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Spinal Cord Injury Anesthesia Management
- 1. Dr. Muneeb
- 2. Epidemiology: ◦ Bimodal fashion between the adolescent ages of 15 and 24 and again at age 75 or older Classification of head injury: ◦ Primary injury ◦ Secondary injury
- 3. Brain Injury Primary Skull Fracture Linear Depressed Penetrating Epidural Hematoma Subdural Hematoma Intracerebral Hematoma Secondary Hypoxia Hypotension Hypercarbia Edema Raised ICP Intracranial Hematomas
- 4. 1. Neurological Assessment ◦ GCS Score ◦ Revised Trauma Score 2. Airway ◦ Intubation ◦ Cervical Spine injury
- 5. Monitoring ◦ Arterial line ◦ Central venous catheter Induction ◦ Thiopental, propofol, opioids, BDZ ◦ Suxamethonium or rocuronium Maintenance ◦ Isoflurane ◦ Nitrous oxide ◦ NDMR
- 6. Intraop fluid ◦ Normal saline ◦ 4% albumin
- 7. Hemodynamic control ◦ Autoregulation has been shown to be defective in an injured brain, thus protection of constant CBF is lost. ◦ cerebral perfusion pressure of 50 to 70 mm Hg ◦ Avoid hypertension ◦ Avoid hypotension
- 8. Intracranial Hypertension ◦ Normal is 7-15 mmHg ◦ Monroe- Kellie Doctrine Treatment of raised ICP ◦ Inc. depth, analgesia ◦ Hyperventilate ◦ Diuretic therapy ◦ Drain Venous blood ◦ Barbiturates
- 9. Glycemic Control ◦ Target less than 180 mg/dL ◦ Brain injury by increase in brain glycolytic rate Temperature Regulation ◦ National Acute Brain Injury study showed no difference in outcome between hypo and normothermic patients.
- 10. A focus of abnormal vascular structures, referred to as a nidus, which is an interface between the arterial and vascular systems in lieu of a capillary bed.
- 11. Contain an arterial, a venous and multiple arbitrary connections with surrounding vessels (feeding arteries)
- 12. Pathophysiology ◦ Chronic hypoxic brain stress ◦ Lack barrier function ◦ Gliotic regions develop ◦ Putative epileptic foci ◦ Dynamic structures
- 13. Presentation ◦ ICH ◦ Rebleed ◦ Seizures ◦ Local manifestations An aneurysm associated with an AVM adds to the complexity of treatment.
- 15. Assessment ◦ CT ◦ CT angiography ◦ MRI ◦ Transcranial Doppler USG Goal of assessment is establishing perinidal architecture
- 18. Microsurgery Neuroendovascular embolization Radiation therapy
- 20. Anesthetic considerations ◦ Hybrid operating rooms ◦ Definite procedure is temporized until the patient is stable ◦ Institutional based protocols
- 21. Preop evaluation ◦ Cardiovascular ◦ Respiratory ◦ Renal ◦ Diabetes ◦ Hypertension ◦ Allergy ◦ Airway
- 22. ◦ Focused rapid neurological examination Presenting complaint Any deficits Procedure to be performed ICP status Pupils and GCS
- 23. Cardiovascular Monitoring ◦ Arterial line ◦ CVC ◦ Transcranial Doppler Cerebral and Neurophysiological Monitors ◦ BIS ◦ Jugular venous oxymeter ◦ SSEP, MEP, AEP
- 24. Induction ◦ Strict BP control ◦ Any induction agent in titrated doses ◦ NMB with sux or rocuronium ◦ Short laryngoscopy time Positioning ◦ Proper padding ◦ Avoid extreme flexion and extension
- 25. Maintenance ◦ Low dose inhalational and opiod infusion ◦ Propofol and opioid infusion ◦ Fast track anaesthesia Fluid therapy ◦ Should be goal directed ◦ Hb around 10
- 26. Anticoagulation and reversal ◦ Anticoagulation with heparin 3000 IU to 5000 IU ◦ Monitor with ACT ◦ Reversal with protamine 1 mg for 100 IU
- 27. Emergencies ◦ For obstructive emergencies, Raise BP with alpha 1 agonists ◦ For hemorrhagic emergencies, heparin reversal, hypotension and cerebral protection
- 28. Cerebral protection strategies in hemorrhagic emergencies ◦ Thiopental ◦ Propofol ◦ Normoglycemia ◦ Hypotenison
- 29. Emergence ◦ Rapid ◦ Normotensive ◦ Transport to imaging centre in case of delayed recovery
- 31. Postoperative Considerations ◦ Normal perfusion pressure breakthrough ◦ Obstructive hyperemia ◦ Postop seizures ◦ Glycemic, pain, temperature control ◦ Respiratory and nutritional care
- 32. Symptoms of SCI are frequently characterized by complete or incomplete losses of neurologic function below the point of damage in any of the three main nervous system tracts— motor, sensory, and autonomic.
