airway management slides

8/3/2019 Airway Management Slides

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Anesthesia for Spine

Surgery

Irene P. Osborn, M.D.

Mount Sinai Medical Center

New York, NY


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Lecture Goals

Overview of modern concepts in

understanding of the spinal cord disease

Review controversies in anesthesia for spine

surgery

Provide strategies for improving patient care


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Why spine? 29.9 million people reported

musculoskeletal impairments.

Back/spine was most frequent,

representing 51.7%. Impairment is

most prevalent in 45-64 year old group.

AAOS, Musculoskeletal

Conditions in the U.S., Feb1992


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Changing times


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General Indications for Spine

Surgery Neurologic dysfunction (compression)

Structural instability

Pathologic lesions

Deformity

Pain


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Spinal Cord Anatomy Structure

Blood supply

Autoregulation?


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Normal C-Spine Films

Lateral view


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Typical Pathologies

Disc lesions

Spinal canal

stenosis

Tumors

Trauma


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Spinal Cord Injury: Incidence/

Etiology

10, 000 new

cases/year in US

Males> females

Causes:

MVA- 40-50%Falls- 20%

Recreational activities-

7-15%

violence


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Cervical Spine Injury Occurs in 10% of head-injured patients

Suspect when patient is flaccid, has

diaphragmatic breathing, hypotension,bradycardia

Minimize head movement during airway

management In-line stabilization, rather than in-line

traction, during laryngoscopy

Criswell JC, et al: Anaesthesia 1994; 49:900-903


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Suspected Cervical Spine Injury

Neck pain

Neurologic symptoms, signs

Unconscious

Mechanism of injury

Intoxication Spondylosis, rhumatoid arthritis

Significant head injury, facial fractures


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Secondary Injury Activation of

biochemical,

enzymatic andmicrovascular

Hemorrhagic necrosis,

edema, inflammation

Vascular stasis,decreased spinal cord

blood flow, ischemic

cell death


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Anesthetic management acute

SCI Airway evaluation

Neurologic evaluation

Pulmonary evaluation

Cardiac evaluation and resuscitation


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Neurologic Deterioration

Associated with Airway

Management in a Cervical Spine-Injured Patient

Hastings RH, Kelly SD

Anesthesiology vol 78:580, 1993


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Details Unrecognized C-

spine injury

Pt becamequadriplegic after

mask ventilation,

repeated

laryngoscopy andeventually

cricothyroidotmy

Hastings,Anesthesiology 1993


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Use of the Intubating LMA-

Fastrach in 254 Patients withDifficult to Manage Airways

Ferson DZ, Rosenblatt WH, Osborn I,

Ovassapian A.

Anesthesiology 2001 vol 95:1175


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Patients with Immobilized

Cervical Spines 70 cases

67 under general

anesthesia

2 awake/topicalized

1 unconscious

No new neurologic

deficits

Ferson et al,

Anesthesiology 2001


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Cervical spine motion: a fluoroscopic

comparison during intubation with

lighted stylet,GlideScope, andMacintosh laryngoscope.

Turkstra et al.

Anesth Analg 2005; 101: 9105


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Tracheal intubation in patients with

cervical spine immobilization:

a comparison of the Airwayscope, LMA

CTrach, and the

Macintosh laryngoscopes

M. A. Malik, R. Subramaniam, S.

Churasia1,C. H. Maharaj, B. H. Harteland J. G. Laffey

BJA 2009


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Cervical Disc: Airway

Strategies Talk to patient

H/O extremity

weakness/tingling

Elicited symptoms

with movement

Neutral position isbest


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Conditions associated with risk

of cervical spine pathology

Downs syndrome

Rheumatoid arthritis

Ankylosing spondylitis

Psoriatic arthritis

Trauma


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On the Incidence, Cause, andPrevention of Recurrent Laryngeal

Nerve Palsies During Anterior CervicalSpine Surgery

Apfelbaum RI, et al: Spine Volume 25(22), 15 November 2000, pp 2906-2912


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Laterality Right > Left

Levels Lower Cervical Level

Multiple Levels More Level Higher Incidence

ETT Pressure Higher Pressure or Failure to Deflate

FactorLeading To Possible Higher

Incidence of RLN Injury


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Risk Factors for Postoperative

Airway Compromise

Duration of surgery

Amount of blood transfusion

Obesity, airway pressure

Operations of greater than 4 cervicallevels or involving C2

Epstein NE. J Neurosurg

94:185 2001


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AnestheticT

echnique Supine induction

Maintenance with any

combination ofopioids, muscle

relaxants, volatile

agents

Careful prone

positioning


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Thorocolumbar Spine Disease Anterior or lateral

pathology

Multiple spinesegments

Scoliosis, tumors,traumatic fractures

Potential largeintraoperative bloodloss


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Methods of Reducing Blood Loss

and Limiting Homologous

Transfusions

Proper positioning to reduce intraabdominal

pressure

Surgical hemostasis

Deliberate hemodilution (?)

