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Anesthesia for Patients with Spinal Cord Injury

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Anesthesia for Patients with Spinal Cord Injury Dr. Ashish Moderator : Dr.R.Tope www.anaesthesia.co.in anaesthesia.co.in_at_gmail.com Outcome Acute spinal injury who ... – PowerPoint PPT presentation

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Title: Anesthesia for Patients with Spinal Cord Injury


1
Anesthesia for Patients with Spinal Cord Injury
  • Dr. Ashish
  • Moderator Dr.R.Tope

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
m
2
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Blood supply
  • Two posterior spinal arteries
  • Anterior spinal artery formed by the confluence
    of two vertebral arteries
  • The lower cervical cord is a region of
    relative ischemia and is vulnerable for ischemic
    injury should the anterior spinal artery be
    compromised between the foramen magnum and C8,
    the cervical watershed.

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Spinal Cord Paralysis Levels
  • C1-C3
  • All daily functions must be totally assisted
  • Breathing is dependant on a ventilator
  • Motorised wheelchair controlled by sip and puff
    or chin movements is required
  • C4
  • Same as C1-C3 except breathing can be done
    without a ventilator
  • C5
  • Good head, neck, shoulder movements, as well as
    elbow flexion
  • Electric wheelchair, or manual for short
    distances

7
  • C6
  • Wrist extension movements are good
  • Assistance needed for dressing, and transitions
    from bed to chair and car may also need
    assistance
  • C7-C8
  • All hand movements
  • Ability to dress, eat, drive, do transfers, and
    do upper body washes
  • T1-T4 (paraplegia)
  • Normal communication skills
  • Help may only be needed for heavy household work
    or loading wheelchair into car

8
  • T5-T9
  • Manual wheelchair for everyday living
  • Independent for personal care
  • T10-L1
  • Partial paralysis of lower body
  • L2-S5
  • Some knee, hip and foot movements with possible
    slow difficult walking with assistance or aids
  • Only heavy home maintenance and hard cleaning
    will need assistance

9
Treatment of Spinal Injuries
  • No Current Effective Treatment
  • Prevention is Key
  • all current medical and surgical treatments aimed
    to prevent further injury to the spinal cord.

10
Spinal Cord Injuries
  • May occur with neck or back trauma
  • Associated with blunt head trauma, especially
    when casualty is unconscious
  • Can occur with penetrating trauma of vertebral
    column
  • Improper handling may cause further injury

11
Mechanisms of Spinal Injury
  • Hyperextension
  • Hyperflexion
  • Compression
  • Rotation
  • Lateral Stress
  • Distraction

12
Pathophysiology
  • Damage Begins centrally in grey matter and
    spreads centrifugally.
  • Primary insult B/W Time of injury and initial
    care
  • Secondary insult Delayed swelling
  • Continued
    mechanical trauma
  • Low perfusion
  • Endogenous factors
  • Initial segmental loss can be withstood because
    only small portion of grey matter neuronal pool
    is involved.

13
  • ASIA A Complete no motor or sensory function is
    preserved in the sacral segments S4-S5
  • ASIA B Incomplete sensory but NOT motor
    function is preserved below the neurological
    level and includes the sacral segments
  • ASIA C Incomplete motor function is preserved
    below the neurological level and more than half
    of key muscles below the neurological level have
    a muscle grade lt3
  • ASIA D Incomplete motor function is preserved
    w/ muscle grade gt 3
  • ASIA E Normal

14
Diagnosis and management of acute spinal cord
injury
  • Initial assessment and immobilization
  • Resuscitation and medical management
  • Radiological diagnostics
  • Anaesthesia management
  • Surgical therapy
  • Post op critical care management

15
Initial assessment and immobilization
History Pain/paresthesias Transient or
persistent motor or sensory symptoms Physical
Examination Abrasions/hematoma Tenderness Interspi
nous process widening
16
  • Immobilize the casualtys head and neck manually
  • Apply a cervical collar, if available, or
    improvise one
  • Secure patient to short spine board if extracting
    from a vehicle
  • Secure head and neck to spine board for
    extraction

17
  • Transfer patient to long spine board as soon as
    feasible
  • Logroll in unison
  • Stabilize head and neck with sandbags or rolled
    blankets

18
  • Secure casualty to long spine board with straps
    across forehead, chest, hips, thighs, and lower
    legs

19
Resuscitation and medical management ATLS
principles
  • Airway
  • Breathing
  • Circulatory
  • Neurologic Classification
  • Spinal Imaging
  • GastroIntestinal System
  • Genitourinary System
  • Skin

