Spinal Fusion Protocol
Flowerdew, January 2009
majority of these patients tend to be relatively healthy ASA I-II
adolescents (mostly female). However,
we are starting to see an increase in the number of more complicated
patients such as spastic cerebral palsy with or without other congenital
conditions. The operative
course as well as the post-operative management tends to differ between
these two groups and perioperative planning needs to take into
consideration these differences. Historically,
we have done 20 pediatric cases per year, but the surgeons have
expressed interest in increasing their volume.
Most of these patients are seen day of surgery.
At 70o curvature patients start to manifest objective
restrictive pulmonary disease during function testing, however, they are
usually asymptomatic. When
curvature approaches 110o patients can have significant
restrictive function and start to become symptomatic.
Acute pulmonary problems such as asthma exacerbations or
respiratory tract infection warrant postponement of surgery (regardless
of overall health and deformity).
The need for intraoperative wake-up test should be discussed with
surgeon prior to start of case. If
a wake-up test is to be done, the patient (and family) should be
informed about such test and the very unlikely chance of recall during
this time. The patient will
probably require reassurance that the wake up is very brief, they will
be comfortable, and they will quickly be put back to sleep.
— CBC, Coags, Type and Cross (2 units of PRBC should be
available), any disease specific testing as required.
— PFTs if curvature > 70o, cardiac evaluation if
known CHD, metabolic disorders, or muscular dystrophies.
— Per anesthesia provider
agents and route per individual provider.
OR should be warmed prior to entering.
Antibiotics per surgeon.
— Standard ASA monitoring including temperature and urine output.
Somatosensory evoked potentials
(SSEP) and Motor evoked
potentials (MEP) are becoming standard of care at many centers and
are being used on most cases at MMC.
— Minimum 2 peripheral IVs, one large bore (18g min, preferably
— Arterial line is required.
Central venous line is not required on healthy adolescents
with good access. If
difficult IV access or the patient has significant developmental or
behavioral issues, central venous line is recommended (helps with
post operative management). Direct
visualization using ultrasound is strongly recommended when
placing central lines (we have had several difficult line placements
recently). There is a
SiteRite ultrasound machine and sterile sleeves/ultrasound gel
available from the equipment room outside of OR room 4.
A Bair Hugger should be used during line placement — an
upper body Bair blanket can be used as a full body blanket for line
placement and then reused as an upper body blanket for the case.
— Jackson table with arms abducted/flexed above head is the usual
head rest and mirror recommended (if appropriate fit) with careful
attention to pressure points, particularly eyes.
Great care should be taken to examine any pressure points
(ECG leads, cables, IV connectors, etc.) and padded appropriately.
MANAGEMENT: These cases
take 6-10 hours depending on complexity and number of levels covered.
Blood loss can be extensive (greater than 1 blood volume) and
actual loss difficult to calculate.
Cell saver is routinely used.
Blood product transfusions are common.
An intraoperative wake-up test is frequently requested even when
SSEP and MEP are used. The
surgeons will normally give adequate warning (30 min) as to when they
desire the wake-up test. Wake-up
tests are not usually requested on kids who are unlikely to be able to
easily follow commands.
— Multiple strategies and techniques may be used to maintain
general anesthesia. Aside
from providing adequate depth of anesthesia, conditions should be
such that SSEP and MEP monitoring is optimal and a wake-up test
easily accommodated if requested.
After intubation muscle relaxation should be avoided.
N2O should also be avoided as it completely wipes
out MEP. Inhalations
agents (Isoflurane and Sevoflurane) have a progressive deleterious
effect on SSEP and MEP as concentrations rise above 0.5 MAC.
Narcotics, midazolam, and propofol have little effect on SSEP
and MEP monitoring. Recommended
maintenance anesthesia (unless contraindicated):
gtt — 0.1-0.4 mcg/kg/min
gtt — 90-150 mcg/kg/min
above anesthetic generally provides a very smooth and stable hemodynamic
course with a mild degree of induced hypotension (MAP 60-65mmHg). In order to facilitate the wake-up test, the propofol and
isoflurane are turned off approximately 10 minutes prior to test.
Remifentanil can be reduced to 0.05-0.03 mcg/kg/min approximately
5 minutes prior to test and result in adequate conditions for wake up
— Blood volume should be calculated for each patient.
Blood gases are recommended every 2 hours, more frequently if
clinical concerns warrant such.
When blood loss approaches 50% of blood volume a STAT cardiac
coagulation panel should be sent.
If surgical field conditions demonstrate any evidence of
impaired coagulation, the cardiac coagulation panel should be sent
earlier. Patients with
spastic cerebral palsy or other congenital disorders may display a
higher propensity to develop coagulopathies as will patients who are
hypothermic. The use of
cell saver is effective at partially restoring red blood loss,
however, factors and platelets are not restored with the cell saver
transfusion. In the
setting of heavy cell saver transfusion (i.e. blood loss) the
patient is at risk for developing a coagulopathic state from
depletion of factors and platelets compounded by a volume
resuscitation dilutional effects.
Several ongoing studies are looking at the use of tranexamic acid (not available at MMC at present) or aminocaproic acid (Amicar) to
help reduce blood loss. Rainbow
Babies and Childrens Hospital has been using Amicar for the
past 10 years and has published 5 studies that demonstrate decreased
blood loss and transfusion rates for idiopathic scoliosis repairs
without any complications related to Amicar.
Unless contraindicated (active DIC, thrombosis, PE,
bradycardia) we should plan on using Amicar for these cases. Dose as follows:
aminocaproic acid (Amicar) 100mg/kg (5g max) loading dose over 15
min, followed by 10mg/kg/hr infusion (page CVAT for assistance).
Most of these patients should be able to be extubated in OR.
All pediatric scoliosis cases are booked with post-operative SCU
beds regardless of airway status. Consideration
should be given to the potential for significant facial and upper airway
— All these patients should receive dexamethasone and zofran
- The surgeons typically will place an epidural catheter intraop.
Several studies have shown that placing 2 epidural catheters
(thoracic and lumbar) provides better relief when compared to a
single catheter and has significantly less side effects when
compared to narcotic based techniques.
We have used 2 catheters at MMC on extensive repairs with
CATHETER - Bolus with bupivacaine 0.25% (0.3mg/kg up to max
15mg) prior to emergence and follow with infusion of bupivacaine
0.125% (0.4mg/kg/hr up to max of 15mg/hr).
CATHETER — Total bupivacaine bolus dose (bupivacaine 0.25%
0.3mg/kg up to max of 15mg) and infusion rates (bupivacaine
0.125% at 0.4mg/kg/hr up to max of 15mg/hr) are the same as
single catheter, but divided
, half in the thoracic catheter and half in the lumbar catheter.
If Remifentanil is used there is an increased risk of hyperalgesia.
Giving morphine 100mcg/kg over the last 30 minutes of the case
helps decrease the incidence.
Patients may require an additional 100mcg/kg in 5-10
minutes after the Remifentanil has been turned off.
Morphine PCA combined with an epideral is usually effective
at controlling pain postoperatively.
In the kids who are unable to use a PCA, morphine infusions
20-30mcg/kg/hr with nursing administered morphine boluses 50mcg/kg
q2-3hrs is often effective. Postoperative
pain control needs to be coordinated with the accepting SCU team.
Transport to SCU with usual monitors and supplemental oxygen.