This document discusses the anaesthetic considerations and challenges for major spinal surgeries. It covers preoperative evaluation of the patient's airway, pulmonary, cardiac, neurological and haematological status. Intraoperative monitoring including neurophysiological monitoring is important. Positioning the patient prone can cause various complications which need to be mitigated. The anaesthetic technique aims to allow for monitoring while maintaining a stable depth. Criteria for extubation and postoperative concerns are outlined.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
DIABETES AND ITS ANAESTHETIC IMPLICATIONSSelva Kumar
This presentation deals with diabetes mellitus and its anaesthetic implications. All about preoperative investigations and intra-operative management are discussed.
Edward Fohrman | Anesthetic Considerations for Carotid EndarterectomyEdward Fohrman
Edward Fohrman, an experienced anesthesiologist in CA, discusses some considerations to take into consideration when it comes to carotid endarterectomy and anesthesia.
One of the hardest specialties is neuro anesthesia. When I initially started, I were so dumb founded. The things in brain did not only change, they become instantly harder. The drugs which were supposed to work now did not because the brain had developed edema or there was no blood supply. I worked real hard on this presentation. Took help from the textbooks and my teachers and has helped me. I hope you will found it somewhat helpful. Some of the answers are beyond the scope of this presentation due to the diversity of the field.
Can read freely here
https://sethiortho.blogspot.com/
Thoracic outlet syndrome
Neurovascular symptoms in the upper extremities due to pressure on the nerves and vessels in the thoracic outlet area
The specific structures compressed are usually the nerves of the branchial plexus and occasionally the subclavian artery or subclavian vein
Anatomy
Thoracic outlet
Entrance/ Exit region of the upper limb
The thoracic outlet is defined as the interval from the supraclavicular fossa to the axilla that passes between the clavicle and the first rib
Anatomy - Scalane triangle
Anatomy of the costoclavicular space
Pectoralis minor space
Located inferior to the coracoid process
anterior to the second through fourth ribs
posterior to the pectoralis minor muscle
The cords of the brachial plexus
Axillary artery
Axillary vein.
Soft-tissue Causes (70%)
Scalene muscle
Variations in insertion
Hypertrophy
Accessory scalenus minimus muscle
Anomalous ligaments or bands
Soft-tissue tumors
Osseous Causes
Cervical rib
Prominent C7 transverse process
Displacement or callus from first rib fracture
Malunited clavicle or first rib fracture
AC or SC joint injury or dislocation
Osseous tumor
Poor posture
Drooping the shoulders
Holding the head in a forward position
Repetitive activity
Athletes and swimmers
Neurogenic TOS
Compression – scalene triangle and costoclavicular space
May be associated with normal anatomy
Traction of the lowest trunk of the brachial plexus
Often in association with arterial TOS
Features of Lower brachial plexus compression - Common
Female predominance
Appearance of Amedio Modigliani painting
Complains of pain and paresthesia extending from the shoulder /down the ulnar aspect of the arm into the medial two fingers
Neurogenic TOS
Upper brachial plexus compression C5,C6 and C7
Less common
Compression mainly occurs in scalene triangle
Symptoms
Unilateral occipito-frontal headache
Facial or jaw pain
The Gilliatt-Sumner hand
A characteristic finding of neurogenic TOS, is described as atrophy of the abductor pollicis brevis and, to a lesser degree, the hypothenar musculature and the interossei.
Venous TOS
Causes
Hypertrophy of the subclavius muscle,
Chondroma formation
Clinical presentation
Most patients are sportsmen, musicians or manual workers undertaking repetitive arm movements.
The condition occurs more commonly in the dominant limb
Male predominance
Clinical presentation
Acute presentation -
Swollen and tensed upper limb
Upper limb aching pain
blueish- purple arm due to venous engorgement
Collateral veins may be visible
Feeling of heaviness that is worse after activity
Symptoms are precipitated by working with the arms elevated and are relieved by dependency, a pathognomonic feature of vTOS.
