Anesthetic management

Anesthetic management in patients with acute cervical spinal cord injury may require the following monitoring and instrumentation: electrocardiography; arterial catheter to measure arterial blood pressure; pulmonary artery catheter to measure cardiac output, pulmonary artery pressure, and pulmonary artery wedge pressure; sophisticated mechanical ventilation devices; end-tidal CO 2; pulse oximetry; blood gas analysis; somatosensory evoked potentials; temperature devices; nasogastric tube to reduce abdominal distension and risk of aspiration, and to measure gastric pH; urinary catheter; warming devices. The optimal technique of endotracheal intubation in patients with cervical spinal injury is related to the condition of the patient and his or her level of co-operation, the neurological deficit, and the training and experience of the individual performing the intubation. In conscious normoxic normocapnic patients without head injury, awake elective nasotracheal intubation may be performed following topical anesthesia of the nose, pharynx, and larynx using the blind nasal technique or fiber-optic devices. In patients with unstable injuries of the spine, neurological function frequently becomes worse as flexion of the neck occurs and thus should be avoided.

Consequently, collar devices and/or manual in-line traction should be used to immobilize the neck and support decompression of the spine during tracheal intubation. Manual in-line traction is performed by applying a traction force of less than 10 lb in the cephalad direction with the mastoid processes in line with the axis of the spine. In unconscious hypoxic hypercapnic patients with or without head injury, emergency oral intubation should be performed using rapid-sequence induction techniques and manual in-line traction. Thiopental (thiopentone) and succinylcholine (suxamethonium) may be used for rapid-sequence induction, since hyperkalemia from denervation sensitivity will not occur until 48 h after injury.

The concept of general anesthesia and sedation in patients with spinal cord injury is based on the maintenance of coupling between metabolism and spinal cord blood flow while achieving hypnosis, analgesia, and a 'relaxed cord'. This concept includes maintenance of normal to high systemic perfusion pressures, normoxia, and normocapnia. No particular anesthetic technique has been demonstrated to be superior, and total intravenous anesthesia using hypnotics (propofol, methohexital) in combination with narcotics (fentanyl, sufentanil, remifentanil) is as appropriate as any balanced technique using a combination of volatile anesthetics (halothane, isoflurane, sevoflurane) and narcotics. Although unproven, nitrous oxide should be avoided since it may produce neuroexcitation in ischemic tissues.

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