May FY23

[A Schutter]

This Month's Journal Club is presented by Amy Swank, CRNA She chose an article from the AANA Journal titled "Asystole During Elective Cervical Spine Surgery: A Case Study

Here is a link to the article.

Questions to engage discussion:

1.  What considerations related to cervical spine surgeries and positioning should be considered with providing anesthesia to these patients?

2.  Have you ever encountered such an event? What pearls of wisdom might you share?

[kels]

In this cervical spine case report the episode of asystole that occurred resulted from surgical retraction . If asystole happens in these types of cases it would not hurt to ask surgery to release any traction on the surgical site if possible . If the head/ neck was extended in any way placing the head back in a neutral position could also be helpful . I have not encountered an event like the ones discussed in the article .

[Anne McNulty CRNA]

(1) Positioning for c spine surgery in the prone position always involves avoiding any pressure on eyes and nose. POVL is a real possibility. Pressure sores on skin, especially large breasts can occur in the prone position. Male genitals have to be carefully padded. Arms must not have any stretch on the brachial plexus. (2) I have done hundred of c spine surgeries and have not had asystole. I have had asystole in prostate surgeries , colonoscopy and bowel surgery. Release of retraction along with .5 mg of atropine resolved the issue. If the heart does not respond to either of these interventions , covering the surgical wound, and turning the patient supine to begin CPR may be the last intervention. This can be a challenge if there is not a stretcher available

[aileenm4]

1. neutral neck position and possibly asking patient to position themselves with neutral neck prior to induction, and use minimal manipulation with intubation. neutral arms/shoulder positioning. I do agree to use Glyco if brady HR is an issue
2. I have never had asystole during spine surgery

[Wai-Ling Lo]

1. What considerations related to cervical spine surgeries and positioning should be considered with providing anesthesia to these patients?
Keep neck in neutral position and minimal manipulation with intubation (fiberoptic intubation if indicated); if pt is in prone position, avoid pressure on eyes/nose/breasts/genital area and maintain head/neck/shoulder/arms/body in neutral position.

2. Have you ever encountered such an event? What pearls of wisdom might you share?
No I haven't. But have significant bradycardia with insufflation of abdomen (Rx: stopped insufflation and gave Atropine). Pearls of wisdom: Stay vigilant and pay attention to what the surgical team is doing will save lives. Good and constant communication between anesthesia and surgical team is also vital.

[nanci]

1. What considerations related to cervical spine surgeries and positioning should be considered with providing anesthesia to these patients?
Consider vagal stimulation with retraction and placement of hardware that can cause vagal events leading to asystole; communication with surgical team important especially during critical times. I had not been aware that it was considered safer for a left sided surgical approach from some studies but will be more aware that Right Vagus (Sinoatrial node) and Left Vagus (AV node) can both result in cardiac impacts.
Hemorrhage (damage to vertebral or carotid artery), venous air embolus, bradycardia, asystole, blood pressure extremes can all happen with spine surgery and should be high on differential for deleterious physiological effects. Positioning prone can delay compressions if needed and when positioned in semi-sitting positions can be associated with greater risk of venous air embolism and tension pneumocephalus.


2. Have you ever encountered such an event? What pearls of wisdom might you share?
Have not yet had any asystole events during cervical spine cases.
Have had severe hemorrhage happen and had the patient remain intubated post op with concerns for potential wound hematoma development that could cause airway obstruction. This patient was an otherwise healthy adult (albeit a smoker like the patient in the case study) and the hemorrhage did not lead to cardiac events.

[Tracey Trainum]

1. Positioning:

Position considerations supine/prone include: Be aware of baseline neuropathies secondary to cervical spine disease and consider having patient position self for induction, minimize head/neck manipulation during DL- consider using CMAC/Glidescope, eye protection, padding of pressure points. Prone position requires special attention to pressure points- including face (eyes, nose, chin), male genitalia, women's breasts.

2. I have not had not encountered this issue so far in my career. Open communication with the surgeon is super important in all cases, but of particular importance when issue begin to arise.