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1-Spine Pasternak Mayo.pptx
- 1. Update On Anesthesia For Major Spine Surgery Jeffrey J. Pasternak, MD Associate Professor of Anesthesiology Chair – Division of Neuroanesthesia College of Medicine – Mayo Clinic Rochester, MN USA
- 2. Objectives • Understand the current epidemiology of major spine surgery • Identify challenges for anesthesia providers when caring for patients having major spine surgery • Appreciate recent advances in the perioperative care of patients undergoing major spine surgery
- 3. Spine Disorders – An Increasing Epidemic • 48% increase in number of Americans with spine problems • 82% increase in estimated health care expenditures: • 1997: $19.4 billion • 2006: $ 35.1 billion 10 15 20 25 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 No. of Americans (million) Year Number in US Receiving Treatment for Spine Problems Martin BI. Spine 2009;34:2077-84
- 4. 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 1993 1995 1997 1999 2001 2003 2005 2007 Year Annual Number of Procedures Craniotomy for Tumor Endovascular (Head and Neck) Shunts Deep Brain Stimulators Spinal Fusion Anesth Analg 2010;110:1686-97
- 5. Cervical Spine Surgery Medicare Beneficiaries Wang MC. Spine 2009;34:955-61
- 6. The Typical Spine Surgery Patient
- 7. Complicated by Complications! Surgery-related • Spinal cord injury • Vascular injury • CSF leak / fistula • Surgical site infection • Bleeding / hemorrhage • Failure to improve signs/symptoms • Loosening of hardware • Bone graft extrusion • Esophageal injury • Sympathetic chain injury • Surgical site hematoma • Thoracic duct injury • Dysphagia Non-surgery-related • Cardiovascular • Hypotension / hypertension • Dysrythmia • Ischemia/infarction • Venous thrombosis / pulmonary embolism • Venous air embolism • Pulmonary • Pneumonia • Aspiration • Airway injury • Transfusion-related acute lung injury • ARDS • Renal • Acute renal injury related to hypovolemia or hypoperfusion • Tubular necrosis • Urinary tract infection • Neurologic • Post-operative pain • Ocular injury/Blindness • Position-related nerve or cervi cal cord injury • Intraoperative awareness • Gastrointestinal • Ileus / colitis • GI hemorrhage / pancreatitis • Hematologic • Transfusion reaction • Disseminated • Adverse reaction to drugs • Decubitus ulcers Surgery or Non-surgery Related • Post-operative airway compromise • Recurrent laryngeal nerve injury
- 9. Topics • Obesity and outcome • Blindness • Antifibrinolytics
- 10. Obesity and Spine Surgery
- 11. Background • 35% of adults in the US are obese • Most common in middle-age and older adults • Obesity is associated with increased risk for other diseases that may increase perioperative risk. • Risk factors for complications after major spine surgery: • Co-morbidities • Age • Case Complexity Ogden CL. JAMA 2014; 311:806-14 Shen Y. J Neurosurg Anesthesiol 2009;21:21-30
- 12. • Healthcare Cost and Utilization Project’s California Database • Of 84,607 spine fusions 1,455 (2%) were morbidly obese • Compared to normal weight, morbid obesity was associated with: • Increased hospital LOS by 1.3 days • Complications: • Overall: (14% vs. 7%) • Most common: Wound complication (6% vs. 3%) • 28% increased cost ($23K) • Higher mortality rate (0.8% vs. 0.3%, p=0.0002) SPINE 2012;37:982-8.
