Anaesthetic management of scoliosis surgery

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