Arterial TOS
Rare but has more devastating consequences
Caused by
Intermittent subclavian arterial compression - Costoclavicular compression with normal anatomy.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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2. Anaesthesia for major spinal surgery, such as
spinal stabilization following trauma or
neoplastic disease, or for correction of scoliosis,
presents a number of challenges
Commonly have preop. co-morbid conditions eg
serious CVS & resp. impairment
Airway management may be difficult
3. Mainly present with one of 5 pathologies:
Trauma (eg unstable vertebral fracture)
Infection (vertebral abscess)
Malignancy (metastatic/primary dz with spinal
instability, pain & neurological compromise)
Congenital/idiopathic (example scoliosis) or
Degenerative disease
6. Patient‟smedical condition
Surgical procedures – duration & surgical
approach
Airway Evaluation
Mallampati Classification & various radiological
predictors of difficult intubation & range of motion
of the neckpain or other neurological
symptoms during manipulation
7. Pulmonary Evaluation
patient at risk of pulmonary dysfunction
corrective surgeries (scoliosis)
old age (degenerative spine diseases)
acute fracture of cervical spine
require special anaesthetic technique like one
lung ventilation
8. Cardiac Evaluation
Cardiac function m/be compromised by
underlying medical conditions, neuromuscular
disorder , rheumatoid arthritis , high cervical cord
injury
Neurologic Evaluation
Careful documentation of preexisting neurological
deficit is essential
Extent of neurological dysfunction may dictate
intubation technique & choice of anesthetic
agents
9. Haematological evaluation
Many pts with spine pathology will have been
taking some NSAIDs for analgesia
Proper coagulation profile has to be ordered
1 author suggest to stop NSAIDs at least 10
days before elective surgeries (Samantaray
2006)
Premedication
Depends on haemodynamic stability and
neurological status of patient
10. Minimum Ix Optional Ix
Airway •Cervical spine lateral x-rays with •CT scan
flexion/extension views (for pts with
rheumatoid arthritis)
•Plain CXR
Resp. system •Arterial blood gas analysis •Pulmonary function tests
•Pulmonary diffusion capacity (bronchodilator
•Spirometry (FEV1, FVC) •reversibility)
•Pulmonary diffusion
capacity
CVS •ECG •Dobutamine-stress
•Echocardiography echocardiograph
•Dypiridamole/thallium
scintigraphy
Blood tests •Full blood count •LFT
•Clotting profile
•Blood cross match
•Urea, electrolytes
•Albumin, calcium (neoplastic
disease)
11. Standard monitoring :
ECG
NIBP
Pulse oximetry
Capnograph
Temperature
12. Special monitoring
for long procedure with potential for large volume shift,
risk of venous air embolism & pts who have
complicated medical hx, haemodynamic instability
(spinal shock) or in procedures where special
anesthetic techniques are planned like deliberate
hypotension, endoscopic surgeries
Invasive BP, CVP, urine output
Swan Ganz cathetersevere cardiac or resp dz
13. Specific monitoring
Neurologic monitoring procedures that may
compromise the integrity of the spinal cord (SC): direct
SC/ nerve damage during instrumentation, distraction
injury or reduced SC perfusion resulting in ischemia
Spinal fusion, removal of SC tumors & vascular lesion
are at more risk
Somatosensory Evoked Potential (SSEP)
Motor Evoked Potential (MEP)
Wake up test ~ adjunct (reliable)
Electromyographic monitoring (EMG)
17. Stimulate a peripheral nerve often post tibial
nerve
Detect a response with epidural or scalp
electrodes
The evoked potentials are averaged more than 2
to 3 mins to eliminate background noise then
displayed as voltage against time
Nerve injury m/be indicated by decreased
amplitude or increased latency
18.
19.
