BJA Advance Access originally published online on October 11, 2006
British Journal of Anaesthesia 2006 97(6):851-857; doi:10.1093/bja/ael273
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Spinal fusion surgery in children with non-idiopathic scoliosis: is there a need for routine postoperative ventilation?
Department of Anaesthesia, Royal Manchester Children's Hospital Pendlebury, Manchester, UK
*Corresponding author. E-mail: nicalm{at}tiscali.it
Accepted for publication August 31, 2006.
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Abstract |
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Background. The perioperative management of children with non-idiopathic scoliosis undergoing spinal deformity surgery has not been standardized and the current practice is to routinely ventilate these patients in the postoperative period. This study reports the experience from a single institution and evaluates the need and reasons for postoperative ventilation. Details of ventilated patients are presented.
Methods. All patients undergoing spinal fusion surgery for non-idiopathic scoliosis were recorded prospectively (2003–4). Patients were anaesthetized according to a standardized technique. Physical characteristics, cardiopulmonary function, intraoperative blood loss and fluid requirement, postoperative need for ventilation and all perioperative adverse events were recorded on a computer database.
Results. A total of 76.2% of patients were safely extubated at the end of surgery without any further complications or need for re-ventilation; 23.8% of patients required postoperative ventilation with half of the cases being planned before operation and 40% of all patients with Duchenne muscular dystrophy (DMD) required postoperative ventilation. There were no specific factors that could predict the need for postoperative ventilation, although an increased tendency for children with DMD and those with a preoperative forced vital capacity <30% towards requiring postoperative ventilation was observed.
Conclusions. Early extubation can be safely performed after spinal deformity surgery for non-idiopathic scoliosis. The use of short-acting anaesthetics, drugs to reduce blood loss, experienced spinal anaesthetists and the availability of intensive care support are all essential for a good outcome in patients with neuromuscular disease and cardiopulmonary co-morbidity.
Keywords: anaesthetic techniques; complications, scoliosis; surgery, spinal; ventilation, postoperative
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Introduction |
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Scoliosis is a complex deformity of the spine with lateral curvature and rotation of the thoraco-lumbar vertebrae with a resulting rib cage deformity. In addition to the lateral curvature, anterior and posterior deformities such as kyphosis and lordosis may occur. Approximately 70% of cases are idiopathic (primary) in origin. The remaining 30% are non-idiopathic in origin and are secondary to congenital, neuromuscular disease, mesenchymal disorder, infection and trauma. As the Cobb angle (lateral curvature) progresses beyond 65° a reduction in lung volumes and a ventilation/perfusion mismatch can be observed. In severe cases (>100°) pulmonary hypertension and right ventricular hypertrophy may develop.1
In addition to the restrictive lung deficit caused by the spinal deformity, children with neuromuscular disease have impaired pulmonary function from muscular weakness and recurrent chest infections as a consequence of poor cough and impaired airway protective reflexes. Furthermore boys with Duchenne muscular dystrophy (DMD) develop dystrophic cardiomyopathy and may present with arrhythmia, ventricular dilatation and heart failure.1
Spinal surgery in these children is designed to halt the progression of the scoliosis and thereby slow the decline in cardiopulmonary function2 and improve the quality of life by achieving a better posture and easing nursing care.
More of these children are now surviving for longer with medical interventions such as home ventilation and steroid therapy. With recent advances in surgical, anaesthetic and intensive care management more children with significantly compromised cardiopulmonary function are now being offered complex spinal surgery.
Pulmonary function testing is still widely used as a predictor of postoperative pulmonary complications and ventilatory requirement.3 However with the use of modern anaesthetic drugs and significant reduction in perioperative blood loss, the need for routine postoperative ventilation is rarely necessary unless there is evidence of significantly compromised cardiopulmonary function, for example forced vital capacity (FVC)<30% or fractional shortening (FS)<25%.1 2 Nevertheless, additional factors such as the duration and type of surgery influence the need for postoperative ventilation.4 5
This study reports the experience from our institution of all children with non-idiopathic scoliosis undergoing spinal deformity surgery over an 18-month period. The aim of this prospective observational study was to see if the use of modern anaesthetic techniques and blood conservation strategies affect the incidence of postoperative ventilation and cardiopulmonary complications, and secondly, what factors influence the need for postoperative ventilation.
