) (P<.05 vs baseline), increased after 5 minutes, and fell again at 30 minutes to a level 3% (6.54%) above baseline. Two patients showed signs of elevated intracranial pressure after the procedures and also had ASrO2 readings exceeding 15%; measures to lower arterial hypertension reduced SrO2 in these patients. CONCLUSION: High interindividual variability of absolute SrO2 values has been confirmed. SrO, fluctuates with maneuvers that change cerebral blood flow in the same way. Changes can precede the onset of other clinical signs.

Consciousness, cognition and brain networks: New perspectives. / Consciencia, cognición y redes neuronales: nuevas perspectivas.

A detailed analysis of the literature on consciousness and cognition mechanisms based on the neural networks theory is presented. The immune and inflammatory response to the anesthetic-surgical procedure induces modulation of neuronal plasticity by influencing higher cognitive functions. Anesthetic drugs can cause unconsciousness, producing a functional disruption of cortical and thalamic cortical integration complex. The external and internal perceptions are processed through an intricate network of neural connections, involving the higher nervous activity centers, especially the cerebral cortex. This requires an integrated model, formed by neural networks and their interactions with highly specialized regions, through large-scale networks, which are distributed throughout the brain collecting information flow of these perceptions. Functional and effective connectivity between large-scale networks, are essential for consciousness, unconsciousness and cognition. It is what is called the "human connectome" or map neural networks.

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.