20. Transcranial electrical impulses stimulate the motor
cortex
Resulting signal detected with epidural electrodes
or as compound muscle action potentials (CMAPs)
Complement with MEP when risk of spinal artery
injury – anterior approach – ascending tract will be
intact
21. Provides snapshot of SC motor function
Surgery is stopped
Volatile/anesthetic agent switched off &
emergence allowed
Pt is asked to move their feet
If can move, anaesthesia recommenced
Assistance is needed to prevent pt movement
which may cause accidental extubation or loss of
vascular cannulae
In the event of new paraplegia, all implants should
be removed, hypotension & anaemia corrected & a
course of high dose methylprednisolone
commenced
22. Incidenceof motor deficit or paraplegia after
surgery to correct scoliosis:
Absence of SC monitoring : 3.7 – 6.9%
With intraop. monitoring : 0.5%
American Academy of Neurology: “considerable
evidence favours the use of monitoring as a safe &
efficacious tool in clinical situations where there is a
significant nervous syst risk, provided its limitations are
appreciated”
It is now considered mandatory to monitor SC function
for these types of procedures
Raw et al, BJA 2003; 91: 886-904
23. Major prob: maintenance of basic CVS monitoring
techniques during positioning of pt
Represent a stress to circulatory integrity & it is very
difficult to prevent an almost total monitoring
“blackout” as anesthetized pts are turned from the
supine to prone position (most frequently used
position)
Particular attention on neck, arms, eyes to protect
pressure-sensitive areas
24. Regardless of how well positioned at start of
procedure, on-going vigilance with regard to
position is essential because pt situation may
change after movement during wakeup test or
manipulation of the operating table
25. Prone Positioner C-Shaped Face Piece
Horseshoe Head Rest Mayfield Tongs
26. Restriction of Obstruction of Inf
diaphragm Vena Cava
by abdominal contents Decreases preload
and weight of pt against Increases perivertebral
thorax venous pressure
Create restrictive
(pronemay improve
defect
oxygenation when
Increased peak
abdomen hangs free-
inspiratory pressure
(barotrauma) chest roll or frame)
27. Complication Strategy
ETT •Reinforced tube
obstruction/malposition
Direct pressure injury •Mayfield head frame
•Ensure eyes, chin, nose are free from contact with any surface;
check vigilantly
•Pad all pressure points
•Place breasts neutrally or medially
•Keep male genitalia free of compression from bolsters or thighs
Increased •Allow for chest excursion and free abdominal movement by using
thoracic/abdominal chest & thigh rolls and/or special mattress for OR table
pressure
Peripheral nerve injury •Avoid positions known to cause pain or paresthesia when pt is
awake
•Pad axillary and ulnar neurovascular bundles
•Arms at sides when turning supine to prone
•Consider use of SSEP and MEP to monitor for brachial plexus
ischemia
•Shoulder abduction < 90° and elbows placed in flexion
28. Complication Strategy
Swelling/dependent •Judicious use of crystalloids for fluid replacement
edema of the tongue and •Check for ETT cuff leak prior to extubation
oropharynx
Vascular occlusion •Avoid extremes of cervical range of motion
•Watch for signs of jugular venous outflow
obstruction
29. Frame based table
Allows abdomen and
chest to hang freely
May allow 180
degree rotation
30. Maintains flexed
position for spinal
surgery
Intrabdominal
pressure may be
increased if
supporting pads are
not properly placed
31. Brachial plexus may be
stretched
Ulnar nerve not properly
padded
Eye damage from pressure
Nose pressure
Excessive compression to
inferior vena cava
(minimized by padding
under inf iliac spine & chest
rolls)
32. Aim: to maintain a stable anaesthetic depth allowing
for intraoperative neurophysiological monitoring
Can be achieved with various techniques
Anaesthetic technique impacts upon SC monitoring
Volatile agents, propofol & nitrous oxide all depress
SSEP and MEP
Opioids have little effect
NMB agents may reduce background noise when
using SSEP but a profound block will prevent CMAP
(Compound ms action potentials)
Decrease in BP & Temp may also depress signals
33. Any standard technique is acceptable
Consider wire reinforced tube to avoid kinking
and occlusion for prone, allows maximal
banding to remove it from surgical field and
prevent compression from retractor during
cervical surgical procedures
34. Cervical spine surgery require special
consideration for airway management
High incidence of difficult airway
20% grade 3-4 glottic visualization
Rheumatoid dz: 48% difficult intubation
Cervical fracture: 23%
Cervical tumor: 24%
Other predictor of difficult intubation include:
Upper vs lower C-spine dz
Presence of external or internal fixation devices
35. Risk of neurologic injury is more when
endotracheal intubation is attempted in patients
suffering from C-spine dz
Various studies have been made for evaluating
optimal techniques for intubating patients at risk
for cervical spine injury
No single technique has been proved to be
superior than the other
Aware that there is risk of SC injury with
laryngoscopy
Recognize the increased probability of
encountering a difficult a/way
Attention to minimizing motion of the C-spine
36. The adult cervical spine below C2 is unstable or
on the brink of instability when one of the
following conditions are met:
(i) all the anterior or all the posterior elements are
destroyed;
(ii) there is >3.5 mm horizontal displacement of one
vertebra in relation to an adjacent one on a lateral x-
ray; or
(iii) there is more than 11° of rotation of one vertebra
to an adjacent one
Above level C2, eg of unstable injuries include:
disruption of the transverse lig. of atlas (distance >3
mm in adults betw. post. corpus ant. arch of C1 &
ant. border of odontoid process
Jefferson burst fracture of the atlas following axial
loading (causes atlantoaxial instability
37.
