1. Postoperative Challenges in Neurocritical Care SNACC and NCS Joint Presentation Andrea Orfanakis, MD Oregon Health and Science University Multi-Level Spinal Fusion with Massive Hemorrhage Complicated by Acute Lung Injury

2. Adult Scoliosis Patient X Chronic pain Extensive narcotic package Significant Co-morbidities Deconditioning Obesity Diabetes Hypertension

3. Adult Scoliosis Patient X T3-Pelvis fusion 396 minute operative time Large wound exposure High volume blood loss and resuscitation expected BeforeAfter

4. Operative Course GETA: 396 minutes; isoflurane switched to TIVA midway (ketamine, propofol, sufentanil) I/O: 8L crystalloid, 9 PRBC, 7 FFP, 1 PLT, 1 Cryoprecip; 3.5L EBL, 2.7L UOP VS on Arrival to ICU: 111/58, 78, 93%; Vol AC, 16, 750 (11cc/kg IBW), PEEP 5

5. Postoperatively VS 4 HR later: 80/43, 111, 88% Requiring norepinephrine infusion Difficulty oxygenating and ventilating Chest radiograph: bilateral “fluffy” infiltrates ECHO: hyperdynamic, IVC collapse with inspiration “What were those yahoos doing to our patient in the OR?”

6. Team Communication in “Handoff”

7. Intra-operative Management Risks Cord/root injury Blood loss Large volume crystalloid exposure Transfusion Systemic vasoplegia and hypoperfusion Goals Anesthetized state +/- neuromonitoring goals Minimize blood loss Avoid over-resuscitation Avoid and correct disruptions in hemostasis Minimize transfusion Support clot stability Maintain organ perfusion

8. Post-operative Management Risks Hemorrhage Consumptive coagulopathy Systemic vasoplegia Organ hypoperfusion Transfusion associated acute lung injury Prolonged intubation and mechanical ventilation Goals: Maintain clot stability Re-establish optimal hemostasis Goal directed therapy with pressors and *volume* replacement Appropriate indications for transfusion Support organ perfusion Ready patient for extubation

9. Intraoperative Challenges Crystalloid versus colloid? Blood transfusion: what’s the risk? Are all pressors created equal? New ‘thinking’ in OR mechanical ventilation?

11. Questioning crystalloid safety?

12. Questioning crystalloid safety Dilution coagulopathy Extravasation of factors Hypertensive hypervolemia may increase blood loss? Hyperchloremic metabolic acidosis Impaired coagulation Endothelial glycocalyx disruption Increased inflammatory markers

13. Safer use of crystalloid peri-operatively Avoid unnecessary volume administration Treat vasoplegia with optimal pressors Warm all fluids Avoid hyperchloremic metabolic acidosis Goal directed therapy of organ perfusion

14. Role for Antifibrinolytics Improve surgical conditions Support clot stability Minimize blood loss Decrease transfusion ?????

15. Fibrinolytic Pathway **tPA, UK, Plasmin

16. Antifibrinolytics Aprotinin: proteinase inhibitor; inhibits kallikrein and plasmin. Not available in USA Aminocaproic Acid, Tranexamic Acid: lysine analogs; block the lysine binding site on plasminogen inhibiting plasmin formation

18. Support Clot Stability Anesthesia and Analgesia 2008

20. Acute Operative Hemorrhage and Consumptive Coagulopathy Dynamic process: ongoing, labs may lag Increasing red cell loss independent risk factor for morbidity Transfusion associated with poorer outcomes Surgical site infection Ventilator days, ICU days, Hospital Days, Mortality Transfusion related acute lung injury, transfusion associated circulatory overload

21. What’s in Fresh Frozen Plasma? Acellular, 90% water, 7% protein and colloid Approximately 1 IU/mL of each clotting factor, fibrinogen, VWF bound FVIII FactorHalf life% Remaining with Transfusion I (fibrinogogen)3-6 days50% II (prothrothombin)2-5 days40-80% V20-36 hours80% VII2-7 hours80% VIII8-12 hours75% IX18-24 hours50% X2 days50% XIII6-10 days10-100% VWF3-5 hours75%

22. Plasma Stewardship 60% of FFP transfused for “inappropriate” or no indication Indications Laboratory supported coagulopathy Massive transfusion (in trauma)** Plasma exchange Optimal Administration Cross matched At the time of hemostatic challenge Warmed No clear INR or PTT “trigger” for transfusion Laboratory data + clinical assessment + communication with surgical colleagues

23. Transfusion-Related Acute Lung Injury < 6 hrs onset 5-10% fatal 0.014-0.08% per product unit

24. Mechanical Ventilation in the OR Prior ThinkingNewer Thinking Large tidal volumes PEEP 0 Frequent circuit disconnects Ambu bag transports without PEEP valves Lower tidal volume based on IBW Appropriate PEEP titrated to OR specific challenges Maintain alveolar recruitment manually Safer transport strategies Manual recruitment maneuvers

25. Low Tidal Volumes Outside of ARDSNET

26. Postoperative Strategy to Minimize Lung Injury Lower tidal volume ventilation both intraoperatively and postoperatively improves outcomes in surgical patient Optimal PEEP on all ventilated patients Manual recruitment maneuvers as appropriate Avoid fluid over-resuscitation “ABCDE”: timely extubation

27. Optimize Perioperative Patient Care