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Vocal cord paralysis is a rare but severe complication after orotracheal intubation. The most common cause is traumatic, due to compression of the recurrent laryngeal nerve between the orotracheal tube cuff and the thyroid cartilage. Other possible causes are direct damage to the vocal cords during intubation, dislocation of the arytenoid cartilages, or infections, especially viral infections. It is usually due to a recurrent laryngeal nerve neuropraxia, and the course is benign in most patients. We present the case of a man who developed late bilateral vocal cord paralysis after pneumonia complicated with respiratory distress due to SARS-CoV-2 that required orotracheal intubation for 11 days. He presented symptoms of dyspnea 20 days after discharge from hospital with subsequent development of stridor, requiring a tracheostomy. Due to the temporal evolution, a possible contribution of the SARS-CoV- 2 infection to the picture is pointed out.

Resumen Objetivos Conocer la practica clinica de los anestesiologos espanoles en la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirurgicos y neurocriticos. Material y metodos Encuesta disenada desde la Seccion de Neurociencia de la Sociedad Espanola de Anestesiologia y Reanimacion, con 22 preguntas, difundida y contestada en formato electronico, disponible entre junio y octubre de 2012. Resultados De los 73 centros hospitalarios con servicio de Neurocirugia incluidos en el Catalogo Nacional de Hospitales, se recibio respuesta valida a la encuesta on line por parte de 41 anestesiologos de 37 centros (tasa de respuesta del 50,7%). Se considero una respuesta de cada centro. Solo el 27% de los centros respondedores disponian de un protocolo escrito especifico para el manejo de estos pacientes. La tromboprofilaxis mecanica se utilizo hasta en un 80%, aunque de forma variable, y la farmacologica en un 75% de los centros. La enoxaparina fue la heparina de bajo peso molecular mas utilizada en pacientes sometidos a craneotomia (78%). En la mitad de los centros respondedores se realizaron craneotomias manteniendo el tratamiento con acido acetilsalicilico en los pacientes con antecedentes de cardiopatia isquemica, stent coronario y antiagregacion dual. Conclusiones La tromboprofilaxis mecanica es mas utilizada que la farmacologica en la poblacion neuroquirurgica de nuestro pais. El manejo de los pacientes tratados previamente con anticoagulantes presenta una marcada variabilidad clinica entre los diferentes hospitales, mientras que el tratamiento con antiagregantes se modifica en funcion de si se trata de profilaxis primaria o secundaria.

Objectives To determine the protocols used by Spanish anaesthesiologists for thromboprophylaxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care patients. Materials 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 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.

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.

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.

Resumen La deteccion y el tratamiento de la isquemia y la hipoxia tisular cerebrales para la prevencion de la lesion secundaria son objetivos fundamentales durante la anestesia para procedimientos neuroquirurgicos. La monitorizacion de la presion tisular de oxigeno es un monitor directo que puede permitir detectar situaciones potencialmente lesivas en tiempo real. Aunque se empleo inicialmente en pacientes neurocriticos, su uso se ha extendido a pacientes quirurgicos. Presentamos el caso de un paciente sometido a cirugia de reseccion de una fistula arteriovenosa dural al que se le monitorizo la presion tisular de oxigeno cerebral en el area perilesional. El hallazgo de un episodio de hipoxia tisular cerebral durante el cierre de la craneotomia, determino el tratamiento del paciente. Destacamos la posible utilidad de esta neuromonitorizacion para la deteccion rapida de eventos hipoxicos cerebrales regionales en el perioperatorio de neurocirugia vascular, procedimientos que presentan un riesgo significativo de episodios hipoxicos fundamentalmente isquemicos.

