Spinal Fusion, Post-Op, Adolescent Idiopathic Scoliosis (AIS) — Intraoperative Considerations for Anesthesia Providers — Clinical Pathway: Inpatient

Inpatient Clinical Pathway for Adolescent Idiopathic Scoliosis (AIS) Spinal Fusion Rapid Recovery — Inpatient

Intraoperative Considerations for Anesthesia Providers

The Anesthesia Team should:

  • Pay attention to positioning (pressure points including face), vascular access based on patient comorbidities and disposition, and hemodynamic goals for the various correction stages
  • Actively communicate with the surgery and nursing teams
  • Tailor intraoperative guidelines to adolescent's needs

Intraoperative

Induction and Maintenance
  • Pre-heat OR to 72° before adolescent’s arrival to offset heat loss during induction/preparation
  • Minimize exposure during preparation and cover with a warm blanket when feasible
  • Inhalational induction acceptable, but consider IV induction for adolescents
  • Bolus Medications
    • Propofol
      • 2-3 mg/kg, two syringes
  • Bolus Medications
    • Fentanyl
      • 1-3 mcg/kg for induction
      • Additional doses available for maintenance
    • Lidocaine (consider for IV induction)
      • 1.0-1.5 mg/kg
    • Methadone
      • Dispensed as 10 mg/ml syringe
      • 0.1 mg/kg, max 10 mg
    • Tranexamic acid
      • 30 mg/kg over 10 min, max 2,000 mg
  • Infusions for TIVA
    • Propofol: 100-250 mcg/kg/min
    • Remifentanil: 0.1-0.2 mcg/kg/min
  • TIVA management
    • Propofol management active throughout case and tailored to response and depth
    • Monitor anesthetic depth in conjunction with neuromonitoring team and document SEF in record
      • Target SEF 13-16 Hz
    • During TIVA, propofol bolus should always be available to quickly deepen anesthetic
    • Communicate with neurophysiologists
      • Boluses, infusion rates, depth of anesthetic/EEG
Airway Positioning Considerations
  • Oral ETT
    • Attention should be paid to securing ETT due to prone positioning
    • Consider benzoin to maximize adhesion and cover tape with Tegaderm®
  • In coordination with attending anesthesiologist, nursing, and neurophysiologist:
    • Tegaderm™ covering eyes after eye ointment, if applied
    • OG tube, temp probe
    • Place bite block to prevent tongue injury
    • Consider Mepilex® or Duoderm® on chin, forehead, other pressure points to prevent skin injury
    • Once prone, ensure Foley is visibly draining
    • Bair Hugger™ lower body forced air warming blanket
Vascular Access
  • 2 Peripheral IVs
  • Arterial line
    • Radial or ulnar preferred
    • Both angiocatheter and arterial catheter kits are acceptable for short-term line
  • Sutures not required to secure catheter
Antibiotics
Analgesic Management
  • Methadone IV
    • 0.1 mg/kg, max 10 mg before incision per anesthesia team
  • Pain service consult placed by surgeons, anesthesia calls after start of case
  • If using remifentanil, addition of intermediate-acting opioid may be required (morphine or hydromorphone)
  • Consider titrating in additional opioid after patient is extubated if not tachypneic, prolonged emergence and sedation has been observed in this surgical population
    • Note: Be especially cautious administering additional opioids if using a fentanyl infusion
  • Acetaminophen IV
    • 15 mg/kg, max 1,000 mg at surgery conclusion
Anti-emetics
  • Dexamethasone IV
    • 0.1-0.2 mg/kg, max 10 mg, pre-incision
  • Ondansetron IV
    • 0.1 mg/kg, max 4 mg, at case conclusion
Fluids
  • Avoid excessive crystalloid
  • Consider lactated ringers at 3 mL/kg/hr
  • Bolus 10 mL/kg lactated ringers PRN for hypotension (see MAP goals)
Laboratory Testing
  • i-STAT® should be available for urgent measurements
  • Consider sending an arterial blood sample to the lab for blood gas analysis before correction
  • Repeat as needed based on clinical status
Hemodynamic Goals and Management
  • BP/hemodynamic goals:
    • Prevent spinal cord ischemia
    • Minimize bleeding
    • Maintain appropriate perfusion pressure
  • Standard MAP guidelines:
    • Dissection/screw placement: 60-70 mmHg
    • Rod placement/distraction: 70-80 mmHg
    • Closure: 65-75 mmHg
  • Vasoactive infusions:
    • Nicardipine: 0.5-2 mcg/kg/min
    • Phenylephrine: 0.1-0.3 mcg/kg/min
  • Loss of signals (SSEP/MEP) – Contact attending anesthesiologist
Ventilation
  • TV 6-8 ml/kg IBW
  • Reduce FiO2 to < 30%, once prone
  • PEEP should be titrated to optimize oxygenation
  • Goal of SpO2 > 95%
  • Consider intermittent blood gas analysis to guide management
  • Consider recruitment maneuver towards conclusion of procedure or for SpO2 < 95% when FiO2 is < 30%
  • Note: Use caution with recruitment maneuvers during procedure; may increase blood loss
Transfusion and Blood Conservation Guidelines
  • Blood transfusion is uncommon in this population
  • One unit of PRBCs should be available in the OR refrigerator before start of case
  • Antifibrinolytic management:
    • Tranexamic acid bolus: 30 mg/kg over 10 min (max 2 grams)
    • Provide bolus before turning prone to maximize onset of medication
    • Tranexamic acid infusion: 10 mg/kg/hr
    • Cell saver arranged by Surgery
    • Maintain hemoglobin > 7 g/dl
    • Discuss transfusion plan with surgery team when indicated
Emergence
  • Arterial line removed at the end of the case, pressure dressing applied
  • Neurological examination not required before transport to PACU/PICU unless intraoperative issues or specific request from surgeon
  • In the event of delayed emergence, suggested criteria for extubation:
    • Respiratory rate > 10
    • Tidal volume > 6 ml/kg
    • Stable ETCO2
Postoperative Disposition Surgical floor