airway management slides
TRANSCRIPT
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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
44
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
47
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
48
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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ASA Closed Claims Project
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
ASA Closed Claims Project
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ASA Closed Claims Project
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.
www.asaclosedclaims.orOverview
Pain Management
Major Risks
Equipment
MAC
Visual Loss
Medication
Premiums
ASA Closed Claims Project
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ASA Closed Claims Project
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.
www.asaclosedclaims.orOverview
Pain Management
Major Risks
Equipment
MAC
Visual Loss
Medication
Premiums
ASA Closed Claims Project
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ASA Closed Claims Project
Ischemic opticneuropathy was the
most common (89%)
cause ofvisual loss
after spine surgery in
the prone position.
www.asaclosedclaims.orOverview
Pain Management
Major Risks
Equipment
MAC
Visual Loss
Medication
Premiums
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.
ASA Closed Claims Project
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ASA Closed Claims Project
1000 ml estimated
blood loss
6 hours anesthetic
duration
www.asaclosedclaims.orOverview
Pain Management
Major Risks
Equipment
MAC
Visual Loss
Medication
Premiums
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.
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