title: Setting up and utilizing a service for measuring perioperative transcranial motor evoked potentials during thoracoabdominal aortic surgery and thoracic endovascular repair.
abstract: OBJECTIVE
  Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'.
  
  
  METHODS
  Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013).
  
  
  RESULTS
  The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes.
  
  
  CONCLUSIONS
  The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Fatemeh
authors.initials: F
authors.lastname: Jafarzadeh
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Mohamad
authors.initials: M
authors.lastname: Bashir
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Tristan
authors.initials: T
authors.lastname: Yan
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: Harrington
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK mlfield@doctors.net.uk.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Field
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Manoj
authors.initials: M
authors.lastname: Kuduvalli
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Aung
authors.initials: A
authors.lastname: Oo
authors.affiliation: Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Desmond
mesh_terms: D000465:Algorithms; D001012:Aorta, Abdominal / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D057189:Checklist / Q000706:statistics & numerical data; D002983:Clinical Competence; D019091:Critical Pathways / Q000706:statistics & numerical data*; D057510:Endovascular Procedures / Q000009:adverse effects*; D019054:Evoked Potentials, Motor; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data*; D059032:Learning Curve; D009044:Motor Cortex / Q000503:physiopathology*; D010264:Paraplegia / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D010348:Patient Care Team; D061214:Patient Safety; D018579:Patient Selection; D011237:Predictive Value of Tests; D012307:Risk Factors; D020760:Spinal Cord Ischemia / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome
keywords: Motor evoked potential; Neuro-monitoring; Paraplegia; Thoracoabdominal surgery