A Multi-Centre Multi-National Survey of Anaesthetists Regarding the Range of Anaesthetic and Surgical Practices for Paediatric Scoliosis Surgery

Abstract

Institutional responses to a detailed multinational survey were used to characterise the range of current anaesthetic and surgical practices for paediatric scoliosis surgery. Questions addressed surgical practice, anaesthetic agents, blood-sparing techniques, neurophysiological monitoring used and recalled major complications. Twenty-seven (87%) institutions responded. The median number of cases of these institutions was 40 per year (range 5 to 700). Common practices included inhaled volatile anaesthetic maintenance (80%), omission of nitrous oxide (81%), intravenous remifentanil (88% [range 0.05 to 2.00 µg.kg-1 .min-1 ]), and double intravenous antiemetic agent prophylaxis (59%); multimodal analgesia with paracetamol and parenteral opioids, non-steroidal antiinflammartory drugs and epidural local anaesthetic or opioid infusion (UK) and intrathecal opioids and subanaesthetic doses of intravenous ketamine by infusion (Australia); use of cell-saver (81%), controlled hypotension (77%) and antifibrinolytic agents (74%) (intravenous aprotinin [59%] or tranexamic acid [44%]); and epidural somatosensory (92%), neurogenic motor-evoked (32%), compound motor action (31%) and transcranial motorevoked potential monitoring (54%), with routine wake-up test used infrequently (19%). Fifty-four neurological or cardiac adverse events or deaths were recalled. While institutional practices varied, common themes were identified. The information obtained may suggest new strategies to various centres and could be useful for planning multi-centre audits and trials.

Cervical Spinal Cord Injury After Thoracic Spinal Instrumentation

“…Epidural anesthesia was placed and used in the fi rst case but not in the second. 11 Intraoperative radiographs documenting a neutral cervical spinal position were obtained in both cases. The cognitive defi cits and behavioral disorder complicated the postoperative care and communication of both patients.…”

Efficacy Assessment of Epidural Blockade and Tranexamic Acid Application in Idiopathic Scoliosis Surgery

“…Corrective surgery for scoliosis is a long-continued and highly traumatic procedure accompanied by considerable blood loss and hence causing a set of complicated reactions at the level of neuroendocrinal tension, metabolism intensification and marked shifts in oxygen delivery [4,5]. Massive blood loss in corrective surgery for scoliosis continues to be a burning issue in anesthesiology and orthopedics.…”

“…The use of antifibrinolytic drugs has been debated for years and antifibrinolytic dosing schedules vary (IV tranexamic acid from medium (mg•kg -1 ) to very large doses up to 100 mg•kg -1 as a loading dose with 1 or 10 mg•kg -1 •h -1 infusion) [5,[14][15][16][17][18][19][20][21][22]. Tranexamic acid has been used in different studies to reduce blood losses during spinal surgery.…”

“…At the same time, 35% of institutions reported the use of controlled hypotension and acute normovolemic hemodilution. The concurrent use of more than one blood-sparing technique was not addressed by the survey [5,19].…”

“…Such factors as the massive trauma induced, significant operative time, inevitable and considerable blood loss, and original cardiopulmonary dysfunctions account for high surgical and anesthetic risks of spinal surgery. There remains a significant incidence of dangerous postoperative complications and rather a high level of postoperative mortality reaching 1.06% [4][5][6]33]. A number of studies have proved that epidural anesthesia is one of the most effective, though invasive, methods of intra-and postoperative pain relief.…”