38. StandardN2O-opioid-based technique with
NMB agent and low dose inhalational agent
supplementation (Samantaray)
Maintenance dose of anesthetics is altered –
may have altered pharmacokinetics due to:
Muscle wasting
Decreased serum albumin
Eg. Suxamethonium contraindicated in muscular
dystrophy – risk of rhabdomyolysis, hyperK,
cardiac arrest
39. Pt
at high risk for neurologic injury intraop m/be
managed with either
Induced hypertension
Maintenance of systemic BP within 10-20% of preop
values
Some centers utilize neurologic monitoring during
placements of patients in the operative position to
prevent position related injury
Type, duration and extent of surgery may guide
the approach to fluid administration & replacement
Avoid dextrose containing solution risk of worsening
neurosurgical outcome in the presence of
hyperglycemia during SC ischemia
40. Surgical procedures involving significant bone
work at multiple levels may be a/w large intraop
bld loss & higher requirement for transfusion of
bld and bld products
Strategies to reduce @ remove risk of allogeneic
transfusion:
Preop autologous donation
Acute normovolemic hemodilution
Perioperative cell salvage techniques
Deliberate hypotension
Pharmacologic interventions; tranexamic acid
41. Complexity & extent of surgery, operative time, pt‟s co-existing dzs
Bld loss/ transfusions
Complications that occurred during or immediately after surgery
Some may need post-op care in ICU
Adequacy of a/way after ETT removal
Leave ETT in place until fully awake, respond to command & able to
manage own a/way
Some leave ETT in place and spray lidocaine down trachea to prevent
or minimize coughing or bucking on ETT for about 15-30 mins
Consider inserting an a/way exchange catheter through ETT before
removal in case need of immediate reinsertion of ETT if a/way
obstruction from early/delayed swelling, bleeding or haematoma
Cuff-leak test, if any uncertainty to perform flexible fibreoptic
Spirometer on modern anesthesia machines can also be used to
quantify leakage; expired-inspired vol
42. Defer extubation Consider extubation
Inability to open eyes & not obeying Awake & obey command
commands
Agitated or combative Regular spontaneous breathing
Poor resp. efforts
O2 sat <94% O2 sat >94%
Hypercarbic (PaCO2 >50) Normocapnic (30<PaCO2<50mmHg)
Hemodynamic unstable Hemodynamic stable
Hypothermic (<36°) Normothermic
Neuromuscular blockade completely
reversed (TOF>90%, sustained head lift &
strong hand grip)
Operating time >10 hrs Operating time <10hrs
Blood transfusion >4 units Blood transfusion <4 units
Evidence of facial edema & macroglossia
-ve cuff-leak test +ve cuff-leak test
Evidence of pharyngeal & laryngeal edema No evidence of pharyngeal & laryngeal
on flexible fibreoptic bronchoscopy edema on flexible bronchoscopy
Table 50.1 Criteria for extubation following complex spine surgery in prone position,
Case Studies in Neuroanesthesia and Neurocritical Care, George A. Mashour & Ehab Farag, page
162
43. Individualized for each patient
To consider preop status, surgical procedures,
intraop cx & pain tolerance
Good post-op analgesia
LA, opioid in epidural space before closing
PCA
Oral/ rectal analgesics
44. Early
Fluid volume deficit
Neurologic injury or deficit
Dural tear with cerebral spinal fluid leakage
Anemia
Urinary retention
Ileus
Atelectasis/ pneumonia
Venous thrombosis
Specific to anterior cervical proedures: dysphagia,
hoarseness, a/way obstruction from oedema
47. Perioperative vision loss (72% of
perioperative vision loss reported are d/t
spine surgery in prone position)
perioperative ischemic optic
neuropathy rare (3/10 000)
Central retinal artery or vein occlusion
Occipital lobe infarct
Corneal abrasion most common eye
injury after spine surgery (rarely leads to
permanent vision problems)
48. Ischaemic Optic Central Retinal Artery
Neuropathy (ION) Occlusion (CRAO)
Etiology Intraop ↓ BP Direct external pressure
Prolonged surgery Emboli
↑ Blood loss
↑ Crystalloid infusion
Mechanism Ischaemia ↓ Ocular perfusion pressure
Orbital edema → stretch and
compression of ON
Clinical Painless Painless
Features Bilateral Unilateral
↓ Light perception Periorbital swelling or
↓ Visual fields echymosis