20
Airway
  • Risk Associated with Level of Injury
  • Decision to Intubate
  • Airway Intervention

21
Risk Associated with Level of Injury contd
  • Ventilatory Function
  • C1 - C7 accessory muscles
  • C3 - C5 diaphragm
  • C3-4-5 keeps the diaphragm alive!
  • T1 - T11 intercostals
  • T6 - L1 abdominals

22
Decision to Intubate
  • Need for Artificial Airway is Usually Related to
    Resp Compromise e.g.
  • Loss of innervation of the diaphragm
  • (C 3-4-5 keep the diaphragm alive)
  • Fatigue of innervated resp muscles
  • Hypoventilation SaO2 lt60, PaCO2 gt45
  • V/Q mismatch PaO2/FiO2 lt250
  • Secretion retention
  • Atelectasis

23
Decision to Intubate Related to Neurological
Level
  • Occiput - C3 Injuries (ASIA A B)
  • Require immediate intubation and ventilation due
    to loss of innervation of diaphragm

24
Decision to Intubate Related to Neurological
Levelcontd
  • C4-C6 Injuries (ASIA A B)
  • Serious consideration for prophylactic intubation
    and ventilation if
  • Ascending injury (requires serial M/S assessment
    by a trained clinician)
  • Fatigue of unassisted diaphragm
  • Inability to clear secretions

25
Airway Intervention
  • Maintaining Spinal Precautions
  • Supine position
  • Maintain neutral C-spine
  • Remove rigid collar and sandbags
  • Manually stabilize C-spine
  • 2 person technique
  • 1st person to provide manual in-line
    stabilization (not traction) of C-spine
  • 2nd person intubates

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Complications of cervical spine immobilization
  • Airwaydelayed tracheostomy-poor oral hygeine
  • Breathing prolonged mechanical ventillation-VAP
  • Circulationdifficult central line insertion and
    access, increased thromboembolism
  • Neurological increased ICP
  • Gut gastrostasis,reflux and aspirationdelayed
    enteral nutrition
  • Skin pressure sores around collar
  • Staffing minimum 4 for log rolling cross
    infection

28
Breathing
  • Cough Function
  • C1-C3 absent
  • C4 non-functional
  • C5-T1 non-functional
  • T2-T4 weak
  • T5-T10 poor
  • T11 below normal

29
Breathing contd
  • Vital Capacity (acute phase)
  • C1-C3 0 - 5 of normal
  • C4 10-15 of normal
  • C5-T1 30-40 of normal
  • T2-T4 40-50 of normal
  • T5-T10 75-100 of normal
  • T11 and below normal

30
Breathing contd
  • SCI Respiratory Sequale
  • Atelectasis
  • Ventilatory failure
  • (PaCO2 gt 50mmHg and pH lt 7.30)
  • Increased secretions
  • Pneumonia
  • Pulmonary emboli
  • Pulmonary edema (Autonomic)

31
Breathing contd
  • Intervention
  • O2 therapy
  • Assisted ventilation
  • Medications (bronchodilators)

32
Circulatory
  • Spinal Shock
  • Temporary suppression of all reflex activity
    below the level of injury
  • Occurs immediately after injury
  • Intensity duration vary with the level degree
    of injury
  • Neurogenic Shock
  • The bodys response to the sudden loss of
    sympathetic control
  • Distributive shock
  • Occurs in people who have SCI above T6 (gt 50
    loss of sympathetic innervation)

33
Hemodynamic Instability Intervention
  • First Line Volume Resuscitation (1-2 L)
  • Second line Vasopressors- (dopamine/norepinephri
    ne) to counter loss of sympathetic tone and
    provide chronotropic support to the heart

34
Hemodynamics and Cord Perfusion
  • Options
  • Avoid hypotension
  • Maintain MAP 85-90mmHg for first 7 days if
    possible

35
Bradycardia Intervention
  • Prevention
  • Avoid vagal stimulation
  • Hyperventilate and hyperoxygenate prior to
    suctioning
  • Pre-medicate patients with known hypersensitivity
    to vagal stimuli
  • Treatment of Symptomatic Bradycardia
  • Atropine 0.5 - 1.0 mg IV

36
Neurological Classification
  • Motor and sensory assessment
  • ASIA Impairment Scale (A-E)
  • Clinical Syndromes (patterns of incomplete
    injury)

