Los 10 últimos años de la Revista Española de Anestesiología y Reanimación: su incorporación a la «formación continuada», su integración al «formato digital» y su objetivo de conseguir un índice de citación internacional / The last 10 years of the Revista Española de Anestesiología y Reanimación: Its incorporation into «continuing education», its integration to «digital format» and its aim to be included in an international citation index

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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.

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)

[The role of recombinant activated factor VII in neuro- surgical and neurocritical patients]. / Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neu- rocríticos.

Central nervous system haemorrhage is a severe pathology, as a small amount of bleeding inside the brain can result in devastating consequences. Haemostatic agents might decrease the consequences of intra- cranial bleeding, whichever spontaneous, traumatic, or anticoagulation treatment etiology. Proacogulant recombinant activated factor VII (rFVIIa) has been given after central nervous system bleeding, with an off-label indication. In this update, we go over the drug mechanism of action, its role in the treatment of central nervous system haemorrhage and the published evidences regarding this subject. We carried out a literature review concerning the treatment with rFVIIa in central nervous system haemorrhage, neurocritical pathologies and neurosurgical procedures, searching in MEDLINE and in clinical trials registry: http://clinicaltrials.gov (last review September 2010), as well as performing a manual analysis of collected articles, looking for aditional references. The results of randomized clinical trials do not support the systematic administration of rFVIIa for spontaneous intracranial cerebral haemorrhage. In other central nervous system related haemorrhages, the current available data consist on retrospective studies, expert opinion or isolated case reports.

Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neu- rocríticos / The role of recombinant activated factor VII in neuro- surgical and neurocritical patients

La hemorragia del sistema nervioso central constituye una patología grave, ya que un volumen de sangrado relativamente pequeño en el cerebro puede presentar consecuencias devastadoras. La utilización de agentes hemostáticos pueden reducir las consecuencias de la hemorragia cerebral espontánea, traumática o secundaria a la anticoagulación. El Factor VII recombinante activado (rFVIIa) es un fármaco procoagulante que se ha empleado en diversas patologías hemorrágicas del sistema nervioso central, si bien esta indicación no se recoge en la ficha técnica del fármaco. En esta revisión se repasa el mecanismo de actuación del fármaco, su potencial en el tratamiento de la hemorragia del sistema nervioso central y las evidencias existentes al respecto. Se realizó una revisión de la bibliografía disponible sobre el uso de rFVIIa en el control de la hemorragia relacionada con el sistema nervioso central, la patolo- gía neurocrítica y procedimientos neuroquirúrgicos, mediante búsqueda en MEDLINE y en el registro de ensayos clínicos: http://clinicaltrials.gov (última revi- sión septiembre 2010), además de revisión manual de las publicaciones a partir de la bibliografía de los artí- culos recuperados. En la hemorragia cerebral espontánea, existen ensa- yos clínicos aleatorios, cuyos resultados desaconsejan la utilización sistemática del fármaco en esta indicación. En el resto de hemorragias relacionadas con el sistema nervioso central, los datos existentes se basan en estu- dios retrospectivos, opiniones de expertos o casos clíni- cos aislados (AU)

Central nervous system haemorrhage is a severe pathology, as a small amount of bleeding inside the brain can result in devastating consequences. Haemos- tatic agents might decrease the consequences of intra- cranial bleeding, whichever spontaneous, traumatic, or anticoagulation treatment etiology. Proacogulant recombinant activated factor VII (rFVIIa) has been given after central nervous system bleeding, with an off-label indication. In this update, we go over the drug mechanism of action, its role in the treatment of central nervous system haemorrhage and the published eviden- ces regarding this subject. We carried out a literature review concerning the treatment with rFVIIa in central nervous system hae- morrhage, neurocritical pathologies and neurosurgical procedures, searching in MEDLINE and in clinical trials registry: http://clinicaltrials.gov (last review Sep- tember 2010), as well as performing a manual analysis of collected articles, looking for aditional references. The results of randomized clinical trials do not support the systematic administration of rFVIIa for spontaneous intracranial cerebral haemorrhage. In other central nervous system related haemorrhages, the current available data consist on retrospective studies, expert opinion or isolated case reports (AU)

[Prologue. Recommendations-Clinical practice guideline for subarachnoid hemorrhage caused by ruptured intracranial aneurysm]. / Recomendaciones-Guía de práctica clínica en la hemorragia subaracnoidea por rotura de aneurisma intracraneal. Prólogo.

