Volume: 30, Issue: 1, January 2019 pp: 17-21 ORIGINAL ARTICLE ANESTHESIA MANAGEMENT IN PEDIATRIC SCOLIOSIS PATIENTS: A RETROSPECTIVE CLINICAL STUDY İD 1 Sedat AKBAŞ ABSTRACT 2 İD Mehmet Fatih KORKMAZ Introduction: Neurological, cardiovascular and respiratory system pathologies are frequently accompanied by pediatric scoliosis surgery. The aim of this retrospective clinical study was to evaluate the demographic characteristics, operation characteristics, and complications associated with anesthesia and surgery in pediatric patients undergoing scoliosis surgery. Material and Methods: In this study, 33 pediatric patients undergoing elective scoliosis surgery were reviewed retrospectively. Demographic characteristics, surgical procedure data, complications related anesthesia or surgery were examined in terms of anesthesia management. Medications, concomitant diseases, laboratory values, postoperative 1 Department of Anesthesiology and service and intensive care unit records were obtained from the university database. Reanimation, Inonu University, School Results: The mean age of thirty-three patients was 13.09 ± 2.98 years. Three patients had of Medicine, Malatya, Turkey. 2 meningomyelocele and one had neuromuscular disease. 72.7 % of patients (24 patients) Department of Orthopedics and have thoracolumbar scoliosis. The duration of anesthesia and surgery was 241.21 ± Traumatology, Istanbul Medeniyet 55.55 min and 214.84 ± 54.55 min, respectively. The mean number of instrumented level University, School of Medicine, Istanbul, was 10.78 ± 3.54. Blood transfusion was performed in 97 % of the patients (32 patients). Turkey. All patients were transferred to the intensive care unit in the postoperative period. In each two patients, bradycardia and hypotension were observed. In the perioperative period, the mean blood loss of the patients was 843.93 ± 246.14 mL. Conclusion: Pediatric scoliosis surgery; is an important orthopedic procedure which ORCID Numbers: may results in serious intraoperative blood loss and postoperative pain and can be Sedat AKBAS: accompanied by syndromes, difficult airway management, serious respiratory and 0000-0003-3055-9334 circulatory system complications during perioperative and postoperative period. Mehmet Fatih KORKMAZ: Evaluation of localization and the extent of curvature, length of surgery, concomitant 0000-0001-7498-6763 diseases and congenital anomalies are important for the management of anesthesia in patients undergoing pediatric scoliosis surgery. Key words: Anesthesia management, Pediatric scoliosis, Spinal surgery, Kyphoscoliosis INTRODUCTION in females (13). Lok et al reported that scoliosis prevalence rate is 1.3-1.5 % in The curvature of the spine is measured (7) by the Cobb angle and the curvature of Turkey . (2) more than 10° is considered as scoliosis . Neurological, cardiovascular and respira- It is often seen with rotation and causes tory system pathologies are frequently anatomical changes in the thorax over associated with pediatric patients under- time. This structural disease is a complex going scoliosis surgery. Difficult airway condition that causes rotation of the management, invasive arterial and central Address: Sedat AKBAŞ, Department of Anesthesiology and spine in its axis, so the deformity is not venous monitoring difficulties, long-term Reanimation, Inonu University, School of only in the coronal plane but also in axial surgery, intraoperative blood loss, neu- Medicine, Malatya, Turkey. and sagittal planes. Scoliosis is the most rologic deficits secondary to surgery and Phone: +90 505 826 39 12 Fax: +90 422 341 07 28 common deformity of the spine. About 80 severe postoperative pain are challenging Mail: [email protected] % of the structural coronal deformities are both anesthesiologists and surgeons dur- th Received: 16 September, 2018. (3) th idiopathic scoliosis. Prevalence of scoliosis ing surgery . Due to the accompanying Accepted: 9 November, 2018. is 4 % in the population. It is 4 times more comorbidities, preoperative evaluation, The Journal of Turkish Spinal Surgery 17 perioperative follow-up and postoperative care are important Foley catheterization, at least 2 large intravenous and serious in this patient group. The aim of this retrospective catheterization, invasive arterial monitoring to the radial clinical study was to evaluate the demographics, operation artery, central venous catheterization to the internal jugular characteristics, and complications related to the anesthesia or subclavian vein was performed to all patients. Arterial and surgery in pediatric patients undergoing scoliosis surgery. blood gas analysis and hemogram were performed at frequent intervals. Patients were transferred to the intensive care unit MATERIAL AND METHODS with