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52 Australasian Anaesthesia 2011Anaesthesia for instrumented spinal surgery 53MANAGEMENT OF BLEEDING AND BLOOD REPLACEMENTIntraoperative blood loss can be significant. In cases of cervical spine surgery and anterior lumbar spine surgerymajor bleeding may occur suddenly but infrequently. However, during PLIF surgery the blood loss occurs during aprolonged period of time and may amount to several litres. Techniques to reduce the loss of red blood cells (RBC)should be considered to reduce the number of allogeneic blood transfusions that may be required 6,7,8 (Table 2).Hypotensive anaesthesia. The use of induced hypotension during anaesthesia has become controversial. TheBrain Trauma Foundation’s guidelines for management of the central nervous system perfusion pressure are alsoapplicable to the spinal cord. This means that the spinal cord perfusion pressure should be maintained in the 50-70mmHg range. 24 The recent awareness of postoperative blindness has further weakened the arguments forhypotensive anaesthesia. 25 In addition, a recent study found a significant increase of intraocular pressure from13mmHg after induction of anaesthesia in the supine position to 40mmHg after 5 hours of spinal surgery in theTable 2. Blood conservation strategies during instrumented spinal surgery• Inhibition of fibrinolysisprone position. 26VISUAL LOSSVisual disturbances have been quoted to occur in approximately 1 in 2000 spinal procedures. 27,28 Visual loss has• Acute normovolemic hemodilutionalso been reported following cardiac surgery and, head and neck surgery. 28 The aetiology remains unclear. The• Cell salvage and autotransfusionAmerican Society of Anesthesiologists’ Postoperative Visual Loss (PVL) Registry identified few common traits in• Hypotensive anaesthesiapatients who have developed postoperative blindness. 29 Eighty-two per cent of the patients sustained a blood lossin excess of 1000mL, and 94% had been anaesthetised for more than 6 hours (mean 9.8 h). Large volumes ofFibrinolysis inhibitors. These agents have been used to reduce blood loss during PLIFs. A recent studydemonstrated good effect on blood loss of intravenous tranexamic acid (TXA). 9 A dose regime of TXA of 10mg/kgbodyweight prior to skin incision followed by 1mg/kg/h has been suggested for instrumented spinal surgery. 9Acute normovolaemic haemodilution (ANH). The technique of ANH remains controversial. ANH has itssupporters but others are critical of its transfusion-reducing capacity. 11 Some authors have found that ANH reducesthe number of patients needing allogeneic transfusion; others have found that ANH does not alter the number ofcrystalloids were used for blood replacement (9.7 l). In an earlier retrospective review of 37 cases of visual lossafter spinal surgery the authors compared a subgroup of 28 patients (with complete notes) with matching historicalcontrols. The authors found that the mean surgery time was 410 min (6h50min) with a mean blood loss of 3500mL. 30Blood pressure changes were similar in both groups and the authors conclude that although hypotension mayincrease the risk of PVL, moderate hypotension alone is rarely the cause. It is common-sense and generally acceptedthat pressure on the eyes and eyeballs should be avoided during the prone positioning of the patient.patients needing transfusion but ANH does reduce the number of units transfused.Anaesthetic risk management with respect to PVL in prone spinal surgery should consider:ANH may be most efficacious in terms of avoiding allogeneic blood transfusion when the blood loss is moderate. 12• Positioning of the head in the neutral position.This is because, firstly, the volume of withdrawn blood must be in the 1000-2000mL range in order to provide a25,30• The use of a soft head rest with cut-outs for eyes, nose and the tracheal tube.meaningful level of hemodilution 12 and, secondly, the surgical blood loss occurs in addition to the volume of withdrawn• Avoidance of direct pressure on the eyes.blood and should therefore probably not exceed 1000mL before re-transfusion is considered. In the clinical reality,25,30• Correction of anaemia (Hb < 80g/L).many patients present with a history of ischaemic heart disease and rarely have a preoperative haematocrit value• Avoidance of prolonged arterial hypotension (SAP
54 Australasian Anaesthesia 2011Anaesthesia for instrumented spinal surgery 55REFERENCES1. Pasternak JJ, Lanier WL. Neuroanesthesiology update 2010. J Neurosurg Anesthesiol 2011; 23: 67-992. Urban MK. Anesthesia for orthopaedic surgery. In: Miller RD ed. Miller’s Anesthesia 7th ed. 2010, p. 2241-59.Churchill Livingstone Elsevier.3. Nuttall GA, Horlocker TT, Santrach WC Dekutoski MB, Bryant S. Predictors of blood transfusions in spinalinstrumentation and fusion surgery. Spine 2000; 25: 596-601.4. Biais M, Barnard O, Ha JC, Degryse C, Sztark F. Abilities of pulse pressure variations and stroke volumevariations to predict fluid responsiveness in the prone position during scoliosis surgery. BJA 2010; 104: 407-135. Lau D, Lin J, Park P. Cranial nerve III palsy resulting from intracranial hypotension caused by cerebrospinalfluid leak after paraspinal tumor resection: etiology and treatment options. Spine J 2011; 11: e10-3(www.thespinejournal.com).6. Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. BJA 2010;105: 401-16.7. Cardone D, Klein AA. Perioperative blood conservation. European J Anaesthesiology 2009; 26: 722-9.8. Carless PA, Henry DA, Moxley AJ et al. Cell salvage for minimising perioperative allogeneic blood transfusion.Cochrane Database of Systematic Reviews. 2010, issue 4, article number CD001888.9. (http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001886/frame.html).10. Wong J, El Beheiry H, Rampersaud YR, Lewis S, Ahn H, De Silva Y, Abrisharmi A, Baig N, McBroom RJ, ChungF. Tranexamic acid reduces perioperative blood loss in adult patients having spinal fusion surgery. Anest Analg2008; 107: 1479-88.11. Cyclocapron Tranexamic acid. Product information 2010, October 8. Pfizer Australia Pty Ltd.12. Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E. Perioperative acute normovolemic hemodilution: ameta-analysis. Transfusion 2004; 44: 632-44.13. Bryson GL, Laupacis A, Wells GA et al. Does acute normovolemic hemodilution reduce perioperative allogeneictransfusion? A meta-analysis. Anesth Analg 1998; 86: 9-15.14. Sloan TB, Myers G, Janik DJ, Burger EM, Patel VV, Jameson LC. Intraoperative autologous transfusion ofhemolyzed blood. Anest Analg 2009:109: 38-42.15. Sreelaksmi TR, Eldridge J. Acute hypotension associated with leucocyte depletion filters during cell salvagedblood transfusion. Anaesthesia 2010; 65: 742-4.16. Kessack LK, Hawkins N. Severe hypotension related to cell salvaged blood transfusion in obstetrics. Anaesthesia2010; 65: 745-8.17. Reitman CA, Watters WC, Sassard WR. The cell saver in adult spinal fusion surgery. A cost-benefit outcomesstudy. Spine 2004; 29: 1580-4.18. Carless PA, Henry DA, Moxley AJ et al. Cell salvage for minimising perioperative allogeneic blood transfusion.Cochrane Database of Systematic Reviews. 2010, issue 4, article number CD001888.19. Blood Transfusion and the anaesthetist. Intraoperative cell salvage. Association of Anaesthetists in Great Britainand Ireland, 2009.20. Gause PR, Siska PA, Westrick ER, Zavatsky J, Irrgang JJ, Kang JD. Efficacy of intraoperative cell saver indecreasing postoperative blood transfusions in instrumented posterior lumbar fusion patients. Spine 2008;33: 571-5.21. Waters JH, ShinJung J, Karafa MT. A mathematical model of cell salvage efficiency. Anesth Analg 2002; 95:1312-7.22. Kang Y, Aggarwal S, Virji M, Pasculle AW, Lewis JH, Freeman JA, Martin LK. Clinical evaluation of autotransfusionduring liver transplantation. Anesth Analg 1991; 72: 94-100.23. Booke M, van Aken H, Storm M, Fritzsche F, Wirtz S, Hinder F, Fat elimination from autologous blood. AnesthAnalg 2001; 92: 341-3.24. Hussain S, Clyburn P. Cell-salvage induced hypotension and London buses (Editorial). Anaesthesia 2010; 6: 661-3.25. Brain Trauma Foundation Guidelines. J Neurotrauma 2007; Suppl 1: 1-95.26. Goepfert CE, Ifune C, Tempelhoff R. Ischemic optic neuropathy: are we any further? Curr Opin Anaesthesiol2010; 23: 582-7.27. Cheng MA, Todorov A, Tempelhoff R, McHugh T, Crowder CM, Lauryssen C. The effect of prone positioning onintraocular pressure in anesthetized patients. Anesthesiology 2001; 95: 1351-5.28. Stevens WR, Maj MC, Glazer PA, Kelley SD, Bradford DS. Ophthalmic complications after spinal surgery. Spine1997; 22: 1319-24.29. Holy SE, Tsai JH, McAllister RK, Smith KH. Perioperative ischemic neuropathy. A case control analysis of 126,666surgical procedures at a single institution. Anesthesiology 2009; 110: 246-53.30. Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, Domino KB. The American Society ofAnesthesiologists’ postoperative visual loss registry: Analysis of 93 spine surgery cases with postoperativevisual loss. Anesthesiology 2006; 105: 652-9.31. Myers MA, Hamilton SR, Bogosian AJ, Smith CH. Visual loss as a complication of spine surgery: a review of37 cases. Spine1997; 22: 1325-9.32. van Elstraete AC, Tirault M, Lebrun T, Sandefo I, Bernard JC, Polin B, Vally P, Mazoit JX. The median effectivedose of preemptive gabapentin on postoperative morphine consumption after posterior spinal fusion. AA 2008;106:305-8.33. Kim JC, Choi YS, Kim KN, Shim JK, Lee JY, Kwak YL. Effective dose of peri-operative oral pregabalin as anadjunct to multimodal analgesic regimen in lumbar spinal fusion surgery. Spine 2011; 36: 428-33.34. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute post-operative pain: a quantitative andqualitative systematic review (Cochrane review). Acta Anaesthesiol Scand 2005; 49: 1405-28.35. Mercadante S, Arcuri E. Hyperalgesia and opioid switching. Am J Hosp Pal Med 2005; 22: 291-4.36. Subramaniam K, Subramaniam B, Steinbrook RA. Ketamine as adjuvant analgesic to opioids: a quantitativeand qualitative systematic review. Anesth Analg 2004; 99: 482-95.37. Acute Pain Management: Scientific evidence. 3rd ed. 2010. Australian and New Zealand College of Anaesthetistsand Faculty of Pain Medicine, Melbourne Vic, Australia.38. Bianconi M, Ferraro L, Ricci R, Zanoli G, Antonelli T, Guilia B, Guberti A, Massari L. The pharmacokinetics andefficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg 2004; 98: 166-72.
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