1
|
Shaw KA, Murphy JS, Koehler R, Harris H, Sachwani N, Bruce R, Devito D, Schmitz M, Fabregas J, Raftis D, West J, Fletcher N. In-hospital post-operative fever after posterior spinal fusion for neuromuscular scoliosis in non-ambulatory cerebral palsy patients: is there value for clinical workup for an isolated fever? Spine Deform 2024:10.1007/s43390-024-00930-y. [PMID: 39069587 DOI: 10.1007/s43390-024-00930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 07/13/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE Children with neuromuscular scoliosis (NMS) resultant to cerebral palsy (CP) are at a heightened risk for complications following surgical treatment. These children have a reported 22-64% rate of post-operative fever development, and additional fever workup has been shown to have limited clinical utility. However, this has yet to be investigated in the setting of an accelerated discharge (AD) pathway. METHODS A retrospective review of children with non-ambulatory CP treated at 2 centers with posterior spinal fusion (PSF) for NMS was performed. One institution uses a standardized AD post-operative pathway for NMS patients, whereas the second institution had no standard pathway. A post-operative fever was defined as temperature > 38.5 °C. Target outcome variables included the development of a fever as well as re-admission within 90 days of surgery. RESULTS A total of 122 non-ambulatory children were identified (82% GMFCS V, mean 14.3 ± 3.4 years at surgery). A post-operative fever was documented in 75.4% of patients (N = 92) and all additional culture studies reported negative results. Children admitted to the PICU were more likely to undergo a fever workup (P < 0.001) and more likely to receive additional or extended antibiotic therapy (P < 0.001). Children treated at the AD pathway had a significantly lower rate of PICU admission (P < 0.001). Post-operative PICU admission was associated with a post-operative fever (49.5% vs 25%, P = 0.03). CONCLUSION Non-ambulatory CP children with NMS undergoing PSF have a 75.4% rate of developing early post-operative fevers. Reflexive fever work-ups provided limited clinical utility while increasing the hospital length of stay and potentially exposing patients to antibiotic-related complications.
Collapse
Affiliation(s)
- K Aaron Shaw
- Department of Pediatric Orthopaedic Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA.
- Children's Healthcare of Atlanta, Atlanta, USA.
| | - Ryan Koehler
- Department of Pediatric Orthopaedic Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hilary Harris
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Numera Sachwani
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Robert Bruce
- Department of Pediatric Orthopaedic Surgery, Emory University at Children's Healthcare of Atlanta Egelston, Atlanta, GA, USA
| | - Dennis Devito
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Michael Schmitz
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Jorge Fabregas
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Daniel Raftis
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Just West
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA
| | - Nicholas Fletcher
- Department of Pediatric Orthopaedic Surgery, Emory University at Children's Healthcare of Atlanta Egelston, Atlanta, GA, USA
| |
Collapse
|
2
|
Lim KBL, Yeo ISX, Ng SWL, Pan WJ, Lee NKL. The machine-vision image guided surgery system reduces fluoroscopy time, ionizing radiation and intraoperative blood loss in posterior spinal fusion for scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3987-3995. [PMID: 37428212 DOI: 10.1007/s00586-023-07848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/10/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE To determine if the novel 3D Machine-Vision Image Guided Surgery (MvIGS) (FLASH™) system can reduce intraoperative radiation exposure, while improving surgical outcomes when compared to 2D fluoroscopic navigation. METHODS Clinical and radiographic records of 128 patients (≤ 18 years of age) who underwent posterior spinal fusion (PSF), utilising either MvIGS or 2D fluoroscopy, for severe idiopathic scoliosis were retrospectively reviewed. Operative time was analysed using the cumulative sum (CUSUM) method to evaluate the learning curve for MvIGS. RESULTS Between 2017 and 2021, 64 patients underwent PSF using pedicle screws with 2D fluoroscopy and another 64 with the MvIGS. Age, gender, BMI, and scoliosis aetiology were comparable between the two groups. The CUSUM method estimated that the MvIGS learning curve with respect to operative time was 9 cases. This curve consisted of 2 phases: Phase 1 comprises the first 9 cases and Phase 2 the remaining 55 cases. Compared to 2D fluoroscopy, MvIGS reduced intraoperative fluoroscopy time, radiation exposure, estimated blood loss and length of stay by 53%, 62% 44%, and 21% respectively. Scoliosis curve correction was 4% higher in the MvIGS group, without any increase in operative time. CONCLUSION MvIGS for screw insertion in PSF contributed to a significant reduction in intraoperative radiation exposure and fluoroscopy time, as well as blood loss and length of stay. The real-time feedback and ability to visualize the pedicle in 3D with MvIGS enabled greater curve correction without increasing the operative time.
