Tethered Cord Evaluation and Perioperative Management — Day of Surgery: Intraoperative Considerations for Anesthesia Providers — Clinical Pathway: Inpatient and Primary Care

Tethered Cord Evaluation and Perioperative Management Clinical Pathway — Inpatient and Primary Care

Day of Surgery
Intraoperative Considerations for Anesthesia Providers

  • Attend to child positioning (care of face and pressure points).
  • Vascular access is based on child’s comorbidities and disposition.
  • Hemodynamic goals for various stages of correction. Active communication between anesthesia, surgery, and nursing team is vital to ensure optimal care. Intraoperative recommendations outlined below meant to serve as guidelines and should be tailored is based on individual needs or considerations.
  • See CHOP formulary for dosing based on age and weight.
Induction and Maintenance
  • Temperature
    • Before OR arrival, pre-heat the room to 75-80°F to offset heat loss during induction/preparation
    • Once in the OR, minimize patient exposure during preparation, cover with a warm blanket when feasible
  • Inhalational induction acceptable, but consider IV induction for teenagers
  • IV bolus medications:
    • Propofol bolus 2-3 mg/kg, two syringes
    • Fentanyl 1-3 mcg/kg for induction and additional boluses available for maintenance as needed
    • Lidocaine 1-1.5 mg/kg, consider for IV induction
  • IV infusions for TIVA:
    • Propofol: 100-250 mcg/kg/min
    • Remifentanil: 0.1-0.3 mcg/kg/min
  • TIVA management:
    • Akinesia can be difficult to achieve in younger children and higher remifentanil rates may be required
    • Propofol Management active throughout the 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 a TIVA, propofol bolus should always be available to deepen anesthetic quickly
    • Communicate with the neurophysiologists
      • Boluses, infusion rates, depth of anesthetic/EEG
Airway Management and Positioning Considerations
  • Standard oral tube
  • Attention to securing the ETT as child will be prone for duration of the surgery
    • Consider benzoin to maximize adhesion and cover tape with Tegaderms
  • Work in parallel with attending anesthesiologist, nursing (Foley for complex tethered cord) and neurophysiologist (IONM) to:
    • Tegaderm the eyes after +/- eye ointment
    • Place OG tube and temp probe
    • Place a bite block to prevent tongue injury
    • Consider placing Mepilex or DuoDERM padding on chin and forehead to prevent pressure injury from prone pillow
    • Make sure Mepilex placed on pressure point sites
    • Prone pillow for larger children: donut with head to side in smaller/younger children
    • Once turned prone, check Foley if placed
    • Place lower body forced air warming blanket (Bair Hugger)
    • Check all pressure points, especially arms and eyes
Vascular Access
  • Peripheral IV x2
  • Arterial line typically not needed
Antibiotics Perioperative Antibiotic Prophylaxis
Analgesic Management
  • Morphine 0.1 mg/kg before incision for simple tethered cords or toward the end of the case for complex tethered cords
  • Local anesthesia injected by surgeon before incision when possible
  • Acetaminophen IV 10-15 mg/kg IV (max dose 1,000 mg) at surgery conclusion
  • Ketorolac (avoid in renal disease) 0.5 mg/kg IV (max dose 30 mg) for simple tethered cords; ask surgeon if acceptable for complex repairs
  • Consider diazepam 0.05-0.1 mg/kg IV bolus (max dose 5 mg)
Anti-emetic Prophylaxis
  • Dexamethasone 0.1-0.2 mg/kg IV pre-incision (max dose 10 mg)
  • Ondansetron 0.1 mg/kg IV at case conclusion (max dose 4 mg)
Fluids
  • Avoid excessive crystalloid administration
  • Consider starting infusion of lactated ringers at 3 ml/kg/hr
  • Bolus 10 mL/kg lactated ringers PRN for intraoperative hypotension
Laboratory Testing Intraoperative labs are typically not required
Hemodynamic Goals
  • BP/Hemodynamic Goals:
    • Maintain SBP within 20% of baseline
  • Vasoactive infusions:
    • Typically, not required
  • Loss of Signals (SSEP/MEP) – Call your attending
Ventilation Strategy
  • TV 6-8 ml/kg IBW, PEEP 5
  • Reduce FiO2 to < 30% once prone with goal of SpO2 > 95%
  • Consider a recruitment maneuver towards the end of the procedure or for SpO2 < 95% when FiO2 is < 30%
  • Caution with recruitment maneuvers during the surgical procedure if there is venous bleeding since this may contribute to increased blood loss
Transfusion and Blood Conservation Guidelines
  • Transfusions rare in this population
  • Blood typically not ordered for these cases but type and screen should be drawn for children ≤ 6 mos undergoing a complex tethered cord repair
  • Maintain hemoglobin > 7 g/dl
  • Discuss transfusion plan with surgery team when indicated
Emergence
  • Neurological examination not required before transport to PACU/PICU unless intraoperative issues or specific request from surgeon
  • Awake or deep extubation acceptable
  • Suggested criteria for deep extubation
    • Respiratory rate > 10
    • Tidal volume > 6 ml/kg
    • Stable ETCO2
  • Goals for post-extubation care are:
    • Avoid elevations in CSF pressure
    • Keep calm
    • Keep flat
    • Consider dexmedetomidine 0.05-0.1 mcg/kg bolus