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Vélez, V. Lara-Erazo, A.F. Caballero-Lozada, A. Botero, G. Lozada, A.F. Velásquez, L.M. Villegas, A. Zorrilla-Vaca" "autores" => array:8 [ 0 => array:2 [ "nombre" => "P.A." "apellidos" => "Vélez" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Lara-Erazo" ] 2 => array:2 [ "nombre" => "A.F." "apellidos" => "Caballero-Lozada" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Botero" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Lozada" ] 5 => array:2 [ "nombre" => "A.F." "apellidos" => "Velásquez" ] 6 => array:2 [ "nombre" => "L.M." "apellidos" => "Villegas" ] 7 => array:2 [ "nombre" => "A." "apellidos" => "Zorrilla-Vaca" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923001348?idApp=UINPBA00004N" "url" => "/23411929/0000007100000004/v1_202406151608/S2341192923001348/v1_202406151608/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192923001403" "issn" => "23411929" "doi" => "10.1016/j.redare.2022.07.005" "estado" => "S300" "fechaPublicacion" => "2024-04-01" "aid" => "1523" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2024;71:304-16" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "304" "paginaFinal" => "316" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gestión del dolor agudo postoperatorio: Condiciones para garantizar la seguridad y la efectividad de los tratamientos analgésicos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 937 "Ancho" => 2925 "Tamanyo" => 319717 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for administration of rescue analgesia or modification of an analgesia regimen.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Esteve-Pérez, M.A. Perez-Herrero, A. Montes-Perez, S. López-Alvarez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Esteve-Pérez" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Perez-Herrero" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Montes-Perez" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "López-Alvarez" ] 4 => array:1 [ "colaborador" => "Grupo de Trabajo de Dolor Agudo SEDAR" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935623001585" "doi" => "10.1016/j.redar.2022.07.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935623001585?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923001403?idApp=UINPBA00004N" "url" => "/23411929/0000007100000004/v1_202406151608/S2341192923001403/v1_202406151608/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Neuraxial anaesthesia in patients with cerebrospinal fluid shunts: A descriptive review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "317" "paginaFinal" => "323" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. García Casas, M. Echevarría Moreno" "autores" => array:2 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "García Casas" "email" => array:1 [ 0 => "paula.garciacasas@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Echevarría Moreno" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen de Valme, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo: revisión descriptiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2111 "Ancho" => 2091 "Tamanyo" => 269777 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Literature review flowchart.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The standard management of patients with intracranial hypertension (ICH) secondary to hydrocephalus includes the implantation of a temporary or permanent cerebrospinal fluid (CSF) shunt that drains excess CSF from the brain to another cavity, thus alleviating the pressure on adjacent areas. The most common devices are ventriculoperitoneal shunts, although ventriculoatrial or ventriculopleural shunts are also used. In case of communicating hydrocephalus, such as idiopathic ICH, the proximal catheter can be inserted into the lumbar subarachnoid space to create a lumboperitoneal shunt.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When working properly, the shunt maintains intracranial compliance in a patient who would otherwise present high intracranial pressure.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">An epidemiological review performed in the United Kingdom between 2004 and 2013 reported an incidence of primary shunt placement in infants, children and adults of 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is difficult to establish the prevalence of CFS shunts in the general population, but it is reasonable to assume that some of these individuals will require a surgical intervention unrelated to their device at some point in their lives.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Spinal anaesthesia in these patients has always been associated with a high risk of complications. Our aim was to review the available literature in order to determine if there is any scientific evidence that spinal anaesthesia is effective and safe in patients with CSF shunts.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">All published studies that met the following criteria were reviewed: 1) patients with some type of CSF shunt; 2) any age and type of hydrocephalus; 3) undergoing a non-device-related surgical or obstetric procedure; 4) scheduled for regional spinal anaesthesia, regardless of whether conversion to another technique was ultimately required. The objective of our study was to determine the effectiveness of spinal anaesthesia (defined as completion of the surgical or obstetric procedure without the need for measures that deviated from standard practice and without the need to modify the approach intraoperatively due to insufficient anaesthesia), and the incidence of anaesthesia-related perioperative complications. We grouped complications as intraoperative complications that jeopardised patient safety during the intervention; postoperative complications caused by device malfunction (appearance of new neurological symptoms or worsening of baseline symptoms suggestive of an increase in intracranial pressure requiring treatment); and postoperative complications due to infection (suspected or confirmed CNS infection that required antibiotic therapy and/or review of the shunt for this reason). The exclusion criteria were: studies that did not address the study objectives; unavailable texts (due to age or pending publication); and studies published in a language other than English or Spanish. No studies were excluded based on quality, methodology, or the date of publication.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We searched Pubmed, the Cochrane library, and the meta search engine TRIP database of evidence-based high quality medical information, and also the clinical practice guidelines Guiasalud and National Guideline ClearingHouse. The references included in the studies identified in the primary search were also reviewed. All sources were consulted up to and including October 2022. The following search terms were used: “cerebrospinal fluid shunt”, “ventriculoperitoneal shunt”, “epidural anesthesia”, “spinal anesthesia”, “caudal anesthesia”, “patient harm”, “patient safety”. The following free-text terms “neuraxial anesthesia”, “neuraxial technique”, “lumboperitoneal shunt”, “cerebrospinal fluid drainage” using the Boolean operator AND to combine terms. The search in Pubmed was performed using the “Clinical Queries” tool, which uses predefined filters designed by experts and validated in research studies. The other databases were searched without filters or limits.