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Materials and methods |
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All children with non-idiopathic scoliosis undergoing spinal deformity surgery at the Royal Manchester Children's Hospital between January 1, 2003 and June 30, 2004 were enrolled in a prospective observational study. The main outcome measure was the need for postoperative ventilation.
Preoperative investigation consisted of spirometry and echocardiography where obtainable, full blood exams and crossmatch.
All patients were anaesthetized by one of three consultant anaesthetists according to a standardized technique. Anaesthesia was induced with propofol 2–3 mg kg–1 and atracurium 0.5 mg kg–1 was used to facilitate endotracheal intubation. Anaesthesia was then maintained with a remifentanil infusion 0.05–0.4 µg kg–1 min–1 and sevoflurane 0.6–0.7 MAC in a mixture of oxygen and air. Mean arterial pressure was kept between 50 and 70 mm Hg. Two large peripheral i.v. cannulae were sited. In addition to standard paediatric general anaesthetic monitoring, invasive arterial pressure monitoring and a urine catheter were used. A central venous catheter was inserted to improve venous access and a means of administering inotropic drugs if required. Central venous pressure monitoring alone may be misleading as a guide of ventricular filling in the prone position.6 A paediatric transoesophageal Doppler (TOD) probe (CardioQ, Deltex Medical, Chichester, UK) was used routinely to assess the left ventricular performance and fluid requirement by continuously monitoring the shape of the TOD waveform.
Temperature monitoring, i.v. fluid warmers and warm air blankets were used for the duration of the procedure to maintain normothermia. Somatosensory evoked potentials (SSEP) were used to monitor the integrity of the spinal cord during the procedure.
Acute normovolaemic haemodilution (ANH) was performed if not contraindicated. In addition to ANH, aprotinin was used to reduce the blood loss. After an initial test dose, a loading dose of aprotinin 4 mg kg–1(28 572 KIU kg–1) was infused over 30 min followed by a maintenance dose of 1 mg kg–1 h–1 (7143 KIU kg–1 h–1) throughout the duration of the surgery. Intraoperative red cell salvage was carried out routinely and blood loss was recorded hourly.
The intraoperative haemoglobin level was assessed 2 hourly with a bedside haemoglobin analyser (HemoCue Limited, Derbyshire, UK). Blood was transfused, if the haemoglobin level decreased below 8 g dl–1. Blood gases, coagulation profile and full blood count were carried out during the procedure guided by intraoperative blood loss and clinical assessment.
All operations were performed by one of two paediatric spinal surgeons. One of the following surgical procedures were performed; an anterior spinal fusion, posterior spinal fusion or a combined anterior release and posterior spinal fusion with instrumentation.
At the end of surgery an epidural catheter was inserted by the surgeons under direct vision at mid-thoracic level for postoperative analgesia. As soon as the patient was sufficiently awake to move the legs, a bolus of levobupivacaine 0.25% was given followed by an epidural infusion of plain bupivacaine 0.125%. All children received morphine 0.1 mg kg–1 at the end of surgery and a nurse-controlled or patient-controlled morphine infusion was started in recovery. Furthermore acetaminophen was prescribed at regular intervals. Patients were either extubated and recovered prior to transfer to the high-dependency unit (HDU) or transferred to the PICU for postoperative ventilation. Criteria for elective postoperative ventilation were: (i) expected surgery lasting more than 8 h; (ii) poor respiratory function (FVC<25%): (iii) poor cardiac function (FS<30%); (iv) severe neurological deficit with impaired control of ventilation and airway protective reflexes.
The following data were collected for each patient:
- Preoperative data: age, body mass index, diagnosis, FVC and FS.