37
Spinal Shock
  • An immediate loss of reflex function, called
    areflexia, below the level of injury
  • Signs
  • Slow heart rate
  • Low blood pressure
  • Flaccid paralysis of skeletal muscles
  • Loss of somatic sensations
  • Urinary bladder dysfunction
  • Spinal shock may begin within an hour after
    injury and last from several minutes to several
    months, after which reflex activity gradually
    returns

38
Central Cord Syndrome
  • Usually involves a cervical lesion
  • May result from cervical hyperextension causing
    ischemic injury to the central part of the cord
  • Motor weakness is more present in the upper limbs
    then the lower limbs
  • Patient is more likely to lose pain and
    temperature sensation than proprioception
  • Patient may complain of a burning feeling in the
    upper limbs
  • More commonly seen in older patients with
    cervical arthritis or narrowing of the spinal cord

39
Brown-Sequard Syndrome
  • Results from an injury to only half of the spinal
    cord and is most noticed in the cervical region
  • Often caused by spinal cord tumours, trauma, or
    inflammation
  • Motor loss is evident on the same side as the
    injury to the spinal cord
  • Sensory loss is evident on the opposite side of
    the injury location (pain and temperature loss)
  • Bowel and bladder functions are usually normal
  • Person is normally able to walk although some
    bracing or stability devices may be required

40
Anterior Spinal Cord Syndrome
  • Usually results from compression of the artery
    that runs along the front of the spinal cord
  • Compression of SC may be from bone fragments or a
    large disc herniation
  • Patients with anterior spinal cord syndrome have
    a variable amount of motor function below the
    level of injury
  • Sensation to pain and temperature are lost while
    sensitivity to vibration and proprioception are
    preserved

41
Cauda Equina Syndrome
  • Injury to the lumbosacral nerve roots w/ in the
    neurocanal resulting in areflexive bladder, bowel
    and lower limbs

42
Spine Imaging
  • the Asymptomatic Patient
  • Option - Xray not needed in alert, sober,
    compliant patient without neck pain and
    tenderness or major distracting injuries
  • Symptomatic Patient
  • Standard Ap lat and odontoid view
  • Option discontinue protection after.
  • normal and adequate dynamic radiography, or
  • normal MRI within 48hrs of injury, or
  • at the discretion of treating MD

43
  • CT myelogram Bony detail of fracture site, and
    anatomic relation of segment to spinal cord.
  • MRI anterior discs, ligamentum flava cord
    contusion.

44
GI System
  • Risk of aspiration is high d/t
  • cervical immobilization
  • local cervical soft tissue swelling
  • delayed gastric emptying
  • Parasympathetic reflex activity is altered,
    resulting in
  • decreased gut motility and
  • often prolonged paralytic ileus

45
  • GI Intervention- Nasogastric tubeIV H2 blockers
  • GU Intervention Catheterisation
  • Skin Intervention
  • Remove spine board
  • Turn or reposition individuals with SCI
    initially every 2 hours in the acute phase if the
    medical condition allows.

46
Pharmacologic Therapy
  • Methylprednisolone-controversial
  • 30mg/kg IV loading dose 5.4 mg/kg/hr (over
    23hrs) effective if administered within 8 hours
    of injury
  • If initiated lt 3hrs continue for 24 hrs, if 3-8
    hrs after injury, continue for 48hrs (morbidity
    higher - increased sepsis and pneumonia)
  • Thromboprophylaxis - LMWH, discontinued at
    3months

47
Secondary Interventions
  • Without mechanical compression on CT myelogram
    External stabilisation
  • Mean arterial pressures are kept b/w 80-90 mmHg
    and CO kept ( N/ high N )
  • Dopamine infusion may be necessary

48
Anaesthesia Management
  • Pre op assessment
  • Medical history
  • Premedication and pt. Education
  • Airway management
  • Positioning
  • Fluid requirements
  • Special intraop requirements(wake up test)
  • Post op pain and pulmonary toilet

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  • Airway evaluation
  • MP classification and range of neck mobility and
    elicitation of pain/ neurological symptom
  • Pulmonary evaluation
  • During spinal shock (3 days 6 wks)
  • ABG- assess adequacy of ventilation, intubation
    if hypoxemia or hypercapnia (on O2 mask)
  • Chronic stage
  • PFT and Chest X ray Restrictive pattern
    (FEV1FVC)

51
  • Severity of functional impairment related to
    Angle of scoliosis, No of vertebrae, cephalad
    location of curve and loss of normal kyphosis.
  • Respiratory function should be optimised
  • Treating infection
  • Bronchodilation
  • Chest physiotherapy

52
  • Cardiac evaluation
  • ECG myocardial ischemia
  • Cardiovascular instability evidenced by
    hypotension, hypertension, brady arry.
    assessment of cardiac reserve and to optimise
    circulatory volume according to cardiac function
    and peri. Vas. Tone.
  • Pacemaker persistently bardycardic.
  • High spinal cord injury initially spinal
    shock,autonomic dys,impaired LVF and later
    autonomic dysreflexia.