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was designed by a single researcher (PGC), who also performed the literature search, screened the studies and reviewed the results. In the first screening round, studies with titles and abstracts that met the inclusion criteria were included. In the second round, the included studies were read in full, and any that did not meet the inclusion criteria were excluded. The data were not analysed statistically due to the low quality of the studies identified.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The search results are shown in the flowchart (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We identified 342 articles, of which 32 were eliminated due to duplication. After reviewing the titles and abstracts of the remaining studies, 290 were eliminated because they did not analyse our study objectives and 5 because no full text was available (3 published before 1995 and 2 pending publication). No studies were eliminated due to language. The full texts of the remaining 15 articles were evaluated, one of which was eliminated due to discrepancies with the data of interest. The 14 studies finally included in our review were case reports (n = 6), case series (n = 5), and narrative reviews (n = 3) that analysed our study objectives.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The most important results of each study are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The studies included a total of 72 patients, half (n = 36) were pregnant and the other half were children. Most patients had a ventriculoperitoneal shunt, while lumboperitoneal shunts were only reported in pregnant patients.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> Regarding the type of spinal anaesthesia, in 52 cases (72%) lumbar or caudal epidural was performed, in 19 (26%) a subarachnoid block was performed, and in 1 case a combined intradural-epidural technique was performed.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Obstetric population</span><p id="par0045" class="elsevierStylePara elsevierViewall">The largest series involved obstetric patients with different types of shunt.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The authors collected data from 37 pregnant patients and followed them during pregnancy, delivery, and postpartum. Twenty six of these patients received some type of spinal anaesthesia (mostly epidural) for labour or caesarean section, and the authors describe the outcome of these interventions. In 3 cases, however, regional anaesthesia was converted to general anaesthesia without specifying whether this was due to obstetric- or anaesthesia-related problems. Five of the total sample of 37 patients presented shunt malfunction, but provided insufficient information to determine whether these events were associated with the administration of spinal anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In another series of 4 patients with different types of shunts who received epidural for labour pain, regional anaesthesia was effective in all cases, but there was no information on post-delivery device malfunction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> More recently, 2 cases of effective, uneventful subarachnoid block for caesarean section in patients with ventriculoperitoneal shunt valves have been published.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Two case reports described successful epidural anaesthesia in pregnant patients with lumbo-peritoneal drainage shunts, benign ICH, and pre-eclampsia, who ultimately required caesarean section for obstetric reasons.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> In the first patient, the epidural catheter was inserted 1 intervertebral space below the shunt scar. The quality of analgesia was not affected by scarring of the epidural space and the catheter was removed without incidence.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In the second case, the epidural catheter was placed 3 lumbar spaces above the shunt. Before removing the catheter, epidurography was performed to confirm that it was located above the shunt.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In another case report, the standard technique needed to be modified to achieve successful analgesia in a patient with a lumboperitoneal shunt. After administering subarachnoid block with a catheter for an obstetric procedure, the anaesthetist needed to repeat doses of the local anaesthetic more frequently than expected (every 15 min) in order to maintain the blockade. According to the authors, the rapid offset of local anaesthetic action was probably caused by washout of the medication into the peritoneal cavity via the lumboperitoneal shunt.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The only case report describing a serious intraoperative complication involved a pregnant woman with a lumboperitoneal shunt who experienced symptoms consistent with high blockade following an unsuccessful attempt at inserting the epidural needle. The authors hypothesised that administration of the local anaesthetic may increase pressure and re-open the puncture made during insertion of the shunt.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The series published by Bradley et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and Wisoff et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> do not provide enough information to conclude that episodes of postoperative shunt malfunction or infection were attributed to spinal anaesthesia. None of the remaining studies in pregnant patients report these complications.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Paediatric population</span><p id="par0065" class="elsevierStylePara elsevierViewall">The second largest series published (25 patients) is also the most recent and involves paediatric patients with ventriculoperitoneal shunts who required caudal or subarachnoid epidural anaesthesia for subumbilical surgery.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The authors do not report any cases in which a change of anaesthesia technique was required; however, as all patients received general anaesthesia due to their age (average 5.7 years), it was difficult to assess the neuraxial technique during the intervention. The authors did not report any cases of postsurgical infection, but they did report 1 case of a patient undergoing lower limb orthopaedic surgery with combined general and epidural anaesthesia who required shunt revision on the 5th postoperative day due to shunt malfunction. The neurosurgeons concluded that the adverse event was not related to the anaesthetic technique.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The other 2 paediatric series published are more limited in terms of sample size and patient information.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> In the first, 5 preterm patients under 4 months of age with neurological and respiratory comorbidity received spinal anaesthesia for abdominal surgery in order to avoid general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The second consisted of 6 patients aged between 9 months and 6 years with congenital or acquired hydrocephalus who received combined general-spinal anaesthesia for various surgical procedures (abdominal, lower limb orthopaedic).