- Intraoperative data: surgical procedure; duration of surgery defined as time from ‘skin incision to skin closure’; estimated blood loss (blood suctioned from surgical field into the cell saver plus the difference in weights between dry and blood soaked sponges); fluids (crystalloids, colloids) administered, blood transfused and any complications.
- Postoperative data: need and length of postoperative ventilation; length of stay in intensive care unit (ICU) or HDU; any postoperative complication.
Statistical analysis
All values are reported as mean (SD) and range. Independent Student's t-test (two-tailed) was used to evaluate the effect of continuous variables (age, BMI, FVC, FS, duration of surgery, blood loss, intraoperative fluids) on postoperative ventilation. The 
2-test and Fisher's exact test were used to evaluate dichotomized variables such as FVC and FS, diagsnosis of DMD and type of surgery. Statistical significance was accepted at P<0.05.
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Results |
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A total of 42 patients underwent spinal reconstructive surgery for non-idiopathic scoliosis during the 18-month-period. Ten patients (23.8%) required postoperative ventilation (group V). Thirty-two patients (76.2%) were extubated at the end of surgery (group NV). There was no need for re-ventilation in group NV and there were no perioperative complications. The underlying diagnoses in both groups are shown in Table 1. Out of 42, 35 (83%) patients suffered from neuromuscular disease. An underlying diagnosis of DMD alone did not predict a need for postoperative ventilation (P=0.12). However, 40% of all patients with DMD required postoperative ventilation.
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There were 9 boys and 1 girl in the ventilated group (Group V) and 19 boys and 13 girls in the non-ventilated group (Group NV). There were no significant differences between the groups with respect to mean age, BMI, FVC or FS (Table 2). Preoperative pulmonary function tests were obtained in 8 out of 10 patients in Group V and 28 out of 32 patients in Group NV. The remaining children were not able to perform the test. In Group V, 3 patients were identified with a FVC<30%, 1 with a FVC between 30 and 40% and 4 patients with a FVC>40%. In group NV, 3 patients had a FVC<30%, 2 patients were identified with a FVC between 30 and 40%, 23 patients had a FVC>40% (Table 3). When patients of both groups were divided into 3 groups according to preoperative FVC: (i) <30%; (ii) >30% to <40%; (iii) >40%, the incidence of postoperative ventilation was 50% (3 out of 6) in Group 1; 33.3% (1 out of 3) in Group 2, and 14.8% (4 out of 27) in Group 3. There was a tendency towards a need for postoperative ventilation as the FVC decreased.
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Interestingly two patients in the non-ventilated group were on nocturnal non-invasive positive pressure ventilation (NIPPV) at home for underlying neuromuscular disease: a girl with congenital muscular dystrophy (FVC 18%) and a boy with spinal muscular atrophy (FVC 10%). Both were extubated at the end of surgery and NIPPV was used during the postoperative period.
Preoperative echocardiography was obtained in 8 out of 10 patients in Group V and in 20 out of 32 patients in group NV. Mean FS was 30.0% in Group V and 32.4% in Group NV. There was no significant difference between the groups (Table 2). Two patients in each group had severe cardiac dysfunction as characterized by a FS below 30%. Anterior spinal release and posterior spinal fusion were performed in 4 children from Group V and 7 from Group NV; posterior spinal fusion was performed in 6 from Group V and 24 from Group NV; anterior spinal fusion was performed in one child from Group NV. There were no significant differences in the surgical procedures performed between the groups. No difference was found between the surgical procedure performed and the need for postoperative ventilation (Table 4).
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There were no significant differences between the groups with respect to the duration of surgery, intraoperative blood loss or the amount of fluids and blood given (Table 4).
Details of ventilated patients
Case 1. A 10-yr-old boy with history of cerebral palsy and epilepsy, underwent an anterior release and posterior spinal fusion. Preoperative spirometry could not be performed and the echocardiograph available was considered to be unreliable because of poor views. Postoperative ventilation was elected because of severe neurological deficit and impaired respiratory control. Blood loss was 33 ml kg–1 Metaraminol was used to correct intraoperative hypotension. He was extubated after 29 h of ventilation. Reintubation was required the following day for respiratory fatigue. The chest radiograph indicated a left pleural effusion and a right upper lobe consolidation. He was successfully extubated on the ninth postoperative day and discharged home on the 14th postoperative day.
