Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos / Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals

El presente trabajo pretende establecer una guía de actuación consensuada entre anestesiólogos y neurofisiólogos para realizar una monitorización neurofisiológica intraoperatoria efectiva en procedimientos tanto neuroquirúrgicos, como en aquellos en los que existe un riesgo de lesión neurológica funcional. En la primera parte, se describen las principales técnicas utilizadas en la actualidad para la monitorización neurofisiológica intraoperatoria. En segundo lugar, se describen los factores anestésicos y no anestésicos que pueden afectar al registro eléctrico de las estructuras del sistema nervioso. Posteriormente, se analizan los efectos adversos de las técnicas más comunes derivados de su utilización. Y, por último, se describen las diferentes pautas a seguir tras la aparición de los diferentes eventos clínicos intraoperatorios.(AU)

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.(AU)

Consensus document for multimodal intraoperatory neurophisiological monitoring in neurosurgical procedures. Basic fundamentals. / Documento de consenso para la monitorización neurofisiológica intraoperatoria multimodal en procedimientos neuroquirúrgicos. Fundamentos básicos.

The present work aims to establish a guide to action, agreed by anaesthesiologists and neurophysiologists alike, to perform effective intraoperative neurophysiological monitoring for procedures presenting a risk of functional neurological injury, and neurosurgical procedures. The first section discusses the main techniques currently used for intraoperative neurophysiological monitoring. The second exposes the anaesthetic and non-anaesthetic factors that are likely to affect the electrical records of the nervous system structures. This section is followed by an analysis detailing the adverse effects associated with the most common techniques and their use. Finally, the last section describes a series of guidelines to be followed upon the various intraoperative clinical events.

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

En 2017 la sección de Neurociencias de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor publicó una encuesta nacional sobre los circuitos de atención y tratamiento postoperatorio en neurocirugía. La encuesta evidenció una gran heterogeneidad de respuestas en función del centro, el anestesiólogo y la afección del paciente. En la actualidad, no disponemos de un estándar de circuito postoperatorio y existe evidencia suficiente para no indicar de forma rutinaria el ingreso en Unidades de Cuidados Críticos Postquirúrgicos a todos los pacientes intervenidos de craneotomía programada. El objetivo de este estudio es hacer una revisión narrativa de los circuitos postoperatorios en la craneotomía programada, para intentar homogeneizar nuestra práctica clínica a la luz de los estudios publicados. Se ha hecho una revisión bibliográfica de los últimos diez años, fecha de actualización noviembre 2019, utilizando las palabras clave neurosurgery and postoperative care y craniotomyand postoperative care en MEDLINE (PubMed)

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

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.

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

El objetivo de esta revisión narrativa es confirmar si el dolor agudo tras craneotomía es frecuente y presenta una intensidad entre moderada-severa. Además, pretende informar de la importancia de tratar no solo el dolor tras craneotomía, sino prevenirlo para disminuir la incidencia de la cronificación del dolor. Debemos conocer que entre las opciones actuales no solo disponemos de los analgésicos convencionales para el postoperatorio (antiinflamatorios no esteroideos, paracetamol, inhibidores de la ciclooxigenasa 2 y opiáceos). La realización de un bloqueo nervioso del cuero cabelludo previo a la incisión quirúrgica o tras la cirugía, el uso de dexmedetomidina intraoperatoria y la administración perioperatoria de pregabalina son alternativas que están ganando fuerza. El manejo del dolor poscraneotomía debe basarse, por tanto, en una analgesia multimodal durante todo el perioperatorio, enmarcándose dentro del concepto actual del protocolo enhaced recovery after surgery

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

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.

Calidad y seguridad del paciente en el código ictus, en el ámbito neurointervencionista / Quality and safety in endovascular therapy for acute ischemic stroke

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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.