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Neither series reported intra- or postoperative spinal anaesthesia or shunt-related complications, although in the series by Platis et al. the combination of spinal and general anaesthesia makes it difficult to assess the technique during the intervention.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Our literature search only identified case reports and case series in either obstetric or paediatric patients. It is striking to note the absence of high quality, case-controlled studies. The case series are based on retrospective data and either omitted information on some of the variables of interest in our review<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,13,15</span></a> or presented the results in group form.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The homogeneity of the criteria used by each author to collect these variables is also uncertain. In 2 series in paediatric patients,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,15</span></a> general anaesthesia was used due to the patients’ age, while in the largest series (in pregnant patients<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>) the authors do not explain why this approach was used in 3 of the patients. This makes it very difficult to assess the effectiveness of the spinal block and the possibility of block-related intraoperative complications, and to determine the exact percentage of cases (72) in which spinal anaesthesia was both effective and uneventful. For this reason, we did not perform a statistical analysis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The relatively larger number of studies in patients (all pregnant) with lumboperitoneal shunts shows the overall interest in this particular scenario.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–12</span></a> The authors of these studies disagreed on the need for preoperative imaging studies and the importance of the lumbar level of the shunt. Abouleish et al. for example, suggest performing a pre-procedural radiological study to determine the shunt’s site of entry in the subarachnoid space in order to plan the spinal approach.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Bedard et al. and Kim et al., however, believe this to be unnecessary because the drainage catheter runs laterally and can therefore be avoided by approaching the epidural space from the midline either above or below the shunt scar.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> After performing an epidurogram, however, Kim et al. observed that the internal path of the drainage catheter can vary with respect to the shunt scar.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Bedard et al. also mention the risk of the epidural catheter becoming entangled with the lumboperitoneal shunt, According to these authors, any abnormal resistance felt during cautious removal of the catheter is a sign of entanglement, and dictates the need for appropriate imaging studies.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> According to Moreno-Duarte et al. performing the spinal block above the shunt will reduce the risk of the local anaesthetic, which tends to migrate cranially, entering the intradural space if it communicates with the subarachnoid space. The also suggest administering the local anaesthetic in small incremental doses.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Evaluation and decision making</span><p id="par0080" class="elsevierStylePara elsevierViewall">The scant number of studies, all of low quality, retrieved from our literature search makes it difficult to establish recommendations for patient management. Nevertheless, it would be reasonable to offer the benefits of spinal anaesthesia to patients that, following an individual assessment, are at low risk of developing complications.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the pre-anaesthesia evaluation, we suggest collecting information on the characteristics of the shunt (indication for placement, date of placement, type and location; consider performing imaging tests in the case of lumboperitoneal shunts), on the existence of theoretical risk factors for shunt-related complications (history of malfunction, infection, or previous replacements), and on other risk factors (immunosuppression, pregnancy, surgical technique, or surgical position). It may be necessary to contact the patient’s neurosurgeon or neurologist to obtain some of this information. If spinal anaesthesia has been decided, it is important to document the patient’s baseline status. We would emphasise that these recommendations are based on a low level of evidence found in this review, on theoretical concepts, and on common sense. In the absence of stronger evidence, they are intended as broad guidelines, but should never override the anaesthesiologist’s opinion.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Limitations</span><p id="par0090" class="elsevierStylePara elsevierViewall">This review has obvious limitations. On the one hand, it is based on small case series and isolated case reports that, due to their nature, lack a patient selection process or a control group. Nine of the 11 studies identified are more than 5 years old, and in several cases the results are presented in group form instead of individually, making it impossible to clearly break down the numbers needed for this review. There is a risk of publication bias, i.e., a reluctance to publish negative results. Our inclusion criteria may have restricted access to other relevant studies, for example, those published in other databases, in other languages, or not available online.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">In the absence of studies providing more solid scientific evidence, and bearing in mind the foregoing limitations, we were unable to draw any firm conclusions on the efficacy and safety of neuraxial anaesthesia in patients with CSF shunts. However, the systematic contraindication of this type of anaesthesia in this patients might not be entirely appropriate. Further studies of higher methodological quality are needed to determine the risk-benefit balance in this scenario.