Case 2. A 16-yr-old boy with Friedreich's ataxia underwent an anterior spinal release and posterior spinal fusion. He was wheelchair bound and had a FVC of 35% of predicted and a FS of 36%. Prolonged surgery was anticipated and postoperative ventilation was again planned. The operative time was 9 h and blood loss was 29 ml kg–1. He was extubated after 15 h of ventilation and was discharged home on the 11th postoperative day.
Case 3. This was another 14-yr-old boy with DMD. His preoperative FVC was 18% of predicted and a FS of 26%. He had a previous history of pneumonia, but had never required ventilatory support. Postoperative ventilation was planned because of his severely impaired respiratory function. Posterior spinal fusion was performed. Blood loss was estimated at 25 ml kg–1. He was extubated on the third postoperative day.
Case 4. A 17-yr-old adolescent with DMD, was noted on preoperative echocardiography to have significant left ventricular dysfunction with a FS of 17%, and on digoxin. His preoperative FVC was 54% of predicted. For this reason postoperative ventilation was planned. During surgery his blood pressure was very unstable throughout despite adequate fluid resuscitation. Dobutamine was used to provide inotropic support and improve cardiovascular stability. Blood loss was approximately 28 ml kg–1. He was extubated on the third postoperative day after 63 h of ventilation, but required CPAP for another 2 days.
Case 5. A 14-yr-old boy with DMD, was noted to be extremely weak apart from small movements of his hands and head. Preoperative FVC was 25% of predicted and a FS of 37%, he was on nocturnal oxygen. Postoperative ventilation was planned. A posterior spinal fusion and instrumentation was performed. Intraoperative blood loss was estimated at 62 ml kg–1. After operation his oxygen requirement increased to 50% and a chest radiograph suggested a right lower lobe atelectasis. He was extubated on day 5, but subsequently developed a pleural effusion for which he received diuretics and the effusion resolved spontaneously.
Case 6. A 13-yr-old boy with DMD, was noted to have a preoperative FVC of 28% of predicted with a weak cough. An echocardiograph revealed a FS of 30%. Surgery lasted for 7.5 h and his blood pressure became unstable despite adequate fluid therapy. A dopamine infusion was started and ephedrine boluses were given intermittently. Blood loss was estimated at 29 ml kg–1. Because of haemodynamic instability he was transferred to the PICU for postoperative ventilation. He was extubated after 24 h and discharged home on the 13th postoperative day.
Case 7. This was a 14-yr-old boy with DMD, who underwent posterior spinal fusion with instrumentation. Preoperative FVC was 52% of predicted and a FS of 30%. Surgery took 6 h and intraoperative blood loss was 61 ml kg–1. Intraoperatively he developed a supraventricular tachycardia and was treated with adenosine and amiodarone. Dopamine and ephedrine were used to treat hypotension. In view of this haemodynamic instability he was transferred to the PICU for further management. He was extubated 3 h later and dopamine was weaned off during the next day. Otherwise the postoperative course was uneventful and he was discharged home on the 11th day.
Case 8. This was a 12-yr-old boy with DMD and Dejerine-Sottas Syndrome, a hereditary motor and sensory neuropathy.7 To our knowledge this is the first anaesthesia description in a patient with Dejerine-Sottas Syndrome and DMD. Preoperative FVC was 61% of predicted and a FS of 34%. A posterior spinal fusion and instrumentation were performed. Blood loss was 23 ml kg–1. Extubation was attempted at the end of surgery, but because of poor respiratory effort the child was ventilated. He was extubated the next day after 23 h of ventilation. Re-intubation was required on the second postoperative day because of marked dyspnoea. A chest radiograph revealed that he had developed pneumonia. He was subsequently extubated on the sixth postoperative day.
