Table 1.

Suggested anesthetic guidelines for the management of surgery for acute spinal cord injury

Preoperative preparation	Expeditious chart review, including medical history, circumstance of injury, hospital course, and images Directed physical examination and detailed airway assessment Difficult airway equipment readily available
Premedication	Early preoxygenation Limit anxiolytic premedication Provide preinduction anticholinergic medication in high SCI Preinduction arterial catheterization
Induction	Careful titration of induction agents with prophylactic fluid/vasopressors Succinylcholine is contraindicated >48 h postinjury
Airway	Video/direct laryngoscopy and endotracheal intubation with MILS in emergent scenarios or an uncooperative patient Awake fiberoptic bronchoscope intubation with topicalization of the airway can be considered in cooperative patients
Maintenance	MAP of 85–90 mm Hg with fluids and vasopressors IONM with TcMEP, SSEP, and EMG using a tailored anesthetic technique
Emergence	Wean sedation for neurologic assessment Leave ETT in situ for complete high cervical SCI Extubate with consideration of patient and surgical factors (length, positioning, volume administered, future interventions necessary) in all other patients

Abbreviations: EMG, electromyography; ETT, endotracheal tube; IONM, intraoperative neuromonitoring; MAP, mean arterial pressure; MILS, manual in-line stabilization; SCI, spinal cord injury; SSEP, somatosensory evoked potentials; TcMEP, transcranial motor evoked potentials.