Resumen Objetivos Conocer por medio de una encuesta la actuacion de los anestesiologos espanoles en el manejo perioperatorio de los pacientes intervenidos neuroquirurgicamente de enfermedades de fosa posterior del craneo. Material y metodos Se remitio a los servicios de anestesiologia de hospitales con servicio de neurocirugia un cuestionario con un planteamiento cerrado sobre la participacion de los anestesiologos en el tratamiento perioperatorio de los pacientes sometidos a cirugia de fosa posterior. Resultados De los 73 hospitales nacionales publicos que disponen de servicio de neurocirugia, completaron el formulario 42 (57,5%). En 36 centros se realiza la cirugia de fosa posterior con el paciente en sedestacion, aunque se emplea con menor frecuencia que el decubito lateral o el decubito prono. La monitorizacion neurologica especifica es escasa, asi como el empleo del Doppler precordial y/o transcraneal para la deteccion de embolia vascular aerea. La tecnica anestesica mas empleada en estos procedimientos es la intravenosa. En menos del 10% de los centros se emplea oxido nitroso, y en un 15% se evitan los bloqueadores neuromusculares cuando se usa monitorizacion neurofisiologica intraoperatoria. Los problemas cardiovasculares durante la cirugia se refieren como muy frecuentes en el 29% de los centros, mientras que en el postoperatorio las complicaciones referidas como mas habituales son los deficit de pares craneales, el edema de via aerea (23%) y los vomitos postoperatorios (47%). Conclusiones Los resultados obtenidos de la encuesta muestran que en las cirugias de fosa posterior la sedestacion se utiliza menos que el decubito prono y que apenas se usa monitorizacion neurofisiologica intraoperatoria.

El objetivo del tratamiento quirurgico para la esco-liosis, cifosis y otro tipo de deformidades del raquis esla fusion de las vertebras para que la columna verte-bral no pueda curvarse. Se colocan implantes metali-cos (barras, tornillos, alambres, placas, etc.), paramantener el raquis mientras las vertebras se fusionan.La artrodesis vertebral se potencia con injerto (autoge-nico y/o alogenico) de hueso. El abordaje quirurgicopuede ser posterior, anterior o combinacion de ambos.La cirugia toracoscopica se puede utilizar en el abor-daje anterior del raquis dorsal.La cirugia correctora del raquis en pediatria y adultoses un procedimiento prolongado (en general mas de 4horas), tiene las complicaciones potenciales de la ciru-gia mayor (hemorragia grave, hipotermia, infeccion,embolismo graso o aereo, hipotension arterial, etc.)

Summary 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.

Resumen Una gestante de 37 anos acudio al hospital al iniciar el trabajo de parto. Como antecedentes personales de interes referia una depresion con un intento autolitico unos anos antes, estando eutimica sin necesidad de tratamiento al ingreso; y un legrado por un aborto. La paciente solicito analgesia epidural y horas despues de realizar la tecnica presento anestesia en zona dorsal del pie y dificultad para la flexion dorsal del mismo. Tras descartar patologia organica, se considero el diagnostico de trastorno conversivo, una enfermedad psiquiatrica de gran incidencia pero habitualmente infradiagnosticada y que se caracteriza por uno o mas deficit neurologicos que sugieren enfermedad organica, que no son intencionados ni fingidos y que no pueden ser achacados a una enfermedad medica, a los efectos de una sustancia toxica o a un comportamiento culturalmente normal; causando un deterioro significativo a nivel clinico, social y ocupacional.

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 patología neurocrítica y procedimientos neuroquirúrgicos, mediante búsqueda en MEDLINE y en el registro de ensayos clínicos: http://clinicaltrials.gov (última revisión septiembre 2010), además de revisión manual de las publicaciones a partir de la bibliografía de los artículos recuperados. En la hemorragia cerebral espontánea, existen ensayos 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 estudios retrospectivos, opiniones de expertos o casos clínicos aislados.

Background: The effect of different opioids on postoperative nausea and vomiting (PONV) has not been conclusively determined yet, thus the aim of this study was to compare the incidence of PONV in propofol-anaesthetized patients receiving either fentanyl or remifentanil as opioid supplement. Methods: Sixty ASA physical status I and II patients scheduled for plastic surgery gave their written informed consent for this prospective, randomized, double-blind study. Anaesthesia was induced with propofol, rocuronium and fentanyl (n = 30; 2 µg kg−1) or remifentanil (n = 30; 1 µg kg−1). After tracheal intubation, anaesthesia was maintained with propofol, oxygen in air and an infusion of the opioid studied, which was modified according to clinical criteria. Baseline postoperative analgesia was achieved with intravenous propacetamol + metamizol. Intravenous morphine was given if visual analogic scale (VAS) for pain was ≥ 4 (scale 0–10) and metoclopramide was administered if a patient presented ≥ 2 PONV episodes (nausea or vomiting) in less than 30 min. Postoperatively (2, 12 and 24 h), we registered VAS, rescue morphine consumption, number of patients with episodes of PONV and number of patients requiring metoclopramide. P