GA2-67
Anesthetic Management During Posterior Spinal Fusion in a Patient with Moyamoya Disease
Romnek M, Martin D, Gill L, Klamar J, Tobias J
Nationwide Children's Hospital, Columbus, OH, USA
Moyamoya disease (MMD) is a central nervous system arteriopathy leading to ischemic and thrombotic strokes. Collateral circulation creates the angiographic appearance of a “puff of smoke†giving the disease its name. Multi-organ involvement and co-morbidities may require surgical intervention. We present a patient with MMD who required anesthesia for posterior spinal fusion (PSF) for neuromuscular scoliosis. Intraoperative physiologic parameter management, cerebral oxygenation monitoring via near infrared spectroscopy (NIRS), and options for anesthetic care are reviewed.
An 18-year-old woman with MMD and prior left middle cerebral artery stroke presented for PSF with instrumentation and pelvic fixation for neuromuscular scoliosis. Medical history included cerebral palsy, spastic quadriparesis, seizures, asthma, G-tube dependence, and sickle cell disease after bone marrow transplant. Prior anesthetic issues were difficult IV access, slow emergence, and perioperative respiratory insufficiency. In the operating room standard ASA monitors, bispectral index monitor, and bilateral NIRS were placed while on room air before induction. Inhalation induction used sevoflurane and a 20 gauge IV was placed. Midazolam, propofol and rocuronium facilitated endotracheal intubation. A 14 gauge IV was placed in the basilic vein using ultrasound and baseline laboratory values were obtained. A radial artery arterial cannula and a double-lumen, internal jugular central venous catheter were placed with ultrasound. Motor and somatosensory evoked potential monitors were placed. Maintenance of anesthesia used a remifentanil infusion (0.1-0.3 µg/kg/min) and desflurane (0.5 MAC) titrated to a BIS of 50-55. Phenylephrine maintained baseline mean arterial pressure (MAP) and NIRS values with goal MAP of 75-85 mmHg. The NIRS monitor ensured adequate cerebral oxygenation and guided MAP, ventilation, and transfusion therapy. Decreases in NIRS indicated changes in MAP, PaCO2, and hemoglobin concentration. Fluids included 4 units RBCs, 3.5 L cell saver, 1 unit FFP, 1 unit platelets, 6 L crystalloid, and 1.7 L 5% albumin. Postoperatively, she was taken to the ICU and her trachea was extubated that evening. Postoperative pain control utilized nurse-controlled analgesia with hydromorphone and scheduled IV acetaminophen.
MMD is found across all ethnicities with increased incidence in the East. Patients present during two age ranges; 5-10 years old with ischemic events and 40-50 years old with hemorrhagic events. Treatment includes medical management with aspirin or surgical management via pial synangiosis. The primary goal in perioperative management is balancing cerebral oxygen delivery and demand with normotension, normovolemia, normocapnia, and normothermia. Our case illustrates the role of NIRS monitoring which provided a continuous measure of the impact of intraoperative physiological parameters on global cerebral oxygenation.
References
1. Scott RM, Smith ER. Moyamoya disease and moyamoya syndrome. N Engl J Med 2009;360:1226-37.
2. Tobias JD. Cerebral oxygenation monitoring: near infrared spectroscopy. Expert Rev Med Devices 2006;3:235-43.
3. Guey S et al. Moyamoya disease and syndromes: from genetics to clinical management. App Clin Gen 2015;8;49-68.
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