- 13. • American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) • 24,196 adults having lumbar spine decompression or fusion • Stratified based on BMI: • Normal (BMI=18.5-24.9 kg/m2) • Overweight (BMI=25-29.9 kg/m2) • Class 1 obesity (BMI=30-34.9 kg/m2) • Class 2 obesity (BMI=35-39.9 kg/m2) • Class 3 obesity (BMI>40 kg/m2) • Excluded underweight (BMI<18.5 kg/m2) SPINE 2014;39:798-804
- 14. Normal Weight Overweight/Obese Variable BMI 18.5-24.9 kg/m2 BMI > 25 kg/m2 P N 5001 (21%) 19,195 (79%) Sex (% male) 43% 54% <0.001 Hypertension (%) 36% 54% <0.001 Diabetes Mellitus (%) 7% 17% <0.001 Operative time (min) 139+99 min 155+102 min <0.001 Anesthesia time (min) 200+118 min 217+121 <0.001 Significant differences in operative and anesthesia time still existed after correcting for demographic differences, comorbidities, resident involvement surgical approach and number of levels. Complication -> Pulmonary Deep venous Wound Urinary Tract Acute Renal Sepsis Mortality Embolism Thrombosis Infection Infection Failure Overweight **** Class 1 obesity **** **** **** Class 2 obesity **** **** Class 3 Obesity **** **** **** **** **** **** 30-Day Complications Compared to Normal Weight Subjects
- 15. Patient Perceptions of Outcome • More long-term back and leg pain • Lower long-term functional status • Lower perceived improvement • More likely to be dissatisfied with their surgical outcome.
- 16. Blindness
- 17. Differential Diagnosis of Post-Operative Visual Loss • Pre-operative visual impairment • Corneal Abrasion • Exacerbation of glaucoma • Central retinal artery occlusion • Retinal detachment • Anterior ischemic optic neuropathy • Posterior ischemic optic neuropathy • Glycine-induced visual loss • Stroke • Posterior reversible encephalopathy syndrome
- 18. Earlier Data • Ischemic optic neuropathy was the cause in most cases • More common in men • Healthy and young patients were not immune • Greatest risk with multilevel lumbar/lumbosacral fusion • Most are bilateral • Most do not recover “usable” vision • Rate 0.017%-0.1% Lee LA. Anesthesiology 2006;105:652-9 Patil CG Spine 2008;33:1491-6 Shen Y. Anesth Analg 2009;109:1534-45 Stevens WR. Spine 1997;22:1319-24
- 19. • 80 patients in ASA POVL Registry with ION • 315 control patients from 17 academic centers • ???Venous outflow? Factor OR (95% CI) P Male Sex 2.53 (1.35–4.91) 0.005 Obesity 2.83 (1.52–5.39) 0.001 Wilson Frame 4.30 (2.13–8.75) <0.001 Anesthesia duration (per hour) 1.39 (1.22–1.58) <0.001 Estimated blood loss (per liter) 1.34 (1.13–1.61) 0.001 Colloid for non-blood replacement (per 5%) 0.67 (0.52–0.82) <0.001 RESULTS OF MULTIVARIATE REGRESSION ANALYSIS POVLSG. Anesthesiol 2012,116,15-24
- 20. • Nationwide Inpatient Sample • Adults having spinal fusion 2002-2009: N=541,485 • Identified POVL by ICD-9 codes: N=105 • Unspecified sudden vision loss • Ischemic optic neuropathy • Cortical blindness • Retinal vascular occlusion • Incidence: 0.019% (1.9/10,000) • ION: 0.005% 28% 22% 49% 1% Ischemic Optic Neuropathy Retinal Vascular Occlusion Cortical Blindness Unspecified
- 21. • POVL most common after: • Thoracic or posterior lumbar fusion • Deformity Surgery • Most were healthy women • Most were thoracic multi-level • Most (81% of cases) involved cortical blindness Characteristic No visual loss Visual loss P Average age (y) 54 37 <0.0005 Sex (% male) 47% 53% 0.23 Charlson Comorbidity Index 2.27 2.97 <0.0005 Surgery for Deformity 6% 56% <0.0005 Number of Levels Fused <0.0005 1-2 82% 39% 3-7 16 14 > 8 2% 47%
- 22. WHAT?? I might wake up blind? • > 80% of patients prefer full disclosure of risk • By the surgeon • Face-to-face discussion • Prior to the day of surgery
