Download - Anaesthesia for spine surgery
ANAESTHESIA FOR SPINE SURGERY
BASSEY, A. E.
OUTLINE INTRODUCTION BRIEF ANATOMY OF THE SPINE INDICATIONS FOR SPINE SURGERY TYPES OF PROCEDURES PREOPERATIVE EVALUATION PREMEDICATION INDUCTION AND INTUBATION POSITIONING MONITORING MAINTENANCE TRANSFUSION MANAGEMENT EMERGENCE AND EXTUBATION POSTOP CARE COMPLICATIONS CONCLUSION
INTRODUCTION
SPINE SURGERIES ARE A WIDE VARIETY OF PROCEDURES, THEY PRESENT DIVERSE CHALLENGES TO THE ANAESTHETIST
4.6 MILLION INDIVIDUALS IN THE USA WILL REQUIRE SPINE SURGERY IN THEIR LIFETIME
SKILFUL ANAESTHETIC MANAGEMENT IS INDISPENSABLE TO OBTAINING BEST OUTCOME
BRIEF ANATOMY OF THE SPINE
BRIEF ANATOMY OF THE SPINE
INDICATIONS FOR SPINE SURGERY
NEUROLOGIC DYSFUNCTION (COMPRESSION) STRUCTURAL INSTABILITY (ABNORMAL
DISPLACEMENT) PATHOLOGIC LESIONS (TUMOUR, INFECTION) DEFORMITY (ABNORMAL ALIGNMENT) PAIN(DISCOGENIC, FACETOGENIC etc)
INDICATIONS
INDICATIONS
INDICATIONS
TYPES OF PROCEDURES
OPEN SURGERY MINIMAL ACCESS
THORACOSCOPIC APPROACH LAPAROSCOPIC APPROACH
PROCEDURES
PROCEDURES
PREOPERATIVE EVALUATION
HISTORY PATHOLOGY – SITE, NATURE PROCEDURE – TYPE, DURATION, APPROACH CO-MORBIDITIES – HTN, CCF, CAD, ASTHMA, RTI DRUGS – ASPIRIN COUNSELLING – COMPLICATIONS, INTRAOP TESTS
EXAM AIRWAY – MOUTH OPENING, MALLAMPATI, NECK ROM?,
PREDICTORS OF DIFFICULT INTUBATION PULMONARY – DYSPNOEA, INFECTION, ASTHMA CVS – DYSFXN MAY BE DUE TO MEDICAL DX, HIGH
CERVICAL PATHOLOGY NEUROLOGIC – FULL EXAM & DOCUMENT DEFICITS MSS - SPINE
PREOPERATIVE EVALUATION
INVESTIGATIONS FBC, EUCr, URINALYSIS, CLOTTING PROFILE CVS – ECG, ECHO PULMONARY – CXR, ABGs, SPIROMETRY (esp. in
elderly, deformities, one-lung ventilation) C-SPINE PATHOLOGY – XRAY C-SPINE
PREMEDICATION
DEPENDENT ON CLINICAL STATUS USE OF OPIOIDS IN PATIENTS AT RISK OF
PULMONARY DYSFUNCTION HAEMODYNAMIC INSTABILITY
INDUCTION AND INTUBATION
INDUCTION INTRAVENOUS OR INHALATIONAL?
PT’S CLINICAL CONDITION AIRWAY C-SPINE STABILITY
MUSCLE RELAXATION CONSIDER INTRAOP MONITORING
INDUCTION AND INTUBATION INTUBATION
AWAKE OR ASLEEP,BOTH SUITABLE. NO EVIDENCE TO PROVE OTHERWISE. HOWEVER, WHILE AWAKE – NEURO EXAM POSSIBLE
DIRECT LARYNGOSCOPY: INTUBATION CAN BE ACHIEVED WITHOUT ANY NECK MOVEMENT (MANUAL IN-LINE STABILIZATION OR A HARD COLLAR)
FIBER-OPTIC LARYNGOSCOPY: FIXED FLEXION DEFORMITIES INVOLVING UPPER T-SPINE/C-SPINE, PTS WEARING STABILIZATION DEVICES SUCH AS HALO VESTS, LIMITED MOUTH OPENING
CONSIDER USE OF WIRE-REINFORCED ETT TO MINIMISE RISK OF KINKING
ENSURE PT’s C-SPINE IS STABLE BEFORE ETT
INDUCTION AND INTUBATION
METHODS C-SPINE MOTION
INTUBATION DIFFICULTY
TIME REQUIRED
RIGID COLLAR NIL
INLINE STABILIZATION
AXIAL TRACTION
BLIND NASAL INTUBATION
RETROGRADE INTUBATION
POSITIONING – PRONE COMMONEST POSITION FOR SPINE SURGERY INDUCTION AND INTUBATION IN SUPINE POSITION TURN PRONE AS A SINGLE UNIT REQUIRING AT LEAST
FOUR PEOPLE NECK SHOULD BE IN NEUTRAL POSITION HEAD MAY BE TURNED TO THE SIDE NOT EXCEEDING
THE PATIENTS NORMAL RANGE OF MOTION OR FACE DOWN ON A CUSHIONED HOLDER.