Collapse
Affiliation(s)
- Kevin Boon Leong Lim
- Division of Surgery, KK Women's and Children's Hospital, Singapore, Singapore.
- Department of Orthopaedic Surgery, KK Women's & Children's Hospital, Singapore, Singapore.
| | - Inez Su Xian Yeo
- Division of Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Stacy Wei Ling Ng
- Department of Orthopaedic Surgery, KK Women's & Children's Hospital, Singapore, Singapore
| | - Woei Jack Pan
- Department of Orthopaedic Surgery, KK Women's & Children's Hospital, Singapore, Singapore
| | - Nicole Kim Luan Lee
- Division of Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
3
|
Lebel DE, Machida M, Koucheki R, Campbell F, Bath N, Koyle M, Ruskin D, Levin D, Brennenstuhl S, Stinson J. Utilization of individual components of enhanced recovery after surgery (ERAS) protocol improves post-operative outcomes in adolescent idiopathic scoliosis: a blueprint for progressive adoption of ERAS. Spine Deform 2023; 11:1117-1125. [PMID: 37233951 PMCID: PMC10425294 DOI: 10.1007/s43390-023-00706-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE Enhanced recovery after surgery [ERAS] is an approach for standardization of perioperative care aimed at improving patient outcomes. The primary aim of this study was to determine if length of stay (LOS) differed by protocol type (ERAS vs. non-ERAS [N-ERAS]) in patients undergoing surgery for adolescent idiopathic scoliosis (AIS). METHODS A retrospective cohort study was conducted. Patient characteristics were collected and compared between groups. Differences in LOS were assessed using regression adjusting for age, sex, BMI, pre-surgical Cobb angle, levels fused and year of surgery. RESULTS Fifty nine ERAS patients were compared to 81 N-ERAS patients. Patients were comparable in their baseline characteristics. Median LOS was 3 days (IQR = 3-4) for the ERAS group, compared to 5 days (IQR = 4-5) for the N-ERAS group (p < 0.001). The ERAS group had a significantly lower adjusted rate of stay (RR = 0.75; 95% CI = 0.62-0.92). The ERAS group had significantly lower average pain on post-operative days 0 (least-squares-mean [LSM] 2.66 vs. 4.41, p < 0.001), POD1 (LSM 3.12 vs. 4.48, p < 0.001) and POD5 (LSM 2.84 vs. 4.42, p = 0.035). The ERAS group had lower opioid consumption (p < 0.001). LOS was predicted by the number of protocol elements received; those receiving two (RR = 1.54 95% CI = 1.05-2.24), one (RR = 1.49; 95% CI = 1.09-2.03) or none (RR = 1.60, 95% CI = 1.21-2.13) had significantly longer rates of stay than those receiving all four. CONCLUSION Adoption of modified ERAS-based protocol for patients undergoing PSF for AIS led to significant reduction in LOS, average pain scores, and opioid consumption.
Collapse
Affiliation(s)
- David E Lebel
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
| | - Masayoshi Machida
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Robert Koucheki
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Fiona Campbell
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Natasha Bath
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Koyle
- Division of Urology, The Hospital for Sick Children, Toronto, Canada
| | - Danielle Ruskin
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Levin
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Sarah Brennenstuhl
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Stinson
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
4
|
Tøndevold N, Bari TJ, Andersen TB, Gehrchen M. The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis. J Pediatr Orthop 2023; 43:e476-e480. [PMID: 36922012 DOI: 10.1097/bpo.0000000000002400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols are often specific to a specific type of surgery without assessing the overall effect on the ward. Previous studies have demonstrated reduced length of stay (LOS) with ERAS protocols in patients with adolescent idiopathic scoliosis (AIS), although the patients are often healthy and with few or no comorbidities. In 2018, we used ERAS principles for patients undergoing AIS surgery with a subsequent 40% reduced LOS. The current study aims to assess the potential collateral effect of LOS in patients surgically treated for neuromuscular scoliosis admitted to the same ward and treated by the same staff but without a standardized ERAS protocol. METHODS All patients undergoing neuromuscular surgery 2 years before and after ERAS introduction (AIS patients) with a gross motor function classification score of 4 to 5 were included. LOS, intensive care stay, and postoperative complications were recorded. After discharge, all complications leading to readmission and mortality were noted with a minimum of 2 years of follow-up using a nationwide registry. RESULTS Forty-six patients were included; 20 pre-ERAS and 26 post-ERAS. Cross groups, there were no differences in diagnosis, preoperative curve size, pulmonary or cardiac comorbidities, weight, sex, or age. Postoperative care in the intensive care unit was unchanged between the two groups (1.2 vs 1.1; P = 0.298). When comparing LOS, we found a 41% reduction in the post-ERAS group (11 vs 6.5; P < 0.001) whereas the 90-day readmission rates were without any significant difference (45% vs 34% P = 0.22) We found no difference in the 2-year mortality in either group. CONCLUSION The employment of ERAS principles in a relatively uncomplicated patient group had a positive, collateral effect on more complex patients treated in the same ward. We believe that training involving the caregiving staff is equally important as pharmacological protocols.
