Institutions around the US often have no defined standard of care (SOC) measures concerning perioperative management of posterior spinal fusion (PSF) surgery patients with a patent foramen ovale (PFO). There is a tacit risk for paradoxical air embolism (PAI) for patients who undergo PSF (1,2,3). The sequelae of PAI include stroke, myocardial infarction, splanchnic infarction, cardiovascular collapse, and death. Upon IRB approval of our survey, data was gathered from 350 pediatric anesthesiologists. There were 49 responses; 46 of whom completed the survey. 81% of respondents practice in surgical settings and 92% provide anesthesia for PSF. 63% had 10-years or more of experience with 88% finishing a fellowship in pediatric anesthesia. Only 6% reported routinely ordering echocardiograms on surgery patients with idiopathic scoliosis vs. 35% in neuromuscular scoliosis patients who present for PSF surgery. Most respondents (61%) do not advise/require PFO closure prior to PSF. Most respondents had not experienced a PSF surgery complication by air embolism (82%) or PAI (86%). Our findings show that 35% of anesthesiologists perform echocardiograms prior to PSF surgery for neuromuscular scoliosis. Echocardiograms were often deferred in patients with isolated idiopathic scoliosis, despite a 3.6% risk of undiagnosed heart disease in the studied population (4). Respondents answered that they would not routinely advise, or require, PFO closure prior to spinal fusion, even with a study suggesting PFO closure is appropriate prior to spinal fusion to aid in mitigating the risk of air embolism (5). Of note, our cardiologists will recommend a known PFO closure prior to PSF. We experienced a low response rate leading to an inconclusive study of the percentage of pediatric anesthesiologists who require PFO closure. Due to this limitation, we were also unable to make a statistically relevant description of the routine use of echocardiography prior to a patient undergoing spinal fusion surgery. It appears most institutions do not require PFO closure prior to spinal fusion. Given the risk of possible fatal events from PAI, this is an area that requires further research.
Spellman, Hank M. MS; Huynh (Wendy) Nguyen MD; Ricardo Falcon MD; Tim Petersen PhD; and Codruta Soneru MD. "Present Anesthesiology Practices in the Context of Patent Foramen Ovale: PFO Anesthesiology Survey." (2021). https://digitalrepository.unm.edu/hsc_qips/68