ARMS SHOULD BE AT THE SIDES IN A COMFORTABLE POSITION WITH THE ELBOW FLEXED (AVOIDING EXCESSIVE ABDUCTION AT THE SHOULDER)
CHEST SHOULD REST ON PARALLEL ROLLS (FOAMS) OR SPECIAL SUPPORTS (FRAME) TO FACILITATE VENTILATION
CHECK ORAL ENDOTRACHEAL TUBE, OTHER ATTACHMENTS
CHECK BREATH SOUNDS BILATERALLY
POSITIONING
ORGAN/SYSTEM
COMPLICATION COMMENTS
AIRWAY ETT KINKING/DISLODGEMENT
VIGILANCE, REINFORCED ETT
NECK CERVICAL ROTATION-COMPROMISED BLD TO BRAIN
PROPER POSITIONING
EYES CORNEAL ABRASION, POVL EYES TAPED SHUT. AVOID EYE COMPRESSION, HYPOTENSN
ABDOMEN COMPRESSION-HYPOVENTILATION, BLD LOSS
USE SOFT SUPPORTS
UPPER LIMBS U NERVE COMPRESSION
LOWER LIMBS DVT, FOOT DROP
PRESSURE SORE FOREHEAD, NOSE, EAR
DETACHED MONITORS
POSITIONING
SITTING POSITION : GOOD DRAINAGE, CLEAR FIELD BUT RISK OFAIR EMBOLISM
MONITORING
STANDARD VITALS, ECG, SpO2, CAPNOMETRY, BLOOD LOSS,
URINE OUTPUT
SPECIFIC SSEP MEP EMG WAKE-UP TEST MULTIMODAL
MAINTENANCE
MAINTAIN A STABLE ANESTHETIC DEPTH POSITIONING OF PATIENT, CHECK AIRWAYS AVOID SUDDEN CHANGES IN ANESTHETIC DEPTH
OR BP MAINTAIN A CONSTANT DEPTH OF NMB MAINTENANCE OPTIONS
0.5 MAC ISOFLURANE / HALOTHANE CONTINUOUS INFUSION OF PROPOFOL CONTINUOUS REMIFENTANYL OR BOLUS OPIOIDS DESFLURANE-REMIFENTANYL
CONTROLLED HYPOTENSIVE ANAESTHESIA
TRANSFUSION MANAGEMENT
SIGNIFICANT BLOOD LOSS MAY OCCUR EBL IN AP DEFORMITY CORRECTION IS 3 – 5L TECHNIQUES TO REDUCE NEED FOR
HOMOLOGOUS BLOOD TRANSFUSION PREOPERATIVE AUTOLOGOUS DONATION INTRAOPERATIVE BLOOD SALVAGE HYPOTENSIVE ANAESTHESIA ANTIFIBRINOLYTIC THERAPY
EMERGENCE AND EXTUBATION PATIENT MADE SUPINE THOROUGH ENDOTRACHEAL AND ORAL
SUCTION OXYGENATED WITH 100% OXYGEN REVERSAL AGENTS – IV NEOSTIGMINE +
ATROPINE LEAVE ETT INSITU TILL PT IS
FULLY AWAKE OBEYS COMMANDS ABLE TO PROTECT HIS AIRWAY
SOME MAY REQUIRE ICU CARE POST OP
POSTOPERATIVE CARE
MOST SPINE SURGERY IS PAINFUL INTRAOP, INSTILL LA + OPIOIDS INTO
EPIDURAL SPACE BEFORE CLOSURE POST OP PCA + ORAL/RECTAL ANALGESICS
ARE BENEFICIAL
POSTOPERATIVE COMPLICATIONS
EARLY HYPOVOLAEMIA NEUROLOGIC DEFICIT DURAL TEAR WITH CSF LEAKAGE ATELECTASIS PARALYTIC ILEUS URINE RETENTION DVT
LATE INFECTION DEHISCENCE SPINAL INSTABILITY IMPLANT FAILURE EPIDURAL FIBROSIS
CONCLUSION
PATIENT UNDERGOING SPINE SURGERY PRESENT DIVERSE CHALLENGE TO THE ANESTHETIST.
OPTIMAL MANAGEMENT DEPENDS ON THE ANESTHESIOLOGIST UNDERSTANDING THE PATHOLOGIC PROCESS AND THE RISKS AND DEMANDS OF THE OPERATIVE PROCEDURE.
THANK YOU
REFERENCES URBAN, M K. ANAESTHESIA FOR ORTHOPAEDIC
SURGERY IN MILLER’S ANAESTHESIA (7TH ED) (CH. 70). ELSEVIER
www.theiaforum.org Regan JJ, Yuan H, McAfee PC: Laparoscopic fusion
of the lumbar Spine: minimally invasive spine surgery. A prospective multicentre study evaluating open and laparoscopic lumbar fusion. Spine 24:402-411, 1999.
Chiu JC, Clifford TJ, Green span M, Richley RC,Lohman G,Sison RB : Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty Mt Sinai J Med 67: 278-282,2000.
Rosenthal D, Dickman CA: Thoracoscopic microsurgical excision of herniated thoracic discs J Neurosurg 89: 224-235, 2000.
REFERENCES Zeidman, S., Ducker, T. & Raycroft, J.. Trends and
complications in cervical spine surgery: 1989-1993. Journal of Spinal Disorders, 10(6), 523-526, 1997.
McNeill, T, & Andersson, G. (1997). Complications of degenerative lumbar spine surgery. In Bridwell, K. & DeWald, R. (Eds), The textbook of spinal surgery. (2nd Ed.) (pp 1669-1678) Philadelphia: Lippincott-Raven Publishers.
Shu-Hong Chang, Neil R. Miller. The Incidence of Vision Loss due to Perioperative Ischemic Optic Neuropathy Associated With Spine Surgery: The Johns Hopkins Hospital Experience. Spine. ; 30 (11): 1299-1302, 2005. ©2005 Lippincott Williams & Wilkins.