- 33. The ASIA Impairment Scale is a classification meant to differentiate a patient’s SCI into one of the five categories
- 34. Spinal Cord injury Non Traumatic Non inflammatory Spondylosis Disk Herniation Stenosis Spondylolithiasis Scoliosis Neoplasm Inflammatory Rheumatoid Arthritis Osteomyelitis Ankylosing spondylitis Demyelinating Traumatic Cervical Spine Thoracic Spine Lumbar spine
- 35. Neurologic effects on other systems Neurologic Effects on other Systems Respiratory System C3 or higher>Diaphragmatic paralysis Below C5 paradoxical movement Above T6 loss of abdominal Muscel strength Gastrointestinal System Paralytic Ileus Vomiting Stress ulcer Bleeding Genitourinary Above T12 reflex Bladder Below T12 Flaccid Bladder Thermoregulation
- 37. Anaesthetic Management 1. Preop assessment 2. Induction 3. Airway management 4. Extubation 5. Neuroaxial Anaesthesia 6. Neurophysiological Monitoring & Wake-up Testing 7. Temperature Control 8. Coagulation abnormalities 9. ION 10.Immediate postop considerations 11.Postop Complications
- 38. History Physical Examination Testing Counseling about wake up testing Airway securing plan Counseling about arterial line and CVC Discuss post op pain management Premedication
- 39. Tailored approach is employed Succinylcholine avoid from 12 to 24 hours of onset to 1 to 2 years on indefinitely Antibiotic cover Pain management with high dose opioids boluses or infusion Arterial line CVC
- 40. Indications of arterial line ◦ Likelihood of new SCI ◦ > 2 levels of open fusion ◦ > 1000 ml of blood loss is anticipated ◦ Significant co morbidities ◦ VAE Indications for CVC ◦ > 4 levels of surgery ◦ Re operation ◦ Comorbidities
- 41. Maintenance ◦ Usually on low dose inhalational complemented by TIVA ◦ TIVA and opioid infusion preferably remifentanil If SCI is already present, surgeans may request raised BP
- 42. RL with MILS maneuver FOI ◦ Awake ◦ Sedated Video laryngoscopes Intubating LMA Bonfils intubating fiberscope
- 44. Deep extubation Avoid Coughing and bucking ◦ Low dose opioid ◦ Intermittent doses of propofol Bailey’s maneuver Beta blockers
- 45. Predictors of Post op intubation ◦ Surgery involving C2 ◦ More than 4 levels ◦ operating time > 10 hours ◦ > 4 pints of transfusion ◦ Difficult airway ◦ > 100 kg weight ◦ Respiratory co morbidities
- 46. Leak test of spontaneously breathing patient ◦ Via comparing insp and exp volumes ◦ Via occluding ett after deflating cuff If patient is likely to be extubated but there is not 100% surety then he can be extubated over conduit.
- 47. Patient co operation Easy to position Hypotension VAE Surgical experties Delayed postop neurological assessment Medico legal issues if deficit is found post operatively
- 48. SSEP MEP EMG
- 49. SSEPs are elicited by stimulating electrically a mixed peripheral nerve (usually the posterior tibial, peroneal, or sural nerves), and recording the response from electrodes at distant sites electrodes are placed in the cervical region over the spinous processes or over the somatosensory cortex on the scalp, or are sited during surgery in the epidural space.
- 51. Decrease in amplitude >50% or increase in latency >10% indicate disruption of sensory nerve pathway
- 52. Motor Evoked Potentials (MEP) are electrical responses recorded from muscles, in response to electrical stimulation of nervous system structures that govern movement. Most common is transcranial electrical stimulation of the motor pathway, using subdermal needle electrodes positioned in the scalp above primary motor cortex.
- 54. Electromygraphy is the recording of spontaneous muscle activity like EEG is the recording of brain activity. Different types of bursts alert to impeding injury to the nerve. Electrode placement is on the muscle supplied by the nerve which is most likely to be injured during the procedure.
- 56. What happens to EMG if a nerve is cut?
- 57. EMG SSEP MEP Long neurotonic trains of activity may be indicative of neural injury and are causes for concern and alarm. Amplitude reduction of 50% or latency increase of 10% of cortical SSEPs is considered significant, although smaller changes may indicate impending compromise. CMAP and D wave amplitude decline has been considered an essential endpoint for stopping the surgery. What to monitor
- 58. Anaesthetics effects ◦ NO2 depress potentials ◦ NMB have effect on MEP NMB of 70% or one twitch response on TOF is adequate for testing ◦ Barbiturates dec SSEP Propofol is used ◦ Preexisting SCI Etomidate and Ketamine inc EP by 200 – 300 %
- 59. Response to deteriorating EP Deteriorating EP IOM monitors Checks equipment Impaired perfusion Nerve compression Anesthesia related Hypoxia High volatile dose Hypotension Hypothermia Surgical Factors Massive bleed compression
- 60. If no factor is present then deliberate hypertension 20% above baseline improved EP If during placement of hardware, MEPS deteriorate or only SSEP is monitored and it deteriorates, surgeons will request wake-up test
- 61. Normothermia should be maintained Hyperthermia can mimic SCI wave forms of EP
- 62. Usually in HRSS ◦ involving >6 spinal levels, >6 hours of surgery Cryoprecipitate is thawed at fibrinogen levels <200 mg/dL and administered at <150 mg/dL. Platelets are ordered when counts are <150,000/μL, and given at <100,000/μL.
- 63. Desmopressin (0.3 μg/kg) is administered for oozing in spite of a platelet count >100,000/μL and normal fibrinogen. Recombinant factor VIIa (30 μg/kg) is given after desmopressin therapy if the INR is >2 and oozing is present
- 64. Causes ◦ venous engorgement ◦ increased intraocular pressure ◦ optic nerve compartment syndrome. Prevention ◦ head-up as possible ◦ increase perfusion pressure ◦ prevent severe anemia ◦ colloid fluids over crystalloids to decrease extravascular edema.
- 66. Rapid awakening Considering extubation Pain control
- 67. Respiratory obstruction ◦ Edema ◦ Bronchospasm ◦ Laryngospasm ◦ Secretions ◦ Pulmonary edema ◦ TRALI ◦ Pulmonary embolism ◦ Cardiac complication ◦ Allergic reaction Repeated neurological examination is mandatory