Preoperative donation of autologous blood


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Prone Position Restriction of

diaphragm

by abdominal contents and weight of pt

against thorax

Create restrictivedefect

Increased peakinspiratory pressure(barotrauma)

Obstruction of Inf

Vena Cava

Decreases preload Increases perivertebral

venous pressure

(prone may improve

oxygenation whenabdomen hangs free-

chest roll or frame)


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Prone Position Surgery Despite induced hypotension, some patients

continue to bleed

Pressure on the abdominal contents may be

transmitted to the inferior vena cava and to

the epidural venous system, causing

increased bleeding


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Flexed Prone Position Brachial plexus may be

stretched

Ulnar nerve not properly

padded

Eye damage from pressure

Nose pressure

Excessive compression to

inferior vena cava(minimized by paddingunder inf iliac spine andchest rolls)


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The Effect of Patient

Positioning on Intraabdominal

Pressure and Blood Loss inSpinal Surgery

CKPark

Anesth Analg 2000;91:552


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Wilson Frame Maintains flexed

position for spinal

surgery Intrabdominal

pressure may be

increased if supporting

pads are not properlyplaced


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Blood loss during spinal surgery Group 1

Blood loss (ml) 878

# of patientstransfused = 5

Fluid replacement

2175 ml

Operating time (min)

136

Group 2

Blood loss (ml) 436

# of patientstransfused = 1

Fluid replacement1865 ml

Operating time (min)134

Park Anesth Analg 2000;91


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Conclusions

IAP and intraoperative blood loss were less

in the wide vs. narrow width of the Wilson

frame

Blood loss per vertebra tended to increase

with an increase in IAP in the narrow pad

support

Park Anesth Analg 2000;91


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Jackson

Table

Frame based table

Allows abdomen and

chest to hang freely May allow 180 degree

rotation


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Lumbar spine surgery Preoperative

pain/disability

Intraoperativepositioning

Anesthetic technique

Blood loss

Postoperative pain

management


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Support Devices Head & Neck

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Surgical pillow/ foam

donut,C-shaped face

piece, horseshoe head

rest, Prone Positioner,

Prone View Helmet. C-Shaped Face Piece

Horseshoe Head Rest Mayfield Tongs

Mayfield tongs: moststable; recommended

in cervical disc disease

Prone Positioner


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Ischemic Optic Neuropathy Rare but increasing

Decreased perfusion

Increased venouspressure

Increased external

pressure

Decreased oxygen

carrying capacity

Williams, et al. Anesth Analg 1995 80:1018


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Injuries:E

ye

46

Corneal abrasions

Orbital edema

Postoperative visual loss ( POVL)

Rare; unclear etiology

ASA Closed Claims Project 12 : management of

anesthesiologists frequently implicated

ASA Professional Liability Committee created the

POVL Registry 13 in 1999

12ASA Closed Claims Project http://www.asaclosedclaims.org/13American Society of Anesthesiologists Task Force on Perioperative Blindness: Practice advisory for perioperative

visual loss associated with spine surgery: a report by the American Society


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POVL Registry

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SPINE 72%

Distribution of cases from the

ASA POVL Registry

Goal: Identify risk factors associated with POVL

Retrospective analysis of patients who reported visual loss < 7

days postop

PION 60%AION 20%

Distribution of 93 ophthalmic lesions

associated with POVL after spine surgery


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POVL

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Ischemic Optic

Neuropathy (ION)

Central Retinal Artery

Occlusion (CRAO)

Etiology Intraop BP

Prolonged surgery

Blood loss Crystalloid infusion

Direct external pressure

Emboli

Mechanism Ischemia

Orbital edema stretch

and compression of ON

Ocular perfusion pressure

ClinicalFeatures

PainlessBilateral

Light perception

Visual fields

PainlessUnilateral

Periorbital swelling or

ecchymosis

ASA Closed Claims Project


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Profound visual loss

Vision loss is usually

unilateral. Vision loss is

usually total.