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2166601" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1837418" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2166600" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1837417" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Obstetric population" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Paediatric population" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Evaluation and decision making" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Limitations" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-12-13" "fechaAceptado" => "2023-05-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1837418" "palabras" => array:6 [ 0 => "Cerebrospinal fluid shunt" 1 => "Hydrocephalus" 2 => "Epidural anaesthesia" 3 => "Spinal anaesthesia" 4 => "Neuraxial anaesthesia" 5 => "Perioperative complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1837417" "palabras" => array:6 [ 0 => "Derivaciones del líquido cefalorraquídeo" 1 => "Hidrocefalia" 2 => "Anestesia epidural" 3 => "Anestesia espinal" 4 => "Anestesia neuroaxial" 5 => "Complicaciones perioperatorias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Neuraxial anesthesia in patients with cerebrospinal fluid (CSF) shunt devices has traditionally been associated with a high risk of complications. In order to gather all available evidence, a structured search was conducted to include published studies involving users of these devices, undergoing any form of neuraxial technique for obstetric or surgical procedures unrelated to them. Effectiveness of the technique and perioperative complications were assessed. Only case series and case reports (n = 72) were identified. One patient was found to have insufficient anesthetic coverage, necessitating a modification of the technique, and another one had an intraoperative complication which compromised the subject’s safety. No infection events or postoperative device dysfunction related to the anesthetic method were described. The evidence found is scarce and of low quality, preventing the establishment of significant conclusions. Nevertheless, patients may obtain benefit from an individualized evaluation.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La anestesia neuroaxial en pacientes portadores de dispositivos de derivación de líquido cefalorraquídeo (LCR) se ha asociado clásicamente a un alto riesgo de complicaciones. Con el fin de recabar toda la evidencia disponible, se realizó una búsqueda estructurada de los trabajos publicados en usuarios portadores de estos dispositivos, sometidos a algún tipo de técnica neuroaxial para procedimientos obstétricos o quirúrgicos no relacionados con el mismo, valorando la eficacia de la técnica y las complicaciones perioperatorias. Solo se encontraron series de casos y casos clínicos (n = 72). Se identificó uno de insuficiente cobertura anestésica, que precisó una modificación de la técnica, así como una complicación intraoperatoria con compromiso de seguridad para el sujeto. No se describió ningún caso de infección ni disfunciones posoperatorias del dispositivo relacionadas con el método anestésico. La evidencia hallada es escasa y de baja calidad, lo que no permite establecer conclusiones significativas, aunque los pacientes podrían beneficiarse de una valoración individualizada.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2111 "Ancho" => 2091 "Tamanyo" => 269777 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Literature review flowchart.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">?: no information or no valuable data; ADP: accidental dural puncture; CSE: combined spinal-epidural; GA: general anaesthesia; ICH: intracranial hypertension. LA: local anaesthetic LL: lower limb; LP: lumboperitoneal; OS: orthopaedic surgery; SA: subarachnoid anaesthesia; VA: ventriculoatrial. VP: ventriculoperitoneal. VPL: ventriculopleural.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient/shunt characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Anaesthesia technique \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Effectiveness \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative complication (safety) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative malfunction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative infection \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comments \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wisoff et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> (1991) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adult pregnant women VP, VA, VPL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not detail each case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bradley et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> (1998)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adult pregnant women VA, VP, LP</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural (n = 24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">?</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Includes GA and postoperative malfunction without detailing each case</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal (n = 2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bédard et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> (1999) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic ICH in pregnancy LP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kim et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> (2000) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic ICH in pregnancy LP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kaul et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> (2002) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic ICH in pregnancy LP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Epidural → ADP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for repeated boluses due to ↓ LA effect \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kachko et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> (2006) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preterms <4 m VP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal surgery avoid GA (NRL and respiratory pathology) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platis et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> (2006) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paediatric (9 m–6 y) VP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caudal + GA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficult assessment due to GA + spinal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Palmeira Goulart <a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> (2009) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnant women VP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urgent caesarean section \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hirs et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnant women VP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elective caesarean section \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moreno-Duarte et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> (2018) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic ICH in pregnancy LP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CSE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High intradural block \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Longhini et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> (2018)</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paediatric (average 5.7 years) VP</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Caudal (n = 16) and spinal (n = 9) + GA</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">?</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">?</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sub-umbilical surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distal catheter obstruction LLOS (SA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Difficult assessment due to GA + spinal \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3569692.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Results of the review.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Idiopathic intracranial hypertension: consensus guidelines on management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.P. 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