Original ArticleLumbar Drains for Vascular Procedures: An Institutional Protocol Review and Guidelines
Introduction
Spinal cord injury secondary to open or endovascular thoracoabdominal and abdominal aortic aneurysm repair can result in paraparesis or paralysis in 2%–10% of patients.1 Spinal ischemia in vascular procedures is multifactorial in nature. Many factors may contribute to microvascular collapse and diminished spinal cord perfusion, including factors such as the patient's underlying vasculature and pathology; intraoperative hemodynamic factors such as hypotension or blood flow interruption owing to occlusion of radiculomedullary or reticulospinal vessels; and postoperative factors such as hypotension, anemia, or excess cerebrospinal pressures.1,2 Spinal cord ischemia may result in paraparesis or paraplegia, loss of sensory function, or compromise of bowel and bladder function.3,4 Techniques to minimize the risk of spinal cord ischemia during these procedures have received considerable attention and include reduced aortic cross-clamping or vascular bypass procedures, pharmacologic protection, hypothermia, and augmentation of the mean arterial pressure (MAP). In addition, cerebrospinal fluid (CSF) diversion via the use of a lumbar drain (LD) is reported to have a salutary effect on spinal cord perfusion.5
Hemodynamic changes associated with cross-clamping of the aorta during surgery result in a dramatic decrease in spinal cord perfusion pressure (SCPP) distal to the clamp site. Placement of an LD allows for CSF drainage that can decrease intraspinal pressure and increase blood flow to the spinal cord, thus reducing the risk of spinal cord injury.6, 7, 8, 9 Although ubiquitously used, LD protocols for vascular procedures are not standardized.4,6,10, 11, 12 As a result, parameters for placement of an LD and management of CSF drainage may vary among institutions. Lumbar CSF drainage is not without complications, particularly in patients who have vascular comorbidities and who may be therapeutically anticoagulated or be receiving antiplatelet agents. Hence, careful standardization of the preprocedural checklist, performance of the procedure, intraoperative management of the drain, and postoperative care in the intensive care unit (ICU) are essential to minimize the risk of complications.13,14 Over the past 2 years, we have standardized a protocol for the placement and management of LDs in patients undergoing vascular procedures with a strict view toward complication avoidance while maximizing protection from spinal cord injury. This protocol was decided on by a multidisciplinary team and subsequently disseminated to nursing and resident staff at our institution to allow uniform implementation.
Section snippets
LD Protocol
The LD protocol developed at our institution includes a preoperative checklist (Table 1) and recommended equipment list (Table 2). Specific guidelines for management of patients on antiplatelet or anticoagulant agents are also followed (Figure 1). Our institution follows the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines for indications of LD placement. These indications include patient age >70 years, renal insufficiency, chronic obstructive
Results
Over the 4-year span 2016–2019, 45 patients had LDs placed for vascular procedures. The indication in all cases was to monitor spinal CSF pressures and SCPP and prevent spinal cord ischemia via drainage of lumbar CSF. The historical cohort from 2016–2017 (group 1) before implementation of the institutional protocol had 19 patients with an average age of 63.7 ± 17.2 and an average BMI of 29.1 ± 7.29 kg/m2. In this group, 14 (73.7%) were female and 5 were male (26.3%). The post-protocol
Discussion
Surgical and endovascular management of aortic disease can be complicated by spinal cord–related neurological deficits, and multiple strategies to mitigate this are essential. Careful coordination of care between the primary vascular surgery team, the anesthesiologists, the neurosurgical consultants, and the resident and nursing staff is required. Among strategies to mitigate spinal cord ischemia during aortic vascular procedures, placement of an LD to monitor SCP and SCPP has been shown to be
Conclusions
An institutional protocol with guidelines for the use of LDs for open and endovascular aortic procedures can be implemented safely in a health care system and have a significant impact on the management of these complex patients. Having defined parameters to monitor and for drainage is helpful. Careful in-service and educational modules are essential to the successful execution of this protocol.
CRediT authorship contribution statement
Faraz Behzadi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Miri Kim: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Tara Zielke: Conceptualization, Data
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Cited by (5)
Risk Factors Associated with Spinal Cord Ischemia During Aortic Aneurysm Repair
2023, Annals of Vascular SurgerySafety and efficacy of fluoroscopically guided cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair
2023, Annals of Vascular Surgery - Brief Reports and InnovationsCon: Lumbar Drains Should Routinely Be Placed by a Landmark Approach and Not by Fluoroscopic Guidance for Elective Thoracic Aortic Repairs
2023, Journal of Cardiothoracic and Vascular AnesthesiaThe Evolution and Future of Spinal Drains for Thoracic Aortic Aneurysm Repair: A Review
2021, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :It has been demonstrated that, in addition to CSF drainage, bundled clinical protocols with standardized application of multiple therapies and interventions significantly reduce spinal cord ischemia.62 Implementation of a protocol also may result in fewer drain-related complications,63 and there are reports of protocols being modified in response to complications that resulted in improved patient outcomes.60,62 The timing and conditions under which the drain is placed usually are not specified in the literature, although it has potential to play a role in drain-related complications either due to inadvertent loss of CSF or vascular injury occurring during placement.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.