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FOCUS POINTS
Somatosensory evoked potentials (SSEPs) indicate the integrity of the afferent pathways of the dorsal columns of the spinal cord.
Increased latency and decreased amplitude are indicators of potential injury to the spinal cord.
Motor evoked potentials (MEPs) are both more sensitive to anesthetic agents and spinal cord injury, but only function in the absence of neuromuscular paralysis.
Careful positioning is paramount to all procedures especially prone and those of long duration; it should be completed in collaboration with the surgeon, anesthesiologist, and nursing staff.
Postoperative visual loss (POVL) is a devastating complication of prone positioning and has been associated with hypotension, anemia, and direct external pressure.
Surgical wound infection prevention is the responsibility of all members of the health care team. It can be minimized by hand hygiene with feedback (monitoring of practitioners), frequent environmental cleaning, patient decolonization, improved line access methods, and infection surveillance.
Congenital and neuromuscular scoliosis patients tend to have significantly higher blood loss than patients with idiopathic scoliosis undergoing spinal fusion.
Maintaining a neutral cervical spine position and awareness of the potential for a difficult airway are the most important anesthetic considerations for patients with Klippel-Feil syndrome.
There are multiple forms of osteogenesis imperfecta (“brittle bone” disease), all of which require extreme care perioperatively to prevent fractures (padding, avoidance of frequent noninvasive blood pressures, etc.).
Patients with Marfan syndrome have skeletal, cardiovascular, and ocular abnormalities. The major cause of morbidity and mortality though is dilation of the aortic root leading to aortic dissection.
When an Ehlers-Danlos syndrome (EDS) child presents for surgery, particular attention should be given to bleeding tendencies with a low threshold to prepare blood products.
The most severe form of cerebral palsy is spastic quadriplegia with higher association of intellectual disability, seizures, and swallowing difficulties.
Cardiomyopathy is a major cause of death in patients with Duchenne muscular dystrophy (DMD) and all patients should undergo a cardiac evaluation with echocardiogram or cardiac MRI prior to an elective anesthetic.
Succinylcholine has been used without incident in spinal muscular atrophy (SMA) patients, but there is a potential for rhabdomyolysis and hyperkalemia and should be used with extreme caution.
Scoliosis repair requires careful planning that includes positioning, adequate access, invasive monitoring, and neuromonitoring (SSEP, MEP). The anesthetic plan should be tailored to the degree of surgical repair and the comorbidities of the patient.
The single most important risk factor for venous thromboembolism (VTE) in the pediatric population is the presence of a central venous catheter (CVC).
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Anesthesia for orthopedic surgery in children is determined as much by the patient’s underlying health status and comorbidities as it is by the specific operation. The anesthetic plan varies depending on individual circumstances. In this chapter, we will outline many of the reasons patients present to the orthopedic operating room, both in elective and emergent circumstances. Conditions and syndromes most pertinent to orthopedic surgery will be described and particular anesthetic concerns will be highlighted.
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