A Day in the Life of a CA-3 at Texas Children's Hospital
Wow...I can't believe I'm finally a senior resident! The responsibilities have certainly ramped up this year, and Texas Children's is no different. Today I got to do a scoliosis repair procedure, one of the most complex cases we get to do - TCH has so many patients, that they sometimes do eight or nine of these cases in a single day!
Coming into TCH always puts a smile on my face. Bright colors paint the hospital walls, drawings by the children line the corridors, and there are so many sculptures and pieces of art to admire while walking from the parking garage to the OR. After setting up the OR, I went to the PACU to see my patient, and as usual, I was greeted by the faces of smiling and laughing children - honestly. I know it might seem hard to believe, but the PACU is setup as a mini-playground of sorts, with toys galore, small cars for the patients to ride, and even video game systems!
I was pretty excited about doing the reconstruction. Unlike most other procedures, these cases are done under total intravenous anesthesia, or TIVA. I got in early to set up all of the infusion pumps and drugs that we were going to use to keep the patient asleep. After doing an inhalational induction, I placed two large IV's and an arterial line to help us manage the blood loss over the course of the case. Though it's not perfect, we used a BIS monitor for EEG evaluation to help make sure that the patient was adequately anesthetized.
Because the surgery was so near the spine, any pressure on the spinal cord could cause temporary or even permanent paralysis. To help reduce the chances of waking up paralyzed, we used a combination of somatosensory evoked potentials (SSEP's) and motor evoked potentials (MEP's) to help guide our management. If too much pressure was applied to the spine, the electrical potentials became depressed, and the surgeons repositioned their hardware or worked in another area.
For this particular patient, there was a remodeling of 13 different spinal levels along with a "wake-up" test in the middle of the case. Wake-up tests can be particularly stressful...as you can imagine, it's a bit challenging to keep a patient comfortable and amnestic when their entire spine is exposed. The reason we did a wake up test today was because both the MEP's and the SSEP's were depressed on the right leg. Sometimes the tests aren't perfect, however, and the only way to make sure that the patient still had function of that leg was to wake them up in the middle of surgery.
Luckily for the patient, when we woke him up, he was very comfortable, and he was still able to move both his legs without any difficulties. After that, we gave him a big bolus of our IV drugs to put him back to sleep, and the surgery was completed without a hitch. Once we were back in the PACU, all the vital signs were stable, our patient had no pain because of the narcotics infusion we were running, and he was able to move all of his arms and legs without any difficulties at all.
In spite of having his entire back opened, spinal cord manipulated and rodded, he now would live a normal life! These procedures are particularly challenging and rewarding for the anesthesiologist that is managing the patient in the operating room. The combination of TIVA, blood loss, hemodynamic and neurophysiological monitoring, as well as the wake-up test touched on almost every concept we use in our practice, and the successful outcome of the patient just reaffirmed that all of our knowledge really does come into play during the more complex cases.
– Raj Sinhal, M.D., Class of 2011