Lumbar CSF Drains for Thoracic Aortic Surgery - … Drain Protocol-Synopsis.pdf · Lumbar CSF...

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Lumbar CSF Drains for Thoracic Aortic

Surgery

John C. Klick, MD

CASE CAG

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

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.

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

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

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

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

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

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

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 48-72 hours postop to minimize chances of delayed neurologic deficits

• Maintain MAP between 80-100 mmHg postoperatively

Puchakayala, MR and Lau, WC. Descending Thoracic Aortic Aneurysms. Continuing Education in Anaesthesia, Critical Care & Pain: 6(2): 54-59

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

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

“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

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

Complications of CSF Drainage

• Subdural hematoma

• CSF leak and spinal headache

• Meningitis

• Catheter Fracture

• Intracranial Hemorrhage

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

Lumbar CSF Drains for Thoracic Aortic Surgery - … Drain Protocol-Synopsis.pdf · Lumbar CSF...

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