Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
Curr Opin Anaesthesiol. 2019 Oct;32(5):600-608. doi: 10.1097/ACO.0000000000000765.
The aim of this article is to review the evidence regarding the anesthetic management of blood loss, pain control, and position-related complications of adult patients undergoing complex spine procedures.
The most recent evidence of the anesthetic management of complex spine surgery was identified with a systematic search and graded. In our review, prophylactic tranexamic acid and optimal prone positioning were shown to be effective blood conservation strategies with minimal risks to the patients. Cell saver was cost-effective in complex surgeries with expected blood loss of greater than 500 ml. As for pain control, most interventions only produced mild analgesic effects, suggesting a multimodal approach is necessary to achieve optimal pain control after spine surgery. Regional techniques and NSAIDs were effective but because of their risks, their usage should be discussed with the surgical team. Further studies are required to assess the effectiveness, cost-effectiveness, and risks associated with combined uses of different analgesic interventions. On the basis of the available evidence, we recommend a combined use of gabapentinoids, ketamine, and opioids to achieve optimal analgesia. Lastly, literature for position-related injuries is heavily relied on case reports and the Anesthesia Closed Claim Study because of their rarity. Therefore, we advocate for a structured team-based approach with checklists to minimize position-related complications.
As the number and complexity of spine procedures are being performed worldwide is increasing, we suggested to bundle the aforementioned effective interventions as part of an ERAS spine protocol to improve the patient outcome of spine surgery.
本文旨在回顾成人接受复杂脊柱手术时有关失血管理、疼痛控制和体位相关并发症的麻醉管理的证据。
通过系统搜索和分级，确定了复杂脊柱手术麻醉管理的最新证据。在我们的综述中，预防性使用氨甲环酸和最佳俯卧位被证明是有效的血液保护策略，对患者的风险最小。对于预计失血量超过 500ml 的复杂手术，血液回收机具有成本效益。至于疼痛控制，大多数干预措施仅产生轻度镇痛效果，表明需要采用多模式方法才能在脊柱手术后实现最佳疼痛控制。区域技术和 NSAIDs 有效，但由于其风险，应与手术团队讨论其使用。需要进一步研究评估不同镇痛干预措施联合使用的有效性、成本效益和风险。基于现有的证据，我们建议联合使用加巴喷丁类药物、氯胺酮和阿片类药物以达到最佳镇痛效果。最后，由于其罕见性，与体位相关损伤相关的文献主要依赖于病例报告和麻醉理赔研究。因此，我们提倡采用结构化的基于团队的方法和检查表，以最大程度地减少体位相关并发症。
随着全球进行的脊柱手术数量和复杂性的增加，我们建议将上述有效干预措施作为加速康复外科脊柱方案的一部分，以改善脊柱手术患者的结局。