To provide evidence-based clinical practice guidelines for managing subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm. The ultimate purpose of the guidelines is to contribute to improving quality of care and reduce unnecessary costs related to the application of futile treatments. Systematic review of the literature indexed in the principal databases. Articles identified were categorized according to levels of evidence (1 to 5) and recommendations that could be derived were classified according to strength (A, B, and C). Some recommendations cannot be based on randomized controlled trials because the utility of certain practices is already clear; no one will investigate them or it would not be ethical to do so. We bore in mind that while many current practices for which no evidence is available may be ineffective, but others may be highly effective even though proof may never be available. Therefore, the guidelines considered that lack of evidence must not be used as the only reason for limiting the use of a diagnostic method or treatment. Nor would lack of evidence be the reason for limiting the use of health care resources.

[Subarachnoid hemorrhage: epidemiology, social impact and a multidisciplinary approach]. / Epidemiología de la hemorragia subaracnoidea: impacto social y abordaje multidisciplinario.

Cerebrovascular disease, whether ischemic or hemorrhagic, is a worldwide problem, representing personal tragedy, great social and economic consequences, and a heavy burden on the health care system. Estimated to be responsible for up to 10% of mortality in industrialized countries, cerebrovascular disease also affects individuals who are still in the workforce, with consequent loss of productive years. Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident that leads to around 5% of all strokes. SAH is most often due to trauma but may also be spontaneous, in which case the cause may be a ruptured intracranial aneurysm (80%) or arteriovenous malformation or any other abnormality of the blood or vessels (20%). Although both the diagnosis and treatment of aneurysmal SAH has improved in recent years, related morbidity and mortality remains high: 50% of patients die from the initial hemorrhage or later complications. If patients whose brain function is permanently damaged are added to the count, the percentage of cases leading to severe consequences rises to 70%. The burden of care of patients who are left incapacitated by SAH falls to the family or to private and public institutions. The economic cost is considerable and the loss of quality of life for both the patient and the family is great. Given the magnitude of this problem, the provision of adequate prophylaxis is essential; also needed are organizational models that aim to reduce mortality as well as related complications. Aneurysmal SAH is a condition which must be approached in a coordinated, multidisciplinary way both during the acute phase and throughout rehabilitation in order to lower the risk of unwanted outcomes.

[Neuroanesthetic management for surgical clipping of a ruptured cerebral aneurysm: clinical practice guidelines]. / Recomendaciones-guía de práctica clínica del manejo neuroanestesiológico para clipado quirúrgico del aneurisma cerebral roto.

Subarachnoid hemorrhage due to spontaneous rupture of a cerebral aneurysm is associated with high rates of morbidity and mortality and requires multidisciplinary treatment. The debate on surgical vs endovascular treatment continues, although short-term clinical outcomes and survival rates are better after endovascular treatment. In Spain, a strong trend toward reduced use of clipping has been noted, and neuroanesthetists are less often called on to provide anesthesia in this setting. Our intervention, however, can be decisive. The neuroscience working group of the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor has developed guidelines for managing anesthesia in these procedures. Based on a national survey and a systematic review of the literature, the recommendations emphasize the importance of ensuring appropriate intracranial conditions, treating complications, and taking steps to protect against cerebral hemorrhage.

[Neuroanesthesia for embolization of a ruptured cerebral aneurysm: clinical practice guidelines]. / Recomendaciones-guía de práctica clínica del manejo neuroanestesiológico para la embolización terapéutica del aneurisma intracraneal.