Case 9. This was a 13-yr-old girl with hypomelanosis of Ito, a neurocutaneous syndrome characterized by hypopigmentation, developmental delay, hypotonia, and seizures.8 To our knowledge this is the first description of anaesthesia in a patient with hypomelanosis of Ito. The child had a history of recurrent aspiration. A recent videofluroscopy had shown a poor cough reflex. Unfortunately she was unable to perform a spirometry test, and an echocardiography revealed a FS of 30%. An anterior release and posterior spinal fusion was performed. Blood loss was estimated at 20 ml kg–1. At the end of surgery extubation was attempted, but failed because of slow recovery from anaesthesia and poor cough. She was extubated on the third postoperative day, but required re-intubation because of a seizure.
Case 10. This was a 12-yr-old boy with neurofibromatosis who could only walk with aid of the frames. Preoperative FVC was 72% of predicted and an echocardiograph had not been performed. He underwent an anterior release and posterior spinal fusion with instrumentation. As the duration of surgery had exceeded 10 h, it was decided to transfer the patient to PICU for ventilation. The patient was extubated after 12 h. The postoperative course was uneventful and he was discharged home on the 10th postoperative day. Table 5 summarizes the data for the patients ventilated.
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Discussion |
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Until recently our practice was to routinely ventilate all children with neuromuscular disease undergoing complex spinal deformity in the postoperative period like most other institutions because of anaesthetic and patient factors.4 9 Avoiding mechanical ventilation may be beneficial, as even brief periods of mechanical ventilation have been associated with life-threatening complications such as barotrauma,10 ventilator induced lung injury11 and ventilator associated pneumonia.12 The other major disadvantage is that neurological assessment for spinal cord injury may be more difficult in sedated children. In addition PICU beds are a scarce and expensive resource that needs to be taken into consideration.
Therefore from early 2002, we have changed both our anaesthetic technique and our practice to routinely ventilate after operation, although we always ensure that a PICU bed is available for postoperative ventilation if necessary. We changed from using inhaled isoflurane and i.v. fentanyl infusion to sevoflurane and i.v. remifentanil. In addition we use aprotinin to reduce blood loss during surgery. Aprotinin has been shown to be effective during deformity surgery.13 14 Massive blood loss may lead to both haemodynamic instability and the need for massive transfusion of blood and blood products with their associated pulmonary complications (transfusion-related acute lung injury, ventilator associated pneumonia).15 16 We also introduced the TOD as part of our routine haemodynamic monitoring in order to assess continuously cardiac output, stroke volume, preload and systemic vascular resistance. Central venous pressure alone is known to be a misleading monitor of volume status, especially in the prone position17 and pulmonary artery catheterization is associated with a number of complications. Recently the oesophageal Doppler has been validated as a non-invasive alternative to the pulmonary artery catheter for continuously monitoring the cardiac status.18 19 In our study, four patients suffered from intraoperative haemodynamic instability requiring inotropic support, in two of them it was the reason for unplanned postoperative ventilation. Haemodynamic instability is caused by either a reduction in preload, an increase in afterload, impaired contractility or any combination of the above. The prone position alone can reduce the cardiac output from decreased venous return and increased intrathoracic pressure.20 Secondly, major blood loss is a significant factor for reduction in preload, this could be a factor in one of our patients who developed haemodynamic instability. Thirdly impaired contractility especially in boys with DMD might be exacerbated by anaesthetic drugs and hypovolaemia. Finally, vascular smooth muscle dysfunction in DMD patients (from a lack of dystrophin) might explain the need for vasoconstrictors despite adequate fluid resuscitation.21 22 Acute heart failure during spinal surgery has been reported by Schmidt.23 A boy with DMD developed intraoperative tachyarrythmia and hypotension despite adequate fluid resuscitation. Furthermore preoperative echocardiography had revealed good ventricular function with a FS of 44%. One of the main reasons why preoperative echocardiography may be a poor predictor of perioperative morbidity is that these are resting tests. They do not give any information as to how the myocardium will perform under stress, such as that during major surgery. Ideally stress echocardiography should be performed as an extension of traditional resting evaluations in order to assess contractile reserve. High-quality ultrasound equipment and special expertise are required though.24
The above results show that our current rate of ventilation is now 23.8%, with half of the cases being planned before operation. Postoperative ventilation was planned for these patients because of either severely compromised cardiac and/or respiratory function, or because a prolonged procedure was anticipated. There were five cases of unplanned ventilation; two patients had poor respiratory effort during recovery, two patients with DMD developed intraoperative haemodynamic instability and one case where the surgery lasted more than 10 h. The two patients who presented with poor cough reflex and weak respiratory effort at emergence suffered both from severe neurological diseases. We suppose that respiratory control was impaired at emergence because of extreme sensitivity to central nervous system depressants. We do not believe inadequate pain relief was the reason for respiratory failure as sufficient analgesia had been administered by the epidural and i.v. route.