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

Introducción. El análisis de los procesos quirúrgicos debe ser un estándar de los sistemas de salud. Describimos el circuito de atención y tratamiento postoperatorio para intervenciones neuroquirúrgicas en los centros de nuestro país. Material y métodos. Desde junio a octubre de 2014 se difundió una encuesta a jefes de Anestesiología de 73 hospitales españoles con neurocirugía y a miembros de la Sección de Neurociencia de la SEDAR, sobre tratamientos perioperatorios y sobre los circuitos postoperatorios tras procedimientos neuroquirúrgicos. Resultados. Obtuvimos 45 respuestas de 30 centros (41,09%). Un 60% de los anestesiólogos realiza tratamiento preventivo analgésico locorregional; la intensidad del dolor es evaluada sistemáticamente por un 78%. Las combinaciones de paracetamol, antiinflamatorios no esteroideos y morfina son las más utilizadas. Un 51,1% conoce la incidencia de NVPO tras craneotomía y el 86,7% considera necesaria la profilaxis multimodal. La dexametasona se administra como antiemético (88,9%) y/o tratamiento antiedema (68,9%). Un 44,4% de los anestesiólogos administra sistemáticamente profilaxis anticomicial en pacientes con tumores supratentoriales (levetiracetam, 88,9%). El 73,3% de los anestesiólogos disponen de protocolos de vigilancia postoperatoria. El anestesiólogo (73,3%) es quien decide el destino del paciente, que suele ser UCI (83,3%) o URPA (50%). La monitorización neurológica en el postoperatorio varió según el tipo de intervención, si bien la fuerza y la sensibilidad se exploraron en el 70-80%. Conclusiones. Existe una gran variabilidad en las respuestas, probablemente atribuible a la ausencia de guías, diferentes estructuras y equipamiento hospitalario, tipo de cirugía y personal cualificado. Necesitamos protocolos consensuados para estandarizar el tratamiento y el grado de monitorización necesaria durante el postoperatorio (AU)

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 (AU)

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.

Vagus nerve stimulation therapy for treatment-resistant epilepsy: a 15-year experience at a single institution.

OBJECTIVE: Treatment-resistant epilepsy (TRE) occurs in 20-30% of patients. The goal of this study is to assess the efficacy and safety of vagus nerve stimulation (VNS) in this group of patients, including adult and pediatric populations and several off-label indications. METHODS: This is a retrospective review of 59 consecutive patients in whom 60 VNS devices were implanted at a single institution during a 15-year period. Patients were evaluated in the Multidisciplinary Epilepsy Committee and complete presurgical workup was performed. The series included indications not approved by the FDA, such as children under 12 years of age, pregnancy and right-sided VNS. Performing the procedure on an out-patient basis was recently adopted, minimizing hospital length of stay. RESULTS: There were 42 adults and 17 children (14 under 12 years of age) and the mean age at implantation was 26 years. Duration of VNS therapy ranged from 6 months to 9 years. For the entire cohort, the mean percentage seizure reduction was 31.37%. Twenty patients (34.48%) were considered responders (seizure reduction ≥50%); 7 patients (12.06%) had seizure reduction of ≥75% and 2 patients had seizure control of ≥90% (3.4%). The patient in whom right-sided VNS was implanted achieved the same reduction in seizure burden and the patient who became pregnant could reduce antiepileptic drugs dosage, without complications. Side-effects were mild and there were no permanent nerve injuries. One patient died in the follow-up due to psychiatric disorders previously known. CONCLUSIONS: VNS is a safe and effective palliative treatment for TRE patients. There are an increasing number of indications and further randomized trials would potentially expand the number of patients who may benefit from it. A multidisciplinary team is crucial for a complete preoperative evaluation and selection of the optimal candidates for the treatment.

Situación de la monitorización de la profundidad hipnótica durante la anestesia y del despertar intraoperatorio en España. Resultados de la encuesta realizada en 2011 / Spanish anesthesiologists approach on intraoperative awareness with explicit recall. Results of a national survey performed in 2011

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Atención sanitaria urgente y salud pública en grandes concentraciones itinerantes / Urgent health care and public health in large itinerant public concentratrions

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