Outcomes of a Spinal Drain and Intraoperative Neurophysiologic Monitoring Protocol in Thoracic Endovascular Aortic Repair.

BACKGROUND: Adjuncts for early detection and treatment of spinal cord ischemia (SCI) in thoracic aortic surgery are supported by robust clinical experience in open repair. The utility of cerebrospinal fluid (CSF) drainage and neurophysiologic monitoring (NPM) in thoracic endovascular aortic repair (TEVAR) is less clear. The purpose of this investigation is to determine the influence of a selective institutional spinal cord protection protocol using prophylactic NPM and CSF on outcomes for standard TEVAR. METHODS: Patients undergoing standard TEVAR entered into a prospectively maintained database from a single institution from 2007 to 2016 were retrospectively reviewed. Preoperative characteristics, aneurysm extent, and etiology were reviewed. Utilization of CSF drains including volume of fluid removed, duration of drainage, and catheter-related complications were collected. NPM data were reviewed to determine the influence on intraoperative management. Exact logistic regression was used to identify independent predictors of SCI. RESULTS: Of 223 patients undergoing TEVAR, 130 met inclusion criteria for the study. CSF drains were used in 71 patients (54.6%), and 56 of 130 (43%) had NPM. SCI occurred in 7 patients (5.4%), of whom 5 had partial or complete recovery. Median time to symptoms of SCI was delayed in all cases (median 52 hr, range 8-312), and none of the 4 of 7 patients with adjunct NPM demonstrated intraoperative changes. Intraoperative changes in NPM occurred in 26 (46%), and represented unilateral leg ischemia in all but 2 cases. In both patients, changes consistent with SCI were associated with intraoperative hypotension and resolved with blood pressure augmentation. Neither patient developed postoperative SCI. Median length of stay (22 vs. 9 days, P = 0.012), operative room time (262 vs. 209, P = 0.040), and perioperative mortality (28.6% vs. 4.1%, P = 0.046) were significantly higher for patients with SCI versus those without. Length of aortic coverage was found to be the sole independent predictor of SCI (odds ratio 8.2, P = 0.026). Complications related to CSF drainage occurred in 4 patients (5.6%) with major complications occurring in 2 patients (2.8%), including 1 with an intrathecal hematoma and permanent bilateral paraparesis. CONCLUSIONS: Selective use of prophylactic CSF drainage in TEVAR was associated with moderate risk and questionable benefit. The use of neurophysiological monitoring allowed for early detection and treatment of spinal ischemia, but its utility is limited by logistical factors and to the minority of patients with intraoperative spinal ischemic events.

Results of adjunctive spinal drainage and/or left subclavian artery bypass in thoracic endovascular aortic repair.

BACKGROUND: The adjunctive use of a preoperative cerebrospinal fluid (CSF) drain and/or left subclavian artery (LSA) bypass for thoracic endovascular aortic repair (TEVAR) to minimize neurologic complications remains controversial. METHODS: A retrospective review was conducted of a prospective database of patients undergoing TEVAR from April 2005 through August 2012. CSF drainage was performed under local anesthesia in a staged fashion prior to TEVAR. When possible, LSA bypass was also performed prior to TEVAR. Adjunctive procedures were not performed for patients in emergent operations. Preoperative characteristics, operative variables, outcomes, neurologic complications, and survival status were recorded. RESULTS: Ninety patients underwent TEVAR at our institution during the study period with a mean follow-up of 23 months (IQR 7-50). Mean age was 67.3 years (SD 13.8) and 48 (53%) were male. One (1%) patient had a connective tissue disorder. Sixty-six (73%) patients presented with degenerative aneurysm, 13 (14%) with chronic type B dissection, 6 (7%) with pseudoaneurysm, and 5 (6%) with traumatic aortic pathology. Fourteen (16%) had acute ruptures. Sixty-seven (74%) patients underwent adjunctive procedures for TEVAR including a CSF drain (n = 48, 53%), LSA bypass (n = 7, 8%), or both (n = 12, 13%). CSF drain placement was uncomplicated in all instances. Cerebral ischemia was seen in 2 (2%), which recovered with further surgical therapy. Embolic stroke was appreciated in 1 (1%). Delayed spinal cord ischemia (SCI) occurred in 3 (3%) patients and was reversed with hypertensive therapy in 2 to ambulatory status at discharge. The 30-day permanent SCI and mortality were 0.9% and 3%, respectively. CSF drain placement was associated with improved 1-year survival (P = 0.03). CONCLUSIONS: Our use of adjunctive procedures for TEVAR demonstrated better SCI results compared with those of prior reports of selective CSF drainage when SCI arises. Our approach was associated with improved 1-year survival. Preoperative CSF drain placement allows for rapid, intensive therapy for SCI and should be considered when clinically feasible.

[Anaesthics incidents - Injuries caused by regional anaesthesia - closed claims of the North German Arbitration Board]. / Anästhesiezwischenfälle - Schäden durch Regionalanästhesie - "closed claims" der Norddeutschen Schlichtungsstelle.

Injuries caused by regional anaesthesia are the second most common reason for a patient to apply to the North German Arbitration Board. Part of the reported injuries are mild and transient, while others are severe and permanent, e.g. a paraplegia after regional anaesthesia. In the majority of the reported cases, the Arbitration Board did not find a medical error as cause of the injury. Nevertheless, every possible effort needs to be made to reduce the number and the severity of the injuries due to regional anaesthesia. In order to reach that goal, medical treatment has to be applied with the appropriate care, including the strict adherence to the height of puncture for epidural and spinal anaesthesia below the Conus medullaris and the use of assisting devices like nerve stimulator and ultrasound-guided puncture. Using these measures, the frequency of injuries caused by regional anaesthesia will be reduced.

Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008.

OBJECTIVE: Spinal fluid drainage reduces paraplegia risk in thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysm repair. There has not been a comprehensive study of the risks of spinal fluid drainage and how these risks can be reduced. Here we report complications of spinal fluid drainage in patients undergoing TAA/TAAA repair. METHODS: The study comprised 648 patients who had TAA or TAAA repair from 1987 to 2008. Spinal drains were used in 486 patients. Spinal fluid pressure was measured continuously, except when draining fluid, and was reduced to <6 mm Hg during thoracic aortic occlusion and reperfusion. After surgery, spinal fluid pressure was kept <10 mm Hg until patients were awake with normal leg lift. Drains were removed 48 hours after surgery. Spinal and head computed tomography (CT) scans were performed in patients with bloody spinal fluid or neurologic deficit. We studied the incidence of headache treated with epidural blood patch, infection, bloody spinal fluid, intracranial and spinal bleeding on CT, as well as the clinical consequences. RESULTS: Twenty-four patients (5%) had bloody spinal fluid. CT exams showed seven had no evidence of intracranial hemorrhage, 14 (2.9%) had intracranial blood without neurologic deficit, and three with intracranial bleeding and cerebral atrophy had neurologic deficits (1 died, 1 had permanent hemiparesis, and 1 with transient ataxia recovered fully). Two patients without bloody spinal fluid or neurologic deficit after surgery presented with neurologic deficits 5 days postoperatively and died from acute on chronic subdural hematoma. Neurologic deficits occurred after spinal fluid drainage in 5 of 482 patients (1%), and 3 died. The mortality from spinal fluid drainage complications was 0.6% (3 of 482). By univariate and multivariate analysis, larger volume of spinal fluid drainage (mean, 178 mL vs 124 mL, P < .0001) and higher central venous pressure before thoracic aortic occlusion (mean, 16 mm Hg vs 13 mm Hg, P < .0012) correlated with bloody spinal fluid. CONCLUSION: Strategies that reduce the volume of spinal fluid drainage but still control spinal fluid pressure are helpful in reducing serious complications. Patients with cerebral atrophy are at increased risk for complications of spinal fluid drainage.

Post-dural puncture bacterial meningitis.

A fatal case of viridans streptococcus meningitis is reported, which occurred as a complication of epidural anesthesia. One hundred seventy-nine reported cases of post-dural puncture meningitis are reviewed. Evidence suggests that most cases are probably caused by contamination of the puncture site by aerosolized mouth commensals from medical personnel, some are caused from contamination by skin bacteria, and, less frequently, other cases are caused directly or hematogenously by spread from an endogenous infectious site. Controversy exists regarding prevention, surveillance, incidence, and treatment of this serious complication.

Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma.

Recent reports and commentaries have emphasized the alleged risk of cerebral herniation complicating lumbar puncture performed to diagnose acute bacterial meningitis. Instead, knowledge of facts relevant to the disease process can provide a rational and reassuring approach to management. All cases of purulent meningitis are associated with increased intracranial pressure, but herniation is a rare complication (5%). Despite suggestions to the contrary, cranial computed tomography (CT) is normal in most cases of purulent meningitis, including those with subsequent herniation. Additionally, CT may be associated with long-term radiation effects. An accurate clinical history combined with recognition of the early systemic and neurologic findings of bacterial meningitis will indicate a safe setting for performance of a diagnostic lumbar puncture with little likelihood of complicating herniation. In contrast, in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation, a delay of the diagnostic procedure is indicated. In this latter circumstance, a different approach in management can be developed.

Presentation and outcome of sporadic acute bacterial meningitis in children in the African meningitis belt: recent experience from northern Nigeria highlighting emergent factors in outcome.

Sixty-six (19.4%) of 341 acutely ill infants and children (> 1 mo-15 yr old) who had a lumbar puncture (LP) done during an inter-epidemic period had bacterial meningitis (BM). No clinical feature was sufficiently characteristic of the presence of BM. Twenty (30.3%) of the 66 patients with BM lacked typical signs of meningitis at the time of diagnosis whereas 61 (22.2%) of the 275 with other illnesses had signs. Three (4.6%) of the 66 patients with BM were discharged against medical advice, 31 (47%) survived intact and 16 (24.2%) each died or survived with sequelae. Case fatality rate was significantly higher in children with coma, focal extracranial infections, delayed diagnosis of BM after admission, irregular administration of antibiotic drugs and treatment with dexamethasone. Among survivors, sequelae rate was significantly higher in children with delayed presentation, convulsions, coma, and prolonged hospitalisation (> 10 days); sequelae rate in patients with convulsions was significantly higher in those with complex convulsions and convulsions occurring after 24 hours of treatment. Irregular provision of drugs by parents and delay in the diagnosis of BM after admission are emergent factors which, in addition to the well known factors of malnutrition and delayed presentation, further worsen the prognosis of BM. A more liberal policy in the use of LPs in acutely ill children is advocated to reduce the risk of missed diagnosis.

The use of lumbar puncture in a district general hospital.

A survey of lumbar punctures performed in adults in a district general hospital over a two year period was carried out. As well as being used for conventional, specific indications, lumbar puncture was often employed as a screening investigation in undiagnosed neurological illness. Although this was not inappropriate in patients with meningeal symptoms and signs, or patients with disordered consciousness, lumbar puncture was also used in patients with focal neurological signs. Although the dangers of lumbar puncture in these latter patients, and the fact that it is unlikely to yield information unobtainable by other investigations have been stated by many authorities, almost 20% of patients fell into this group. This suggests that these points require further emphasis.