Visual loss in spine

surgeries

85% Ischemic Optic

Neuropathy (ION)

11% Central retinal artery

occlusion (CRAO)

4% Other Diagnoses

www.asaclosedclaims.orOverview

Pain Management

Major Risks

Equipment

MAC

Visual Loss

Medication

Premiums



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Visual loss in spine

surgeries

85% Ischemic Optic

Neuropathy (ION)

11% Central retinal artery

occlusion (CRAO)

4% Other Diagnoses

CRAO can result from

pressure on the globe.


Pain Management

Major Risks

Equipment

MAC

Visual Loss

Medication

Premiums



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Over two-thirds of

cases reported to the

POVL Registry wererelated to spine

surgery in the prone

position.Lee LA, et al. The American Society of Anesthesiologist Postoperative

VisualLoss Registry: Analysis of 93 Spine Surgery Cases with

Postoperative VisualLoss. Anesthesiology. 2006 Oct; in press.


Pain Management

Major Risks

Equipment

MAC

Visual Loss

Medication

Premiums



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Ischemic opticneuropathy was the

most common (89%)

cause ofvisual loss

after spine surgery in

the prone position.


Pain Management

Major Risks

Equipment

MAC

Visual Loss

Medication

Premiums

Lee LA, et al. The American Society of Anesthesiologist Postoperative





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1000 ml estimated

blood loss

6 hours anesthetic

duration


Pain Management

Major Risks

Equipment

MAC

Visual Loss

Medication

Premiums

Lee LA, et al. The American Society of Anesthesiologist Postoperative



In 96% of prone positionspine cases, at least one of

the following was present:


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Postoperative Vision Loss-

Risk Factors Atherosclerotic disease

Hypotension Anemia

Excessive blood loss

Long duration of surgery Head dependent positioning

Cheng MA Neurosurgery

46:625, 2000


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Cardiovascular Support

Maintain MAP above 70 mmHg

Fluid management-blood & crystalloid

Pressors if needed


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Spine Surgery- Monitoring

Routine

Arterial line

CVP/ PA catheter

Neurophysiologic


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Monitoring the Spinal Cord

SSEP

MEP

Wake up test

EMG


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Indications for SSEPs

Spinal

instrumentation

Scoliosis correction Spinal cord

operations

Aortic surgery


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Spine surgery: Times of

Increased Risk

Spinal distraction

Sublaminar wiring

Induced hypotension

Inadvertent cord compression

Certain instrumentation (Lugue rods)

Ligation of segmental arteries


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Dorsal /

Posterior

Ventral /

Anterior

MEP

MEP

SSEP

SSEP


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Damage in the territory of the anterior

spinal artery might theoretically occur

without causing significant impairment ofthe dorsal sensory tracts, particularly when

the spine is approached from the anterior

side.May DM, Jones SJ,Crockard HA.

Somatosensory evoked potential monitoring in cervical surgery:

identification of pre- and intraoperative risk factors associated with neurological deterioration.

JNeurosurg1996;85:5667


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SSEP


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Loss of SSEP & MEP


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Caveats for MEP monitoring

You CAN intubate

with non-depolarizing

agent (there will betime for it to wear off)

When closing,

administer NMB to

allow decrease ofhypnotic agents


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Anesthetic Considerations

Patients often on chronic pain medication

Hypotension may occur with acute blood loss

Dexmedetomidine

Use perioperatively

May decrease narcotic use Hemodynamic stability

Patients comfortable postoperatively


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Pain management strategies

IV PCA

Multimodal therapy

Epidural opioids(catheter placed by

surgeon)

Cooperation with pain

service


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Lumbar spine surgery

Performed by

neurosurgeons and

orthopedics Minimally invasive

techniques


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The ProSeal laryngeal mask airway in

prone patients: a retrospective audit of

245 patients

Patients positioned prone for induction

Mask ventilation followed prone insertion Digital insertion in 237 pts,GEB technique

in 8 pts

No complications- ONLY for experienced

practitioners!

Anesth Intensive Care

2007:35


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Caveats for prone LMAs

Have good technique

Avoid light anesthesia

Position carefully andconfirm placement

tests

Have stretcher

available (just in

case!)


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Conclusions

Understand and appreciate the anatomy and

physiology of the spinal cord

Communicate with your surgeons

Explore new techniques but remember to

perfuse and monitor the patient

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