New ACC Thoracic Aortic guidelines: CSF drains; changing DLETT at the end of surgery

The guidelines can be downloaded from the Web site http://content.onlinejacc.org/cgi/reprint/55/14/e27.pdf

Anesthesiology News notes, regarding CSF drains:

In particular, the recommended strategy for spinal cord protection during descending aortic open surgical and endovascular repair is likely to change practice, according to David Reich, MD, professor and chair of anesthesiology at Mount Sinai School of Medicine in New York City. The class I recommendation (section 14.5.2) states that in patients at high risk for spinal cord ischemic injury, drainage of cerebrospinal fluid (CSF) protects the spinal cord.

Dr. Reich said the key phrase in the recommendation is patients at high risk for spinal cord ischemic injury. “That’s new,” he said. “Clinicians will be concerned as to determining what constitutes high risk, and what will happen if they did not do CSF drainage in a patient who is paralyzed postoperatively.” He said that the definition of high risk is fairly well defined in the surgical literature.

Anesthesiology News notes, regarding changing a double lumen ETT at the end of the case:

Another recommendation that affects anesthesiologists is found in section 14.2: The routine changing of double-lumen endotracheal (endobronchial) tubes to single-lumen tubes at the end of surgical procedures complicated by significant upper airway edema or hemorrhage is not recommended. According to Dr. Reich, this recommendation is based on expert opinion (level of evidence classified as C).

CSF drains are not without complications of course.

I have seen emergent tracheostomy, and poor outcome, after airway obstruction following removal of a DLETT.  One approach could be to start with a Univent or bronchial blocker, with possibly less secure lung separation.  Another is to cut the distal balloon on the DLETT left in place to minimize malposition problems in the ICU.  Never an easy decision.

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