Spine-1 - ANESTHESIA FOR PEDIATRIC SPINAL SURGERY Dr...

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Unformatted text preview: ANESTHESIA FOR PEDIATRIC SPINAL SURGERY Dr Deborah Elkon S colios is – one or more a bnorma l la te ra l, rota tiona l curve of the s pine Kyphos is – a n a bnorma l pos te rior d e via tion of the s pine R ib hump C OBB’S ANGLE Me a s ure s s e ve rity Inte rs e cting a ngle be twe e n line s dra wn from uppe r a nd lowe r s urfa ce s of ve rte bra e a t the e nd of the curve 1 00 C a us e s of S colios is • Idiopathic – Infantile – Juvenile – Adolescent • Congenital – Vertebral abnormalities • Neuromuscular – Neuropathic • UMN eg CP, tumour, trauma, syringomyelia, degenerative • LMN eg polio, meningomyelocoele – Myopathic • muscular dystrophy • myotonia dystrophica C a us e s of S colios is • Neurofibromatosis • Mesenchymal – Congenital eg Marfan’s – Acquired eg Rheumatoid • Traumatic – fractures, surgery, irradiation • Extraspinal contractures – post-burns, post-empyema • Bone infections • Metabolic – rickets, osteogenesis imperfecta • Non-structural – postural, hysterical T he Hippocrate s s olution The m o d e rn e q uiv ale nt K alib is s p lint Mo uld e d o rtho tic Harring to n ro d s w ith Luq ue w iring R e s pira tory Abnorma litie s • • • • • • • Lung v o lum e s re d uc e d Co m p lianc e d e c re as e d Re s tric tiv e p atte rn Ab no rm al V/Q S hallo w , rap id b re athing Alv e o lar hy p o v e ntilatio n Hy p o xe m ia PROGRES S ION OF RES PIRATORY DIS EAS E WITH INCREAS ING DEGREE OF S COLIOS IS < 10 no rm al > 25 inc re as e d PA p re s s ure s > 40 s urg e ry c o ns id e re d > 65 re s tric tiv e lung d is e as e > 100 e xe rtio nal d y s p no e a > 120 alv e o lar hy p o v e ntilatio n NEUROMUS CULAR S COLIOS IS – s e v e re re s p irato ry d y s func tio n - w o rs e d e fo rm ity - w e ak re s p m us c le s - ine ffe c tiv e c o ug h, unab le to c le ar s e c re tio ns - inc o o rd inate s w allo w ing , im p aire d airw ay d e fe nc e s - im p aire d c e ntral re s p d riv e - e xag g e rate d re s p d e p re s s ant e ffe c t o f d rug s - im m o b ile , re tain s e c re tio ns - re c urre nt c he s t infe c tio ns C ARDIOVAS CULAR ABNORMALITIES • Pulm o nary Hy p e rte ns io n – Chro nic hy p o xia – Re d uc e d flo w thro ug h c o m p re s s e d lung – Im p aire d d e v e lo p m e nt o f p ulm v as c b e d • Co r Pulm o nale • Card iac Failure O the r Ca rdiova s cula r As s ocia tions • Id io p athic s c o lio s is - m itral v alv e p ro lap s e • Mus c ular d y s tro p hy - c ard io m y o p athy , a rrhy thm ias • My o to nia - d y s rhy thm ias , c o nd uc tio n a b no rm alitie s , m v p P re -ope ra tive Eva lua tion • His to ry & e xam inatio n - ty p e o f s c o lio s is , a s s o c . p ro b le m s ( ne uro m us c ular, airw ay , G IT, MH, late x alle rg y ), re s p and c ard iac • CXR , ECG, Blo o d te s ts • S p ine Xray – s e v e rity & lo c atio n • Ec ho c ard io g ram • Lung Func tio n Te s ting (if re d uc e d ET o r s e v e re d e fo rm ity ) – Lung v o lum e s (>40% re d uc tio n ~ p o s t-o p c o m p lic s ) – Flo w v o lum e lo o p – ABG S P INAL CORD MONITORING 1. The Wake Up Te s t 2. S o m ato s e ns o ry Ev o ke d Po te ntials (S S EPS ) 3. Mo to r Ev o ke d Po te ntials (MEPS ) THE WAKE UP TES T • Mo nito rs m o to r func tio n, s im p le to p e rfo rm • Dis c o ntinuo us • Pro b le m s - e xtub atio n/line s /hard w are , a ir e m b o lis m , aw are ne s s , fals e ne g . • Co ntaind ic atio ns – p are s is , unc o o p . • Mo d ifie d fo r us e in s m all c hild re n (w ithd raw al to te tanic s tim ulus ) S OMATOS ENS ORY E VOKED P OTENTIALS • Co ntinuo us • S e ns o ry trac ts • Late nc y (> 0.2m s e c s ) • Am p litud e (> 50% d e c re as e ) • Co rtic al o r S p inal S p inal S S EPS m o nito re d fro m d iffe re nt s ite s The Effe