Lumbar CSF Drains for Thoracic Aortic Surgery

Transcription

1 Lumbar CSF Drains for Thoracic Aortic Surgery John C. Klick, MD CASE CAG

2 Why do them? Open descending thoracic aortic aneurysm repair (still the gold standard) has an incidence of postoperative paraplegia between 2.7% and 14.3% There is no data supporting a survival advantage of endovascular thoracic stent therapy over open repair, although the incidence of paraplegia does appear to be lower Glade GJ, Vahl AC, Wisselink W, Linsen MAM, and Balm R:Mid-term Survival and Costs of Treatment of Patients with Descending Thoracic Aortic Aneurysms; Endovascular vs. Open Repair: A Case-controlled Study. European Journal of Vascular and Endovascular Surgery 2005; 29:28-34

3 Why do them? Data from three randomized controlled trials (a total of 289 patients) showed a reduction in lower limb neurologic deficits from 33% to 12% Postoperative paraplegia and paralysis are associated with a 20% increase in mortality Cina CS, Abouzahr L, Arena GO, et al. Cerebrospinal Fluid Drainage to Prevent Paraplegia During Thoracic and Thoracoabdominal Aortic Aneurysm Surgery: A Systematic Review and Meta-Analysis. Journal of Vascular Surgery 2004: 40:36-44.

4 Mechanism of Spinal Cord Injury Mechanism of injury is multifactorial Inadequate pre-existing vascularization of spinal cord Interruption of blood flow Inadequate revascularization of spinal arteries during aortic reconstruction Spasm of the microcirulation Increased spinal fluid pressure Cina CS, Abouzahr L, Arena GO, et al. Cerebrospinal Fluid Drainage to Prevent Paraplegia During Thoracic and Thoracoabdominal Aortic Aneurysm Surgery: A Systematic Review and Meta-Analysis. Journal of Vascular Surgery 2004: 40:36-44.

5 Aortic Cross Clamping and the Spinal Cord Aortic cross clamping decreases distal MAP and increases CSF pressure (CSFP) due to increased CVP and CSF production Net result is that spinal cord perfusion pressure (SCPP) is decreased (MAP-CSFP) Puchakayala, MR and Lau, WC. Descending Thoracic Aortic Aneurysms. Continuing Education in Anaesthesia, Critical Care & Pain: 6(2): 54-59

6 The Kit Various commercial CSF drainage kits are available At UH, we use the Medtronic lumbar drainage kit which is available in the OR sterile supply area with the neurosurgical supplies

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9 Insertion Technique Sterile technique, including chlorhexidine prep, full gown, sterile drape, sterile gloves, mask, hat Insertion is typically at L3-L4 or L4-L5 After infiltration of local anesthetic, the 14 gauge tuohy needle is advanced into the intrathecal space and the free flow of CSF is confirmed

10 Insertion Technique The CSF drainage catheter is advanced 5-7 cm into the intrathecal space CSF drainage is confirmed, and the catheter is taped to the skin with a clear occlusive dressing

11 Intraoperative Drainage Connect the drain to a pressure transducer and level it at the level of the right atrium CSF is generally drained in 10 ml increments with a goal CSF pressure of less than 10 mmhg Estrera AL, Sheinbaum R, Miller CC, et al., Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. The Annals of Thoracic Surgery, 2009; 88: 9-15

12 Management of the Lumbar Drain Set drain to overflow at a CSFP of 10cm H2O or intermittently drain to maintain a CSFP around 10 cm H2O Continue drainage for at least hours postop to minimize chances of delayed neurologic deficits Maintain MAP between mmhg postoperatively Puchakayala, MR and Lau, WC. Descending Thoracic Aortic Aneurysms. Continuing Education in Anaesthesia, Critical Care & Pain: 6(2): 54-59

13 Postoperative Drainage If the CSF pressure exceeds 10mmHg, CSF is drained to a limit of 15 ml/hour when the patient is neurologically intact If delayed neurologic deficit occurs, CSF is drained without limit to maintain a pressure of less than 5 mmhg, provided there is no visible blood in the CSF Estrera AL, Sheinbaum R, Miller CC, et al., Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. The Annals of Thoracic Surgery, 2009; 88: 9-15

14 COPS Protocol for Delayed Neurologic Deficits BP=Blood Pressure, BSA= Body Surface Area; COPS=CSF Drainage/Oxygen Delivery/Patient Status; CSFP=Cerebrospinal Fluid Pressure; MAP= Mean Arterial Pressure; SCPP or spinal cord perfusion pressure=mean arterial pressure-cerebrospinal fluid pressure Estrera AL, Sheinbaum R, Miller CC, et al., Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. The Annals of Thoracic Surgery, 2009; 88: 9-15

15 Bloody Tap If there is a bloody tap, the needle is reinserted at a different interspace If blood is still obtained on a second attempt and does not clear from the CSF after a few cc aspiration, the case is delayed

16 Surgical Techniques to Minimize Spinal Cord Injury Reduction of cross clamp time Reattachment of intercostal arteries (indiscriminately or after localization of spinal cord circulation contributors) Distal perfusion Pump bypass Cina CS, Abouzahr L, Arena GO, et al. Cerebrospinal Fluid Drainage to Prevent Paraplegia During Thoracic and Thoracoabdominal Aortic Aneurysm Surgery: A Systematic Review and Meta-Analysis. Journal of Vascular Surgery 2004: 40:36-44.

17 Complications of CSF Drainage Subdural hematoma CSF leak and spinal headache Meningitis Catheter Fracture Intracranial Hemorrhage Estrera AL, Sheinbaum R, Miller CC, et al., Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. The Annals of Thoracic Surgery, 2009; 88: 9-15

18 Complications of CSF Drainage Overall complications have been reported as high as 5% Most significant complication is intracranial hemorrhage, with an associated mortality as high as 50% High volume centers report a complication rate closer to 1.5% Any blood noted in the CSF drainage should lead to cessation of drainage and immediate head CT Estrera AL, Sheinbaum R, Miller CC, et al., Cerebrospinal Fluid Drainage During Thoracic Aortic Repair: Safety and Current Management. The Annals of Thoracic Surgery, 2009; 88: 9-15