D.2. Two hours following arrival in the ICU, the patient is unable to move his lower extremities. How are symptoms of spinal cord compromise or ischemia managed?
Answer:
Postoperative neurologic complications can contribute to significant morbidity following open TAAA repair. The incidence of perioperative stroke is 2% to 3%, and spinal cord injury is 3% to 10%. Neurologic assessment, especially of lower extremity movement, is paramount in the immediate postoperative period. The degree of neuromuscular block should be noted upon exiting the operating room (OR), and reversal considered to facilitate a neurologic assessment. An effective sedation strategy can include liberal opioid administration and limited sedatives/hypnotics.
Spinal cord injury can be immediate or delayed. Spinal cord injury occurs more often with type I and II TAAAs, emergent operations, intercostal sacrifice, and intraoperative hypotension. The majority of deficits are immediate; however, delayed deficits can occur hours to weeks postoperatively. Immediate-onset deficits are irreversible and portend a poor prognosis, whereas delayed-onset deficits typically have a better prognosis with partial and reversible deficits and acceptable functional outcomes. Management of immediate- and delayed-onset deficits focuses on CSF drainage to a CSF pressure of 12 mm Hg and limited to 20 mL/h, maintaining systemic blood pressure to a MAP of 85 to 95 mm Hg for improved spinal cord perfusion, and a hemoglobin threshold of 10 g/dL for oxygen delivery. Further increases in MAP or additional CSF drainage can be considered with continued evidence of spinal cord ischemia.
References
- Chatterjee S, Casar JG, LeMaire SA, Preventza O, Coselli JS. Perioperative care after thoracoabdominal aortic aneurysm repair: The Baylor College of Medicine experience. Part 2: Postoperative management. J Thorac Cardiovasc Surg. 2021;161:699-705.
- Coselli JS, LeMaire SA, Orozco-Sevilla V, Preventza O, Moon MR, Barron LM, Chatterjee S. Current approaches to spinal cord protection during open thoracoabdominal aortic aneurysm repair. Ann Cardiothorac Surg. 2023;12:429-437.
- Khan FM, Naik A, Hameed I, et al. Open repair of descending thoracic and thoracoabdominal aortic aneurysms: a meta-analysis. Ann Thorac Surg. 2020;110:1941-1949.