49. Lat. curvature & rotation of the thoraco-
lumbar vertebrae with a resulting rib cage
deformity
Idiopathic @ secondary to neuromuscular
dz, infection, tumor or injury
Cobb Angle > 10° considered abnormal
Surgery indicated when >40°
Restrictive lung defect & dyspnoea on
Cobb Angle
exercise: > 65°
Resp. failure, pulm. HPT, Rt heart failure:
>100°
50. Lat. curvature & rotational deformity of the thoraco-
lumbar vertebrae with a resulting rib cage deformity
occurs in up to 4% of the population
Most cases idiopathic (70%) with male:female ratio of
1:4
Idiopathic/secondary to neuromusc. dz, infection, tumor
or injury
Cobb Angle > 10° considered abnormal
Surgery: Cobb angle >50° in the thoracic, or >40° in the
lumbar spine
Restrictive lung defect & dyspnoea on exercise: > 65°
Resp. failure, pulm. HPT, Rt heart failure: >100°
51. Classification of scoliosis aetiology – taken from BJA CEACCP 2006;6:1;13-16
Idiopathic (70%) Early onset (infantile)
Late onset (juvenile)
Neuromuscular (15%) Crebral palsy
Myopathies
Poliomyelitis
Syringomyelia
Friedreich‟s ataxia
Congenital Vertebral anomalies
Rib anomalies
Spinal dyraphism
Traumatic Vertebral fractures
Radiation
Surgery
Syndromes Marfan‟s
Rheumatoid arthritis
Osteogenesis imperfecta
Mucopolysaccharide disorders
Neurofibromatosis
Neoplastic Primary tumours
Secondary tumours
Infection Tuberculosis
Osteomyelitis
52. Surgery may slow the decline in resp. fx & improve
QOL by improving posture & helping nursing care
Pts should be offered stabilization before the
cardio-resp. dysfx prevents surgery
Surgery aim to correct curve & fuse the spine,
improving posture & halting the progression of
pulm. dysfx
Approach: posterior, anterior or combined, recent –
thoracoscopy
Left untreated, idiopathic scoliosis rapidly
progresses & is often fatal by the 4th/5th decade of
liferesult of pulm. HPT, right vent. failure, or
resp. failure
53.
54. Most commonly used
Skin & supraspinous lig. are incised & paraspinal
ms reflected
The vertebral laminae are then decorticated, facet
joints destroyed & spinous processes removed
Bone graft is packed over the raw decorticated
surfaces & stainless steel rods are used to correct
the deformity & provide stability for bony fusion
(secured with pedicle screws or laminar hooks)
55. Large thoraco-abdominal incision
Exposure of vertebral bodies & removal of
intervertebral discs to allow for greater
movement
One lung ventilation is rarely necessary to
improve surgical access, except in high
thoracic curves
Combined ant & post in single operation
results in more rapid recovery & less time in
hospital
56. Take note aetiology, location & degree of
scoliosis
All pts require full hx, physical examination &
appropriate investigations focusing on CVS &
resp. system
Routine investigations Routine (blood tests ) Additional investigations
Plain CXR FBC ABG – if spirometry not
Pulm fx tests Coagulation screen possible
FEV1 and FVC Urea & electrolytes ECG & ECHO (non-
Ca & phosphate idiopathic scoliosis)
Blood cross-match
57. Good exercise tolerance & absence of resp. sx
indicates acceptable cardio-resp. reserve
Pts with more severe degrees of scoliosis > 100°,
right ventricular hypertrophy on ECG, or evidence
of right HF on examination require ECHO
Scoliosis surgery can be well tolerated despite
severe restrictive lung dz (FVC <32%)
Approx. 25% pts with idiopathic scoliosis have
mitral valve prolapse rarely of clinical
significance & antibiotic cover is given
58. Preop assessment of pt with neuromuscular ds
or immobility is more difficult
Unable to give a hx of exercise tolerance or
perform spirometry adequately
Muscular dystrophies m/be complicated by
subclinical cardiomyopathy
Duchenne muscular dystrophy: >50% have
some degree of dilated cardiomyopathy & EF
<45% by 15 yo
Need ECHO to assess left ventricular fx
Normal study does not exclude significant
pathology
59. Use of invasive monitoring lines & catheters along
with postop analgesia plan should be explained
fully to pt & family
Sedative premed. with oral midazolam (0.5mg/kg)
can be offered
Pts with Duchenne muscular dystrophy m/be on
corticosteroid therapy – require perioperative
supplementation