- 23. Antifibrinolytics and Spine Surgery
- 24. Background • Bleeding is a major complication of major spine surgery • Recent meta-analysis of data from adults WITHOUT protective strategies:1 • Rate of RBC transfusions: 50-81% • Range of total EBL: 650-2839 mL • Transfusions are NOT benign! 1Elgafy H. Spine 2010;35:S47-56
- 25. Some Perioperative Blood Conservation Strategies • Optimize preoperative use of anticoagulants and antiplatelet drugs • Autologous pre-donation • Acute normovolemic hemodilution • Intraoperative red blood cell salvage • Hemostatic drugs • Antifibrinolytics • Recombinant activated factor VIIA • Desmopressin • Controlled hypotension • Maintenance of normothermia • Intrathecal morphine • Surgical modifications • Restrictive transfusion trigger
- 26. Antifibrinolytics – Mechanism of Action
- 27. Scoliosis N TXA Dosing Key Findings Sethna NF. et al. Anesthesiol 2005:102:727-32 44 100 mg/kg then 10 mg/kg/hr 41% decrease in EBL 35% decrease in PRBCs (NS) No complications Shapiro F. et al. Spine 2007;32:2278-83 56 100 mg/kg then 10 mg/kg/hr 42% decrease in EBL 46% decrease in PRBCs 42% decrease in cell saver No complications Grant JA. et al J Pediar Orthop 2009:29:300-4. 26 HIGH: 20mg/kg then 10mg/kg/hr LOW: 10 mg/kg then 1 mg/kg/hr High dose vs. low dose: 84% reduction in RBC units per patient 50% decrease in PRBCs (NS) No complications Yagi M. et al. Spine 2012:37:E1336-42 106 1 g then 100mg/hr 43% decrease in intra-op EBL 41% decrease in postop EBL 32% decrease in transfusion volume No complications
- 28. Tranexamic Acid • 157 adults randomized to: • Placebo • Tranexamic acid: 10mg/kg then 1 mg/kg/hr • No notable vascular occlusive complications TXA Placebo P Total EBL (ml) 1592+1315 2138+1607 0.026 Intraop EBL (ml) 1078+895 1600+1301 0.044 Postop EBL (ml) 336+471 737+524 0.039 % requiring transfusion 31% 40% 0.2 Post-op serum hemoglobin (g/dl) 9.4+1.4 8.9+1.3 0.03 Wong J. Anesth Analg 2008; 107:1497-86
- 29. • 9 RCTs including 581 patients • Variable dosing of tranexamic acid • Decrease in intraoperative EBL: 128 ml (p=0.008) • Decrease in postoperative EBL: 99 ml (p<0.001) • Decrease in total EBL: 389 ml (p=0.003) • 39% reduction in rate allogenic transfusion (p<0.0001) • 1 DVT reported. No other thrombotic complications Yang B.PLOS ONE 2013;8:e55436
- 30. Tranexamic Acid Versus AMICAR • 84 patients with scoliosis • EBL: • 51% decrease with tranexamic acid • 7% decrease with amicar • Total blood transfused: • 13% decrease with tranexamic acid • 20% INCREASE with amicar • Cell salvage transfusion: • 45% decrease with tranexamic acid • 14% INCREASE with amicar Dhawale AA. Spine 2012;37:E549-55.
- 31. Tranexamic Acid vs. AMICAR • Meta-analysis or RCTs: • Tranexamic acid vs. placebo (n=7 studies) • AMICAR vs. placebo (n=2 studies) • Mean difference in total blood loss: • Tranexamic acid vs. placebo = -285 ml (CI = -507 to -64 ml; p=0.01) • AMICAR vs. placebo = -338 ml (CI = - 583 to -93 ml; p<0.005) • Mean difference in blood transfused: • Tranexamic acid vs. placebo = -243 ml (CI = -423 to -63 ml; p=0.008) • AMICAR vs. placebo = -358 ml (CI = -608 to -108 ml; p=0.005) • DVT rates: • 0 per 335 in experimental groups • 3 per 329 in control groups Yuan C. PlosOne 2013;8: e82063
- 32. Summary - Antifibrinolytics • Tranexamic acid is probably effective at reducing: • Intraoperative blood loss • Postoperative blood loss • Red blood cell transfusion rates • Superior drug is unclear • Higher doses are probably more effective • Theoretical concern of thrombotic/vaso-occlusive complications • Overall low rates of complications
- 33. Thank You