When the neuroanesthesia working group of the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor surveyed Spanish anesthesiologists to learn the degree of their involvement in the diagnosis and treatment of spontaneous subarachnoid hemorrhage, a surprising finding was that anesthetists did not participate in endovascular repair of intracranial aneurysms when the procedure was carried out in an interventional radiology department. These interventions, which are considered minimally invasive and are performed outside the operating room, are not risk-free. Based on the survey results and a systematic review of the literature, the working group has provided practice guidelines for the perioperative management of anesthesia for endovascular repair of ruptured cerebral aneurysms. In our opinion, the diversity of practice in the hospitals surveyed calls for the application of practice guidelines based on consensus if we are to reduce variability in clinical and anesthetic approaches as well as lower the rates of morbidity and mortality and shorten the hospital stay of patients undergoing exclusion of an aneurysm.

[Systemic complications of subarachnoid hemorrhage from spontaneous rupture of a cerebral aneurysm]. / Complicaciones sistémicas de la hemorragia subaracnoidea por rotura espontánea de aneurisma intracraneal.

Systemic complications secondary to subarachnoid hemorrhage from an aneurysm are common (40%) and the mortality attributable to them (23%) is comparable to mortality from the primary lesion, rebleeding, or vasospasm. Although nonneurologic medical complications are avoidable, they worsen the prognosis, lengthen the hospital stay, and generate additional costs. The prevention, early detection, and appropriate treatment of systemic complications will be essential for managing the individual patient's case. Treatment should cover major symptoms (headache, nausea, and dizziness) and ambient noise should be reduced, all with the aim of achieving excellence and improving the patient's perception of quality of care.

[Neurologic complications of subarachnoid hemorrhage due to intracranial aneurysm rupture]. / Complicaciones neurológicas de la hemorragia subaracnoidea por rotura de aneurisma intracraneal.

The high rates of morbidity and mortality after subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm are mainly the result of neurologic complications. Sixty years after cerebral vasospasm was first described, this problem remains unsolved in spite of its highly adverse effect on prognosis after aneurysmatic rupture. Treatment is somewhat empirical, given that uncertainties remain in our understanding of the pathophysiology of this vascular complication, which involves structural and biochemical changes in the endothelium and smooth muscle of vessels. Vasospasm that is refractory to treatment leads to cerebral infarction. Prophylaxis, early diagnosis, and adequate treatment of neurologic complications are key elements in the management of vasospasm if neurologic damage, lengthy hospital stays, and increased use of health care resources are to be avoided. New approaches to early treatment of cerebral lesions and cortical ischemia in cases of subarachnoid hemorrhage due to aneurysm rupture should lead to more effective, specific management.

[Fraudulent pain research: a hurt so deep nothing can alleviate it]. / Algología fraudulenta. Un dolor demasiado profundo para una adecuada analgesia.

Untruthfulness in research is reprehensible. Dr Scott S. Reuben, an anesthesiologist at Baystate Medical Center in Springfield, Massachusetts in the United States, a leader and pioneer in the field of multimodal analgesia, has been accused of fraud, specifically of having falsified results in at least 21 manuscripts published over a period of 15 years. This may come to be seen as one of the largest-scale and longest-running acts of medical research fraud ever. Apart from fabricated data, it seems the author committed other acts of misconduct. His coauthors have not been accused of wrongdoing, as they allege their names were falsely appended to the manuscript. The editors of the 2 most implicated journals, Anesthesiology and Anesthesia & Analgesia, have published editorials retracting the papers they judge to be fraudulent. Because Dr Reuben is a major figure in postoperative multimodal analgesia, many studies by other authors whose hypotheses have emerged from findings announced in the discredited papers may also now be considered contaminated by association. The definitions of scientific misconduct and the procedures for pursuing offenders vary greatly from country to country, creating a certain degree of uncertainty about how to proceed when we confront this problem. Beyond any possible legal liability that might arise, there are the questions of how fraud might affect patients' health or the medical knowledge base. Although the concept of multimodal analgesia may continue to be defended, we cannot be absolutely sure of its benefits without carrying out new clinical trials to repair the damage done by this act of misconduct.