60. Aim to maintain stable anaesthetic depth allowing
intraop. neurophysiological monitoring
Induction by IV propofol
Non-depo NMB drug
Tracheal intubation with an armoured tracheal tube
Anaesthesia maintained by sevoflurane at 0.6 MAC
in air & oxygen
Infusion of remifentanil
Bolus of IV morphine toward the end of surgery
Suxamethoniumcontraindicated in muscular
dystrophy dt risk of rhabdomyolysis, hyperkalemia,
cardiac arrest
61. Bld loss & heat loss, potential for haemodynamic
instability
Addition to standard paediatric GA monitoring :
Invasive arterial pressure monitoring
Urinary catheter
2 large peripheral iv cannulae
Central venous cannula if significant comorbidity or
inadequate iv access
CVP may be misleading as a guide of ventricular
filling in prone position
Cardiac ouput monitoring with oesophageal Doppler
Temp monitoring + IV fluid warmers, warm air
blankets at induction and throughout procedure
62. Monitor volume status & bld loss carefully in all
pts
Regular Hb, platelet & coagulation estimations
Children with neuromuscular dz are at increased
risk of excessive bld loss: they have more
osteopenic bone & it has been suggested that
the absence of dystrophin causes vascular
pathophysiological changes
63. Careful positioning to avoid IVC compression
Prevent hypothermia
Correction of caogulopathy
Good surgical technique
Compression stockings, pneumatic boots as
thromboprophylaxis
Avoid anticoagulants
Controlled hypotension MAP 50-60 mmHg
remifentanil infusion & volatile agent w/out need for
vasodilators
Hypotension & surgical manipulation may reduce SC
perfusion & so risk neurological injury
Important to maintain continuous neurological
monitoring & adequate haematocrit to ensure oxygen
delivery
66. Good post-op analgesia essential to allow
frequent physiotherapy & early mobilization
Reduce risk of resp. complications
Multimodal approach
Combined simple analgesics, systemic opioids &
regional anaesthesia
Epidural catheter or paravertebral catheter during
an anterior correction can be placed intraop. by
the surgeon
After initial neurological assessment, a loading
dose of LA is given followed by a continuous
infusion
67. Additional analgesia is needed d/t the size of
the wound & the surgical disruption of the
epidural space
Opioids can be administered intravenously,
intrathecally or via the epidural space
Epidural infusion + CMI + regular Paracetamol
± NSAIDS
68. Good post-op analgesia essential to allow
frequent physiotherapy & early mobilization
Reduce risk of resp. complications
Multimodal approach
Combined simple analgesics, systemic opioids &
regional anaesthesia
Epidural catheter or paravertebral catheter during
an anterior correction can be placed intraop. by
the surgeon
After initial neurological assessment, a loading
dose of LA is given followed by a continuous
infusion
69. Airway assessment & management
Anticipate difficult a/way
Limited mouth opening & limited neck movement
Establish the range of symptom-free neck movement
Elicit sn & sx of possible nerve impingement or SC
compression
Pain on mastication – TMJ involvement
Increasing hoarse voice – suggest arytenoid
cartilages involvement
Atlantoaxial instability
Radiograph of cervical flexion & extension for all pts
with neurologic sx & those taking regular steroids or
dz-modifying antirheumatic drugs
70. Neutral position – to prevent damage to neurologic
structures
This m/be different for each pt & care should be taken
to enlist the pt‟s cooperation in finding the most
comfortable neck position
Extubation – gross assessment of neurologic fx had
been completed before extubating as worsening of fx
may precipitate need for urgent imaging or re-
operation
During preop need to warn pt that they may awake
with a breathing tube in place & ask to perform simple
tasks on command
Check for leak before extubation
Head-up position & use of corticosteroids may
accelerate resolution of edema
71. Autosomal dominant d/o
Melanogenic abnormalities café-au-lait macules,
freckling, hyperpigmentation
Tumor formation usually manifests in puberty
May present for surgical procedures involving
peripheral nervous syst. tumors (neurofibromas),
CNS tumors(benign optic gliomas, astrocytomas),