53
  • Neurological evaluation
  • Document preexisting deficits
  • Neurological dys may dictate intubation
    tech,monitoring and choice of agents.
  • Pharmacology
  • Altered P/K because of muscle wasting,inc volume
    of distribution,dec serum albumin

54
  • Preop preparation
  • Hb, Hct, WBC and urinalysis
  • Other tests indicated by history
  • SE, BUN, Creatinine, PT,aPTT, Platelet count,
    ECG, Chest radiograph, ABG and PFT.
  • Echo to assess LV function pulmonary artery
    pressures and stress echo in sedentary patients

55
  • Premedication
  • If anxious IV midazolam Under supervision
  • Atropine if HR lt 70 Dose 0.04mg/kg
  • H2 receptor blocker/ PPI
  • Induction
  • Unnecessary/ contraindicated for unconscious,
    recently injured patients with spinal cord trauma
    / those with severe shock.

56
  • Technique of intubation
  • Elective - fiberoptic intubation
  • Emergency MILS with rapid sequence
  • Maintenance
  • Nitrous oxide, inhalation agent

57
Positioning
  • Goals
  • Adequate surgical exposure
  • Anatomic position of extremities head
  • Avoid abdominal pressure
  • Adequate padding
  • Various positions
  • a) Prone
  • b) Supine
  • c) Sitting (obsolete

58
PRONE POSITION MOST COMMONLY USED
  • EYES
  • Corneal abrasion
  • Optic neuropathy
  • Retinal artery occlusion
  • HEAD NECK
  • Venous and lymphatic obstuction
  • ABDOMEN
  • Impaired ventilation
  • Decreased CO

59
Monitoring
Physiological Pulse oximetry Continuous ECG
monitoring EtCo2 CVP Temperature Urine
output Invasive BP Swan Ganz catheter?
  • Neurological
  • Wake up test
  • SSEP
  • Transcutaneus MEP

60
Post operative pain relief
  • NSAIDS (IM,IV,P/R)
  • IV opiods (Intermitent / continuous infusion )
  • PCA

61
Post op critical care management
  • Indications for post op ventilation
  • Preexisting NM disorder
  • Severe restrictive VC lt35
  • Obesity / RVF
  • Prolonged surgery
  • Surgical invasion of thoracic cavity
  • Blood loss gt 30ml/kg

62
post op contd Prepare for weaning
  • Adequate nutrition and metabolic state
  • Infection May be masked(Poikilothermia)
  • Optimal fluid management
  • Treat mechanical impairment to breathing like abd
    distention, tight halo cast, position
  • Psychological preperation

63
Post op contd
  • Chest Physiotherapy Postural drainage, chest
    wall percussion and vibration, tracheal
    suctioning and breathing exercises.
  • Cough Glossopharyngeal breathing and huffing.
  • Breathing exercises

64
Perioperative complications of spine surgery
  • Airway obstruction edema, hematoma,recurrent
    laryngeal nerve palsy.
  • Respiratory motor paralysis and infection
    (pneumonia).
  • Cardiovascular hypotension, bradycardia,
    arrhythmias, hypertension ( spinal cord injury,
    carotid sinus stimulation).
  • Neurological
  • Injury to nerve roots as a result of direct
    surgical
  • manipulation
  • Injury to lower cranial nerves VII, IX, X, XII
  • Injury to peripheral nerves - as a result of
    positioning
  • Injury to spinal cord .

65
  • e) Vessel injury vertebral and carotid artery
    during
  • dissection
  • f) Tracheal and oesophageal injury
  • g) CSF leaks - due to tear of dural and
    arachnoid
  • membranes can lead to meningitis,
    pseudomeningocoele, permanent CSF fistula
  • h) DVT seen in 30 of neurosurgical
    patients, especially those who had been
    paraplegic. Pulmonary embolism may occur

66
Outcome
  • Acute spinal injury who survive gt24hrs,85alive
    at 10years
  • Most common causes of death-pneumonia,
    non-ischemic heart disease (occult autonomic
    dysfn), suicide (lifelong impact of injury)



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