Scoliosis surgery can lead to several respiratory, visual, bleeding, and positioning related complications under anesthesia. This document discusses prevention strategies for these complications. It recommends preoperative breathing exercises, lung protective ventilation, fluid management, and normothermia to prevent respiratory complications. Proper positioning, blood pressure control, and fluid therapy can help prevent postoperative visual loss. The use of antifibrinolytics and careful positioning can reduce bleeding risks. Monitoring of vital signs and padding pressure points can help prevent organ injuries and neural injuries from the prone position.

1. Scoliosis Surgery: Anaesthetic
Complications
Dr. Souvik Maitra MD, DNB, EDIC
Assistant Professor
Department of Anaesthesiology, Pain Medicine & Critical Care
All India Institute of Medical Sciences, New Delhi

2. Scope
• Respiratory Complications
• Postoperative visual loss
• Bleeding
• Positioning related injuries

3. Respiratory Complications
• Pneumonia
• Pleural effusion
• Hypoxia
• Atelectasis
• Respiratory failure
Preoperative Respiratory Compromise
Prolonged Surgery
Massive Blood loss
Higher Cobb’s angle
PLoS One. 2018;13:e0207657.
Eur Spine J. 2019;28:1356-1362.

4. Prevention of POPC: Preoperative
• Incentive spirometry-
Continued postoperatively
• Deep breathing exercise
• Inspiratory muscle training
 Improved lung function
 Reduced atelectasis
Clinical benefit unproven
Cochrane Database Syst Rev. 2015;(10):CD010356.
Cochrane Database Syst Rev. 2014;(2):CD006058.

5. • Lung protective ventilation
• PEEP titration
• Maintenance of normothermia
• Goal directed fluid therapy
• Adequate reversal of NMB
Prevention of POPC: Intraoperative
Current Opinion in Anesthesiology 2017;30:399-408.
Extrapolated data from cardiac/ abdominal surgery

6. Prevention of POPC:
Postoperative
• Adequate multimodal
analgesia
• Early ambulation
• Postop CPAP- Prevention &
Management
Cochrane Database Syst Rev. 2014;(8):CD008930.

7. Cochrane Database Syst Rev. 2015;(10):CD009134.

8. Postoperative Visual Loss
• True incidence- Unknown
• ~ 0.2% after spine surgery
• 90% cases- Followed by
spine sx
• 94% cases- anesthesia
duration> 6h
Front Surg. 2017; 4: 34.

9. How to prevent?
• Proper positioning
• Blood pressure management
• Intraoperative fluid therapy
• Blood transfusion- Threshold ?
Anesthesiology. 2012;116:274-85.
Avoid direct pressure
Neutral head position
Head- above or at the level of
the heart
CVP ?
Colloids ?
Periodic checking

10. Blood Loss Prevention:
Positioning
• Positioning- Avoid increased
IAP
• Wilson Frame
• Allen’s Table
• Jackknife position

11. Antifibrinolytic
• Lysine analogue- Prevents activation of plasminogen
• Prevent fibrinolysis- ‘clot stabilizer’
• Up to ~ 50% reduction in blood loss
• EACA or Tranexamic acid
• VTE NOT increased
Global Spine J. 2020 Jan; 10: 71S–83S

12. Antifibrinolytic: Dose?
• Low dose: 10- 15 mg/kg bolus, 1-2
mg/kg/h
• High dose: 30- 50 mg/kg bolus, ~5-
10 mg/kg/h
 Reduced blood loss ~ 300- 500 ml
 Reduced RBC transfusion
J Pediatr Orthop. 2017;37:e552-e557.
High dose TXA in adults- Higher AMI & AF
Spine J. 2019;19:1690-1697.

13. Hypothermia
• Hypothermia ⇢ ? Deranged
coagulation
• Wound infection
• Prolonged awakening
• Arrhythmia
• Interfere with MEP/ SSEP
 Forced air warmer
 Warm Fluid
 Warm blood & blood products
Prevention

14. Prone Position Related Injuries
• Resp. system
↑ AwP, ↑ Oxygenation
• CVS
↓ CO, ↓ BP, ↑CVP
• Splanchnic
↑ IAP
↓ Splanchnic perfusion ⇢ Hepatic & Renal injury

15. Prevention of organ injury
Monitor
• PO2, PCO2, lactate & BE
measurement
• Hourly urine output
• Arterial blood pressure
• Respiratory system compliance
Do
 Free abdomen
 Bolster & padding- chest & pelvis
 Wilson Frame

16. Neural Injury
• Brachial plexus
• C- spine
• Ulnar nerve
Padding of pressure points
Avoid hyperextension of joints
Avoid hypotension
Neutral head position
Prevention

17. Thank You!
souvikmaitra@live.com