orotracheal intubation after surgery. Postoperative analgesia management of all patients was provided by In this study, 33 pediatric patients undergoing elective multimodal analgesia technique with appropriate doses of scoliosis surgery between January 2015 and January 2018 paracetamol (20 mg / kg, IV) and tramadol (0.5-1 mg / kg, in Inonu University Medical Faculty operating room were IV). reviewed retrospectively. Demographic characteristics, surgical procedure data, complications related to anesthesia The duration of anesthesia was defined as the time from or surgery and hospital records were reviewed. Medications, admission in operating room until the transfer of the patient comorbid diseases and treatments, laboratory values, service to the intensive care unit. The duration of the surgery was and intensive care follow-up information were obtained from defined as the time from the first skin incision until the the university patient database. This study was prepared with closure of last skin suture. Mortality indicates the mortality the guidelines of the CONSORT study group (9). rate associated with anesthesia or surgery during the patient’s stay in the hospital. Pediatric patients under the age of 18 undergoing scoliosis surgery were included in the study. Patients with uncontrolled Data were analyzed using SPSS (Statistical Package for Social diabetes mellitus, lung disease or cerebrovascular disease Sciences Statistics for Windows, Version 22.0 Software. and patients without written informed consent or lack of Armonk, NY: IBM Corp.). Quantitative data were expressed preoperative anesthesia evaluation were excluded from the as mean and standard deviation, and qualitative data was study. expressed as number and percentage. P value less than 0.05 was considered significant. Premedication was performed with midazolam for all patients except the ones with difficult airway. After the patients were RESULTS taken to the operation room, heart rate (HR), noninvasive blood pressure (NIBP), electrocardiogram (ECG), peripheral The mean age of the 33 patients was 14.09 ± 1.98 years. 42.4 oxygen saturation (SpO2), body temperature measurement % of the patients were male (14 patients) and 57.6% were and bispectral index (BIS) were performed. Because of the female (19 patients). ASA scores were I in 51.5 % (17 patients) high intraoperative blood loss risk, preoperative blood samples and II in 48.5 % (16 patients). The Mallampati classification were drawn before the surgery for each patient. was I in 75.8 % (25 patients) and II in 24.2% (8 patients). Mean hemoglobin value was​​ 12.75 ± 0.66 mg / dL and mean A standard general anesthesia protocol was applied to all hematocrit value ​​was 37.90 ± 3.50 %. Of the patients, 9.1 % patients by an experienced anesthesiologist. After pre- (3 patient) had meningomyelocele and 3 % (1 patient) had oxygenation (100 % 4 L / min O2, at least 3 min), intravenous neuromuscular disease. Demographics are shown in Table-1. (IV) anesthesia induction was performed with propofol (0.5– 2 mg / kg), rocuronium (0.4–0.6 mg / kg), and fentanyl (1 The scoliosis was at thoracic spine in 24.2 % (8 patients), at μg / kg). After the orotracheal intubation, the patients were lumbar spine in 3 % (1 patient) and at thoracolumbar spine in ventilated with Dräger Primus anesthesia device (Dräger 72.7 % (24 patients). The duration of anesthesia and surgery AG, Lübeck, Germany) with 8 mL / kg tidal volume, 10-24 was 241.21 ± 55.55 min and 214.84 ± 54.55 min, respectively. breathing frequency and 5 mmHg positive end-expiratory The mean number of instrumented level was 12.78 ± 3.54. All pressure (PEEP). End-tidal carbon dioxide (EtCO2) of the patients undergoing surgical procedure were followed monitoring was performed after intubation. Tidal volume by invasive arterial monitoring, central venous catheterization, and respiratory frequency were adjusted so that the partial nasogastric catheterization, bladder catheterization with foley pressure of EtCO2 was between 35-45 mmHg in arterial catheter and bispectral index (BIS) monitoring to measure the blood gas analysis. Patients were given 50 % oxygen in the depth of anesthesia. The total consumptions of crystalloid and oxygen-air mixture. Since neuromonitoring was applied to colloid were 1854 ± 403 mL and 393 ± 102 mL, respectively. scoliosis patients, maintenance of anesthesia was provided Blood transfusion was performed in 97% of the patients (32 by total intravenous anesthesia (TIVA) with propofol and patients). All patients were transferred to the intensive care remifentanil infusion at appropriate doses. unit in the postoperative period. No mortality occurred during 18 The Journal of Turkish Spinal Surgery the hospital stay. The surgical procedure data of the patients