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Anaesthetic consideration in patients with spinal injury

Dr. A ChoDept. A&IC, PWH

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Spinal cord trauma

TimingAcute(upto 3 days)IntermediateChronic(> 3 months)

LevelHigh(higher than T7), LowAbove or below C4

Other associated injuries

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Acute injury

Suxamethonium (depolarizing muscle relaxant)

May be used in first 24 to 48 hoursTo be avoided after the acute stageOtherwise hyperkalemic cardiac arrest can occur

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High level acute injury

Spinal shockSpinal cord below lesion is areflexicPeripheral vasodilataionHypotension Level above T1 to T5, bradycardia is commonRecovery starts in first 24 hrsComplete recovery takes several weeks

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Cervical injuries

Above C4respiration compromised

Below C4some loss of diaphragmatic functionVentilation usually preserved

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Difficult airway

Risk of permanent neurological damage during intubationProblem presented by traction device & collar

Awake fibreoptic intubationAsleep

In line immobilizationFibreopticIntubating laryngeal mask

Spine table

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Awake fibreoptic intubation

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Two dedicated suction

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Warm fluid to soften ET tube

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Lignocaine through suction channel

2 mls lignoacine, 2 mls airClamp suction just prior to injectionInject immediately when larynx position correctInject forcefully to creat a jet of fluid

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Asleep- Fibreoptic mask

If patient is asleep and needs ventilation during fibreopticintubation

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Fibreoptic mask

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Thin membrane can be cut for ET tube to pass through

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Intubating laryngeal mask

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Inserted with minimal movement of neckSilicone ET tube passed though LMA

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Spine table

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Goals of anaesthesiaMaintain blood pressure

Art. lineMinimize bleeding

Low intrathoracic pressureGood oxygenation

Normal CO2Protection of pressure points

eyes, neck, nervesDVT prophylaxisAvoid hypo/hyperthermia

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Maintain blood pressure

Pressure transducer at level of spinal cord

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Figure 4. Branches of the segmental artery. Each intercostal or lumbar arterysplits into several branches as it comes around the vertebral body. One branch enters the foramen alongside the spinal root and splits into dural branches and a radicular artery. At most levels, the radicular artery connects to the posterior spinal artery.

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Minimize bleeding

Make sure abdomen is free from pressureLowest possible intrathoracicpressureLow pressure in epidural veins

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Prone position- eyes

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Neck position

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Positioning

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Supine position

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Ulnar nerve

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Sequential compression device

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Hypo/hyperthermia

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Monitoring

Wake up testSomatosensory Evoked Potentials (SEPs)Motor evoked potential(MEPs)

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Wake up test

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Somato-sensory evoked potential

Median nerve or post tibial nerve stimulatedMonitoring

by scalp surface electrodesepidural intrathecal

affected by inhalational agents, temp, hypoxia, hypotension, anemia, hypercapnia

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Motor evoked potential

Motor cortex stimulated by scalp surface electrodesSignals monitored at spinal cord, peripheral nerve, or muscleaffected by all anaesthetics, muscle relaxants, etc.

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Extubation

Swollen airwayRespiratory compromiseSurgical haematoma

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Extubation over exchange catheter

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Chronic spinal injuries

Autonomic dysreflexiaMass reflexDifficult airway-previous operationRespiratory compromisePressure soresRenal problemsLack of temperature regulation ability

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Autonomic dysreflexia

Acute sympathetic activity in response to stimulus below level of high(>T7) spinal cord lesionStimulus

hot, cold cutaneous stimulusurine cath, bladder irrigation, retentionenema, PRsurgical procedure

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Signs hypertensionbradycardia, arrhythmiasweating, gooseflesh

Symptomssevere headache, blurred visionsweatingnausea

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Additional signsconvulsion, LOCcessation of respirationvisual field defectsCVA

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Mass reflex

Uncontrolled hyperreflexic spasms of musclecaused by hyperactive spinal reflexes controlling muscle toneNeed gentle handling

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End