Anesthetic Management of Spine Fusion

Abstract

Spine fusion in children with cerebral palsy (CP) is a more extensive surgical procedure fusing T1 to the sacrum, unlike in idiopathic scoliosis patients where spine fusion is limited to thoracic and lumbar vertebral segments. Significantly greater blood loss, need for central venous line as well as arterial line in addition to at least two large-bore intravenous catheters, and availability of blood and blood products are to be anticipated. Greater blood loss sustained is both due to the more extensive nature of the surgery and the suboptimal levels of clotting factors present in CP patients. Preoperatively, a plan for timely administration of anticonvulsants both in the immediate postoperative period and thereafter needs to be in place. Hypothermia is a constant threat to CP patients who sustain hypothermia easily and to a greater degree than their normal counterparts. To conserve temperature, in addition to controlling the environmental factors such as the temperature in the operating room and use of forced air warmer unit draped on the patient, pre-warming the CP patients in the preoperative holding room is what we have found to be effective. Neuromonitoring should be employed in CP patients except a select few whose baseline evoked potentials are not recordable. Choice of anesthetic agents will be such that neuromonitoring is facilitated and only minimal and unavoidable degradation of the signals should be tolerated. Carefully chosen anesthetic agents would also allow extubation of the trachea in the majority of patients at the end of the anesthetic or shortly thereafter. In our experience the patients extubated earlier experience an easier recovery period with shorter duration PICU and overall hospital stay.