Collapse
Affiliation(s)
- Niklas Tøndevold
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | |
Collapse
|
5
|
Menapace B, McCarthy J, Schultz L, Leitsinger N, Jain V, Sturm P. Utilizing two surgeons for neuromuscular scoliosis suggests improved operative efficiency. Spine Deform 2023; 11:985-992. [PMID: 37067777 DOI: 10.1007/s43390-023-00678-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/11/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE Neuromuscular scoliosis (NMS) patients tend to have significant comorbidities with complex medical and surgical histories. When undergoing posterior spinal fusion (PSF), NMS risks can be much higher than the idiopathic population. This study aimed to identify the impact of two experienced pediatric cosurgeons (CS) compared to a single spine surgeon (SS) on the intra- and postoperative results of NMS PSF. METHODS A database of NMS patients who had undergone PSF 2016-2021 identified 53 patients, of which 32 were CS, while 21 were SS. Patients' sex, age, weight, diagnosis, curve severity, fusion performed, estimated blood loss (EBL), transfusion rates, hemoglobin, anesthesia and surgical times, length of stay, and complications were collected. RESULTS Patient demographics were similar between groups. Curves were more severe in the CS group (p = 0.013). Intraoperatively, CS patients underwent larger corrections (p = 0.089) but in significantly shorter anesthetic (p = 0.0018) and operative (p = 0.0025) times. Blood loss and transfusions were similar. Postoperatively, intensive-care unit (ICU) admission and length of stay (LOS) were similar, but SS had higher rates of both unplanned ICU admissions (p = 0.36) and 30 day readmissions (p = 0.053). Complications overall were similar between the groups both within 30 days (p = 0.40) and in the short-term period (31-90 days, p = 0.76), though the CS cohort had less Grade 2 immediate postoperative pulmonary complications (p = 0.16). CONCLUSION Utilizing CS for NMS PSF has been found to reduce operative times. Downstream, additional potential impacts trended toward fewer unplanned ICU admissions, less-frequent postoperative pulmonary complications, and reduced 30-day readmission rates.
Collapse
Affiliation(s)
- Bryan Menapace
- Department of Orthopaedic Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA.
| | - James McCarthy
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lindsay Schultz
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nichole Leitsinger
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Viral Jain
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
6
|
Hariharan A, Sees JP, Pargas C, Rogers KJ, Niiler T, Shrader MW, Miller F. Mortality after spinal fusion in children with cerebral palsy and cerebral-palsy-like conditions: A 30-year follow-up study. Dev Med Child Neurol 2023. [PMID: 36882978 DOI: 10.1111/dmcn.15568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 03/09/2023]
Abstract
AIM To report survival probability of a large cohort of children with cerebral palsy (CP) after spinal fusion. METHOD All children with CP who had spinal fusion between 1988 and 2018 at the reporting facility were reviewed for survival. Death records of the institutional CP database, institutional electronic medical records, publicly available obituaries, and the National Death Index through the US Centers for Disease Control were searched. Survival probabilities with different surgical eras, comorbidities, ages, and curve severities were compared using Kaplan-Meier curves. RESULTS A total of 787 children (402 females, 385 males) had spinal fusion at a mean age of 14 years 1 month (standard deviation 3 years 2 months). The 30-year estimated survival was approximately 30%. Survival decreased for children who had spinal fusion at younger ages, longer postoperative hospital stays, longer postoperative intensive care unit stays, gastrostomy tubes, and pulmonary comorbidities. INTERPRETATION Children with CP who required spinal fusions had reduced long-term survival compared with an age-matched typically developing cohort; however, a substantial number survived 20 to 30 years after the surgery. This study had no comparison group of children with CP scoliosis; therefore, we do not know whether correction of scoliosis affected their survival.