scoliosis or other skeletal abnormalities
Association with phaeochromocytoma
Thorough & systematic approach to pt is essential
72. Particular concern airway
Difficulties presented by cervical spine
immobilization
Neurofibromas may develop in the trachea &
resp. tree
Tracheobronchial tumors m/be asymptomatic for
many years & may present with normal chest
radiographs
Recent history of dyspnea, cough, dysphagia,
dysarthria, stridor or change in voice
Awake fibreoptic intubation
May use dexmedetomidine as sedation
preservation of resp. drive (+ fentanyl)
74. Aims to reduce ts trauma, prevent iatrogenic prob. &
preserve spinal segmental motion & stability
The most compelling advantages of endoscopic
procedures over open surgery are:
Smaller incisions & less ts trauma
Minimal bld loss
Earlier return to activities & work
Easier operative approach in obese pts
Local/regional anesthesia combined with conscious
sedation can be used
In most cases, less postop. pain medication is required
As a consequence, outpt procedures are possible
75. ENDOSCOPIC SPINE SURGERY
Indications: Contraindications:
Clinically relevant instabilities
Lumbar, thoracic & cervical Central spinal canal stenosis
disc herniations with radicular
symptoms
Relative contraindications:
Lateral spinal canal (recess) &
foraminal stenoses with Large disc herniations with
radicular symptoms cauda equina synd. or a fresh
motor deficit
Degenerative facet joint cysts
with radicular symptoms With the exception of cases with
large interlaminar windows &
good
Interlaminar endoscopic access,
adequate decompression may
not be possible
76. Many surgeons prefer GA for the traditional
techniques, but LA with or w/out conscious
sedation is an option for most endoscopic
approaches
However, one consideration should be that in a
pt in the prone position, a conversion from local
to GA would require complete abandoning of the
procedure, endotracheal intubation, repositioning
and renewed preparation of the operative field
Especially with cervical procedures, unconscious
head& neck movement are difficult to control &
may incur additional risks
79. GA
Adult & children >45kg double lumen tube
Children <45kg may require selective
intubation of the ventilated lung
Position checked by fibreoptic
Pt position in lateral decubitus then check tube
position by auscultation & fibreoptic
81. Manoeuvres are directed at minimising atelectasis in
the ventilated lung & shunt in the non-ventilated lung
Set initial VT at 10 ml/kg & adjust resp. rate to
maintain normocapnia
Use FIO2 0.5 initially & increase to 1.0 if required
Ensure proper tube position (auscultate,
bronchoscopy) & suction at regular intervals
Apply continuous positive a/way pressure to the non-
ventilated lung to expand it just enough so as not to
interfere with the surgery, thus reduce shunt
82. Application of PEEP to the ventilated lung may
reduce atelectasis but oxygenation may deteriorate
d/t increase in shunt through the other lung
Oxygenation can be insufflated into the non-
ventilated lung via a suction catheter
Alternatively, the non-ventilated lung can be
inflated briefly with 100% O2 at intervals
Persistent hypoxia that does not respond to the
above manoeuvres must be treated with
resumption of two-lung ventilation with 100% O2
Failing this, clamping of the pulmonary artery (of
the surgical lung) should improve oxygenation
83. Spinal anaesthesia in adults, D. A. Raw et. al, BJA
2003; 91: 886-904
Anesthesia for spine surgery, A. Samantaray,
Indian Anaesthetists„ Forum 2006
Scoliosis surgery in children, M.A. Entwistle and D.
Patel, Continuing Education in Anaesthesia,
Critical Care & Pain, BJA , 2006; 6: 1: 13-16
Anaesthesia for scoliosis surgery in children,
Euroanaesthesia, Glascow, Woloszczuk – Gebicka
2003
84. Clinical Anaesthesiology by G. Edward Morgan
Oxford handbook of anaesthesia by Keith G.
Allman
Yao & Artusios‟s Anaesthesiology
Intraabdominal pressure, blood loss and spinal
surgery, Anesthesia-Analgesia 2000;91:552–7
Ames et al, Local anaesthesia for laminectomy
surgery, British Journal of Neurosurgery, 1999,
Vol. 13, No. 6 , Pages 598-600
Case Studies in Neuroanesthesia and
Neurocritical Care by George A. Mashour and
Ehab Farag