c t o f Ane s the tic Ag e nts o n S S EPS MOTOR EVOKED POTENTIALS - S tim ulate m o to r c o rte x o r s p inal c o rd - s p ine , ne rv e , o r m us c le m e p s - m ulti-p uls e s tim ulatio n - inhib itio n b y ane s the tic ag e nts P ATIENT P OS ITIONING • S up ine , Late ral o r Pro ne • Airw ay – ETT d is lo d g e o r kink – Ed e m a and p o s t-o p s trid o r afte r p ro lo ng e d s urg e ry • Ve ntilatio n – Lim ite d c he s t e xp ans io n – De c re as e d c o m p lianc e – Mus t ke e p ab d o m e n fre e P ATIENT P OS ITIONING • He m o d y nam ic – De c re as e d v e no us re turn – Inc re as e d b le e d ing • Pe rip he ral Ne uro p athie s – Brac hial, ulnar, fib ular • Ey e s – Is c he m ic o p tic ne uro p athy – Co rne al ab ras io ns P ATIENT P OS ITIONING • Pre s s ure p o ints • Blo o d v e s s e ls – Arte rial o r v e no us o c c lus io n o f the u p p e r lim b – Kinke d fe m o ral v e in • Air e m b o lis m BLOOD LOS S • Exte ns iv e d e c o rtic atio n o f b o ne c aus ing e xc e s s iv e b le e d ing • Plan to ad d re s s this p ro b le m • S urg ic al s kill and s p e e d are c ruc ial • Po s itio ning and v e ntilatio n MINIMIZING BLOOD LOS S 1 . Ad e q uate v e no us ac c e s s 2. Mo nito r b lo o d lo s s 3. Po s itio ning - ab d o m e n fre e and le g s s lig htly down 4. Ve ntilatio n - av o id hig h airw ay p re s s ure s & PEEP - n o rm o c ap nia av o id s v as o d ilatatio n 5. S urg ic al - s ub c ut e p ine p hrine ( 1: 500,000 ) - m e tic ulo us c aute ry MINIMIZING BLOOD LOS S - CONT 6 . Pre -o p b lo o d d o natio n - a ny ag e o r w e ig ht - Hb > 11 - 10% o f EBV - Fe s up p le m e ntatio n +/-- e ry thro p o ie tin - re ac tio ns and trans fus io n e rro rs 7. Ac ute no rm o v o le m ic he m o d ilutio n (ANH) - B le e d to Hc t o f 25-28% - V = EBV x (init Hc t – final Hc t) / av Hc t - re p lac e w ith c ry s tallo id o r c o llo id - re infus e in re v e rs e o rd e r MINIMIZING BLOOD LOS S - CONT 8. Blo o d s alv ag e - >10 kg , e xp e c t >20% EBV lo s t - p late le ts and c lo tting fac to rs lo s t 9. De lib e rate hy p o te ns io n - ? lo w e r lim it o f MAP - h y p o te ns io n and p re s s ure c an c aus e c o rd is c hae m ia - A NH and d e lib hy p o te ns io n s afe 10. DDAVP - 0 .3ug /kg iv i o v e r 30 m ins - n o t s ho w n to re d uc e b lo o d lo s s MINIMIZING BLOOD LOS S - CONT 11. Ap ro tinin (Tras y lo l) - S e rine p ro te as e inhib ito r (p las m in, try p s in, k allikre ins ) ; fro m b o v ine lung - Re d uc e s b lo o d lo s s and trans fus io n - Do s e e ffe c t - Co m p lic atio ns - anap hy laxis - ? t hro m b o s is - Lo w ris k v s Hig h ris k p atie nts - C o s t e ffe c tiv e ne s s and ris k-b e ne fit v s allo g e nic b lo o d MINIMIZING BLOOD LOS S - CONT 12. Ep s ilo n am ino c ap ro ic ac id (Am ic ar) Flo re ntino -Pine d a (S p ine 2004) - All id io p athic s c o lio s is - 100m g /kg o v e r 20m in, the n 10m g /kg /h - S tric t trans fus io n trig g e rs - De c re as e in p e rio p b lo o d lo s s and trans fus io n Othe r s tud ie s hav e s ho w n le s s e ffic ac y than A p ro tinin MINIMIZING BLOOD LOS S - CONT 13. Trane xam ic Ac id (Cy c lo kap ro n)) Po te nt analo g ue o f EACA ; b lo c ks ly s ine b ind ing s ite o f p las m ino g e n, p las m in and tp a ~ d e c r fib rino ly s is and c lo t d e g rad atio n Ne ilip o v itz (Ane s th Analg 2001) - 4 0 p e d iatric p o s t. s p inal fus io n p atie nts - 1 0m g /kg o v e r 15m in, the n 1m g /kg /h - t rans fus io n trig g e r 7 g /d l - 2 8% le s s b lo o d in TXA p atie nts v s p lac e b o - n o ad v e rs e e ffe c ts Ma na ge me nt of P os t-op P a in PCA > 6 y e ars Intrathe c al o p iate s p re -e m p tiv e ly o r n e ar the e nd o f s urg e ry Ep id ural c athe te r at the e nd o f s urg e ry No NS AIDS x 24 ho urs ...
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