Collapse
Affiliation(s)
- Arun Hariharan
- Paley Orthopedic & Spine Institute, West Palm Beach, FL, USA
| | | | - Carlos Pargas
- Department of Orthopaedics, Nemours Children's Health, DE, Wilmington, USA
| | - Kenneth J Rogers
- Department of Orthopaedics, Nemours Children's Health, DE, Wilmington, USA
| | - Tim Niiler
- Department of Orthopaedics, Nemours Children's Health, DE, Wilmington, USA
| | | | - Freeman Miller
- Department of Orthopaedics, Nemours Children's Health, DE, Wilmington, USA
| |
Collapse
|
7
|
Contartese D, Salamanna F, Brogini S, Martikos K, Griffoni C, Ricci A, Visani A, Fini M, Gasbarrini A. Fast-track protocols for patients undergoing spine surgery: a systematic review. BMC Musculoskelet Disord 2023; 24:57. [PMID: 36683022 PMCID: PMC9869597 DOI: 10.1186/s12891-022-06123-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/29/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND CONTEXT Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm. PURPOSE The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field. METHODS We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery. RESULTS We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery. CONCLUSIONS According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.
Collapse
Affiliation(s)
- Deyanira Contartese
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Salamanna
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Silvia Brogini
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Konstantinos Martikos
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristiana Griffoni
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Ricci
- grid.419038.70000 0001 2154 6641Anesthesia-resuscitation and Intensive care, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Visani
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Milena Fini
- grid.419038.70000 0001 2154 6641Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
8
|
Shaw KA, Harris H, Sachwani N, Ruska T, Murphy JS, Fletcher ND. Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol. Spine Deform 2022; 11:671-676. [PMID: 36538190 DOI: 10.1007/s43390-022-00635-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway. METHODS A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission. RESULTS A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission. CONCLUSION The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.
Collapse
Affiliation(s)
- K Aaron Shaw
- Department of Pediatric Orthopaedic Surgery, Scottish Rite for Children, Dallas, TX, USA
| | - Hilary Harris
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Numera Sachwani
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Tracy Ruska
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Nicholas D Fletcher
- Department of Pediatric Surgery, Children's Healthcare of Atlanta at Emory University, Atlanta, GA, USA.
| |
Collapse
|
9
|
Paediatric Spinal Deformity Surgery: Complications and Their Management. Healthcare (Basel) 2022; 10:healthcare10122519. [PMID: 36554043 PMCID: PMC9778654 DOI: 10.3390/healthcare10122519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.
Collapse
|
10
|
Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
Collapse
Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| |
Collapse
|
11
|
Simpson BE, Kara S, Wilson A, Wolf D, Bailey K, MacBriar J, Mayes T, Russell J, Chundi P, Sturm P. Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. Hosp Pediatr 2022:e2021006196. [PMID: 35174385 DOI: 10.1542/hpeds.2021-006196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical correction remains the most effective treatment of patients with severe neuromuscular scoliosis (NMS). However, postoperative inpatient clinical care after spinal surgery for NMS patients is highly complex and variable, depending on the provider and/or institution. Our project used a quality improvement methodology to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery, with the global aim of decreasing postoperative hospitalized length of stay (LOS). METHODS A multidisciplinary team developed a postoperative pathway for nonambulatory patients with NMS after their primary, nonstaged corrective spinal surgery. The outcome measure was mean LOS, and the process measure was percentage compliance with the newly implemented NMS pathway. The team used statistical process control charts and measures were evaluated over 3 phases to assess the impact of the interventions over time: pretesting, testing, and sustain. RESULTS The mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases. CONCLUSIONS Using quality improvement methodology, we successfully standardized major components of clinical care for patients with NMS after spinal corrective surgery. Through enhanced care consistency, the mean postoperative LOS decreased by nearly 3 days and decreased LOS variability. Robust multidisciplinary involvement with key stakeholders ensured sustainability of these improvements.
Collapse
Affiliation(s)
- Blair E Simpson
- Divisions of Hospital Medicine
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Setenay Kara
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Debra Wolf
- Division of Pain Management, Departments of Anesthesia and
| | | | | | | | | | - Pavan Chundi
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | |
Collapse
|