Although there were no specific factors that could predict the need for postoperative ventilation, there was an increased tendency for children with DMD and those with a preoperative FVC<30% of predictive towards requiring postoperative ventilation. Zhang reported similar findings in their study.25
In our series 76.2% of patients were safely extubated at the end of surgery without any further complications or the need for re-ventilation. Furthermore only 9.5% of patients in our series required ventilation for more than 3 days, which is much lower, than compared with other studies. Yuan reported prolonged postoperative ventilation in 32% of children with a FVC<40% of predicted.5
Our intraoperative and postoperative cardiopulmonary complication rate was 9.5%, respectively; this was less than that reported by Rawlins26 and Anderson27 who had a 19% and 20.7% incidence of postoperative pulmonary complications in their respective studies.
Patients with DMD have a higher risk of perioperative complications as both respiratory and cardiac function may be severely reduced. Moore considered an FVC<25% and left ventricular ejection fraction of <50% a contraindication for elective surgery.28 Furthermore blood loss is often increased because of changes in the structure of vascular smooth muscle.29 In our series 40% (6 of 15) of patients with DMD required postoperative ventilation; 2 of them had postoperative pulmonary complications, but no patient required tracheostomy or long-term ventilation and there was no mortality. Four patients had an FVC<30%. Marsh30 reported 30% complication rate in patients with DMD irrespective of their preoperative FVC. All patients were routinely ventilated after operation for a mean time of 77 h; in addition two patients required a tracheostomy and long-term ventilation. Routine postoperative ventilation of these children did not appear to confer any specific advantage or reduce the rate of postoperative complications. Unfortunately all the above-cited studies do not give any detailed description of the anaesthesia technique used. Hence no direct comparison with our findings is possible.
Recently the use of NIPPV for early extubation of boys with DMD has been described.31 Two patients in our study with extremely low FVC (18% and 10%) were on nocturnal non-invasive ventilation before surgery. They were extubated at the end of procedure in theatre and transferred to their NIPPV devices after operation. This may be a technique that needs to be considered in the future, as more children are being offered early home NIPPV as a means of preventing the development of respiratory complications.
Clearly early extubation is possible in this patient group, provided that the FVC>30%, intraoperative haemodynamic stability is maintained, good postoperative pain relief is achieved with a combination of epidural analgesia and i.v. morphine. Using ultra short-acting potent analgesics such as remifentanil and rapidly eliminated inhalation anaesthetics such as sevoflurane have a distinct advantage in the recovery. Recently the favourable profile of remifentanil and desflurane on intraoperative wake-up test and postoperative emergence has been described.32 We believe our success with early extubation in this patient group has been a result of these new drugs.
In conclusion, our results show that early extubation can be safely performed after spinal fusion surgery in patients with non-idiopathic scoliosis. Comprehensive preoperative assessment and careful patient selection by the spinal team is paramount. The use of short-acting anaesthetics, drugs to reduce blood loss, postoperative pain relief, experienced spinal anaesthetists and the availability of intensive care support are all essential for a good outcome after major spinal surgery in patients with non-ideopathic scoliosis and cardiopulmonary co-morbidity.
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