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Monitoring and management of spinal cord ischemia during thoracic aortic repair: Rapid overview*

Monitoring and management of spinal cord ischemia during thoracic aortic repair: Rapid overview*
Intraoperative continuous neuromonitoring of MEPs and/or SSEPs are used to identify any evidence of spinal cord ischemia. The following overview of intraoperative treatment of spinal cord ischemia assumes preoperative placement of an intra-arterial catheter for continuous monitoring of MAP and a lumbar intrathecal catheter for continuous monitoring of CSF pressure.
Assessments and communications
  • If the neuromonitoring technician reports spinal cord ischemia, immediately communicate regarding specific evidence
  • Check anesthetic agents and doses to assess possible interference with neuromonitoring*
  • Communicate with surgeon to assess potential effects of surgical procedure on spinal cord perfusion
  • Assess MAP and prepare to treat if MAP is <80 mmHg
  • Assess CSF pressure and prepare to treat if CSF pressure is >10 mmHg
  • Calculate SCPP: SCPP = MAP minus CSF pressure
Initial treatment
  • Increase MAP to ≥80 mmHg in 5 mmHg increments, up to 100 mmHg:
    • Administer vasopressor therapy
    • Expand intravascular volume (if appropriate)
  • Drain CSF via intrathecal drain to decrease CSF pressure to 8 to 10 mmHg:
    • Limit CSF drainage to <20 mL during the first hour of surgery
    • Limit CSF drainage to <40 mL during any four-hour period
  • Recalculate SCPP; maintain SCPP ≥70 mmHg:
    • Also check CVP; if CVP>CSF pressure, increase MAP further to increase the likelihood that SCPP is maintained ≥70 mmHg
  • Ensure optimal oxygen delivery to the spinal cord:
    • Maintain adequate cardiac output
    • Maintain optimal O2 content in blood perfusing the spinal cord (high arterial PaO2, high Hgb saturation, adequate Hgb level ≥8 mg/dL)
Further treatment (if evidence of spinal cord ischemia is still present)
  • Communicate with neuromonitoring technician regarding any changes in evidence of spinal cord ischemia (improving, worsening, or no change)
  • Reassess MAP; continue efforts to increase MAP up to 100 mmHg
  • Reassess CSF pressure; continue efforts to drain CSF to decrease CSF pressure to 8 to 10 mmHg
  • Recalculate SCPP; maintain SCPP ≥70 mmHg:
    • Also check CVP; if CVP>CSF pressure, increase MAP further to increase the likelihood that SCPP will be maintained ≥70 mmHg
  • Consult surgeon regarding possible additional surgical treatments (eg, reimplantation of intercostal vessels, distal aortic perfusion)
  • (In some cases, there are no additional options to eliminate spinal cord ischemia; however, neuromonitoring is continued)
Prepare for postoperative management
  • Plan for postoperative monitoring for spinal cord ischemia
MEPs: motor evoked potentials; SSEPs: somatosensory evoked potentials; MAP: mean arterial pressure; CSF: cerebrospinal fluid; SCPP: spinal cord perfusion pressure; CVP: central venous pressure; O2: oxygen; PaO2: partial pressure of oxygen; Hgb: hemoglobin.
* Refer to UpToDate content discussing neuromonitoring in surgery and anesthesia.
¶ Refer to UpToDate content and algorithm for treatment of spinal cord ischemia after thoracic aortic repair.
Data from:
  1. Sinha AC, Cheung AT: Spinal cord protection and thoracic aortic surgery. Curr Opin Anaesthesiol 2010; 23:95.
  2. Estrera AL, Sheinbaum R, Miller CC, et al. Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management. Ann Thorac Surg 2009; 88:9.
  3. Estrera AL, Sheinbaum R, Miller CC 3rd, et al. Neuromonitor-guided repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2010; 140:S131.
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