1 / 34

Perioperative management for patients with a chronic spinal cord injury

This comprehensive guide by Dr. S. Parthasarathy covers the physiological changes, triggers, respiratory and muscle effects, blood-related issues, urological and gastrointestinal complications, psychological aspects, intrathecal baclofen pumps, pre-operative assessment, drug considerations, DVT risks, and anesthetic options for patients with chronic spinal cord injuries. The text includes insights on autonomic dysreflexia, spasticity management, and perioperative care strategies.

leomam
Download Presentation

Perioperative management for patients with a chronic spinal cord injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Perioperative management for patients with a chronicspinal cord injury Dr. S. Parthasarathy MD., DA., DNB, Dip. Diab., DCA, Dip. Software statistics- PhD ( physiology) , IDRA, FICA

  2. Do we really need to know

  3. Spinal cord injury • First phase – one hour – sympathetic discharge and hypertension • Acute phase – shock – first eight weeks • Flaccid paralysis – areflexia • Hypotension , bradycardia • Myocardial dysfunction • Chronic phase – autonomic hyperreflexia

  4. PHYSIOLOGICAL CHANGES IN CHRONIC SPINAL CORD INJURED PATIENTS

  5. Autonomic dysreflexia (AD) • Level of injury T 6 or above • acute elevation of arterial blood pressure (BP) and bradycardia (slow heart rate), although tachycardia (rapid heart rate) also may occur. • Objectively, an increase in systolic BP greater than 20–30 mmHg is considered a dysreflexic episode • alterations in connections within the distal spinal cord lead to the abnormal sympathetic responses

  6. Consequences • increase in pressure may cause • intracranial or retinal haemorrhage, • seizures, • myocardial ischaemia, • pulmonary edema and death. It may start any time between 3 weeks and 12 years of injury Vasodilation above – nasal congestion Mild facial edema !

  7. Pictures from the internet for closed academic purpose only

  8. Triggers – non surgical • Bladder distension • Colonic stimulus • Anal fissure • Uterine interventions • Misoprostone • Ingrowing toe nail • Pressure sore manipulation Sacral triggers ??

  9. Clonidine for spastic ADR Intravesical capsaicin for bladder

  10. Respiratory changes • Shallow respiration • Thoracic musculature weakness • Weak cough • Accessory muscles • Increased secretions • Leads on to atelectasis

  11. Muscle • An increase in acetylcholine receptors on muscle membrane follows spinal injury. • Hyperkalaemia and cardiac arrest is a risk. • Increased muscle tone occurs in the reflex phase and a violent spasm may be caused by minor proprioceptive or cutaneous stimuli

  12. Blood • Blood volume decreased • Postural hypotension ( IPPV ? ) • A normochromic, normocyticanaemia is common. • Hypoalbuminaemia may be present. • Risk of deep vein thrombosis in the initial stages of injury (up to 30%) • prophylaxis may include warfarin or unfractionated heparin for several weeks.

  13. Others • Significant osteoporosis occurs in cord injured patients and predisposes them to fractures • A high spinal cord injury impairs the ability to shiver, vasodilate and sweat. • Prone for pressure sores and the inherent risks of the sores

  14. Urology and GI • Urinary tract infection, proteinuria, reflux and calculi occur commonly. • Renal failure may rarely supervene. • An acute gastroparesis and ileus may occur after acute spinal cord injury. • Chronic spinal cord injured patients may have delayed gastric emptying.

  15. Psychological complications of post SCI include depression, suicide, and drug addiction. • Chronic pain can complicate 60 % of cases • Renal and liver impairment can complicate certain cases

  16. All changes • Pertain to T6 • If its C5 , changes may vary • 90 % of respiration – accessory muscles ?

  17. Intrathecalbaclofen pumps • Baclofen pumps are used in patients which severe spasticity requiring large doses of anti-spasmodic medications precipitating unwanted side-effects. • The operation includes insertion of a lumbar or low thoracic catheter, tunnelled to the connecting pump that is inserted in the lower abdominal wall

  18. PRE-OPERATIVE ASSESSMENT • Nature , Timing of neurological injury • Sensory and motor level. • Vagally mediated reflexes intact? – antispasmodics • The occurrence of autonomic dysreflexia will be revealed by questions about sweating, flushing, headache or directly about elevated blood pressure. • PFT and ABG SOS • I.V. access is often difficult because of atrophic, hyperaesthetic skin with reduced cutaneous blood flow.

  19. Pre op drugs • Baclofen , tizanidine – can omit one dose • Diazepam, clonazepam – as adjuncts • Marijuana for spasticity • Oxybutinin is a frequently used anticholinergic drug. It is an antisialogogue and may enhance the sedative effects of general anesthetic agents.

  20. DVT • Initial six weeks after injury – DVT is 85 % • Chronic – very less – no need for prophylaxis • Muscle spasticity and venous collapse attributed • But perioperative heparin advocated

  21. ANAESTHETIC OPTIONS • Local • Regional • General • Can we do without anesthestist ?? NO 500 ml of Ringer – must

  22. Spinal - YES • Spinal anesthesia is safe in patients with CSCI and is an effective way of abolishing ADR and spasms. (1.5 - 2 ml is enough for most procedures) • Spinal anesthesia is becoming a widely accepted technique in patients with pre-existing spinal cord pathology.. • Difficult to put ?? • Difficult to assess – babinski ? Flaccidty ?

  23. Epidural • Epidural anesthesia has been demonstrated to be effective in reducing ADR in labouring women; • it is less reliable for general and urological surgical procedures. • Prolonged procedures and post op ADR prophylaxis – can be used

  24. Nerve blocks • Upper limb surgery - brachial plexus block, • done under ultrasound guidance • nerve stimulators unreliable in the presence of cervical injuries. • Beware of phrenic injury • Go for axillary if acceptable !

  25. Premed with ? Nifedipine • Lower doses of general anesthetics • Muscle mass is less ! VRG !! • volume of distribution ?? • Vasopressors use ? Prophylaxis ??

  26. Scoline – 6 months old ? • Denervated muscle results in an increase of extrajunctional acetylcholine receptors, spreading from motor end-plate of affected muscle fibres to cover the whole muscle membrane • Beware of scoline

  27. Airway • Positioning and difficult airway • RSI if ? • Laryngeal mask airway – OK • Aspiration risk is theoretical • Tracheostomy – change to cuffed tube ?

  28. Fluid warmers are OK • No warm mattresses • Cant react fast to hypothermia

  29. Recovery • Muscle function • Temperature • Sores and cautery pads • Respiration and oxygen

  30. CSCI and pregnancy • Further reduction in respiratory reserve • Reduction in FRC • Prone for atelectasis and respiratory failure • Prone for urinary infections • DVT • Anemia Worsens ??

  31. Level below T 10 – pain perceived • But ADR – onset of labour ?? • Epidural prior to onset of labour • Continue for 48 hours to abolish ADR

  32. Summary • CSCI -Surgeries • Changes • ADR • Spinal • Epidural or GA • Post op • Labour

More Related