1
|
Su L, Wu F, Wang H. Enhanced recovery after surgery in children with congenital scoliosis. Sci Rep 2024; 14:19270. [PMID: 39164304 PMCID: PMC11335747 DOI: 10.1038/s41598-024-66476-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/01/2024] [Indexed: 08/22/2024] Open
Abstract
To assess the impact of Enhanced Recovery After Surgery (ERAS) protocol in children undergoing corrective surgery for congenital scoliosis. A retrospective analysis was conducted on children undergoing surgical correction for congenital scoliosis, with participants categorized into either the ERAS group or the control group. Comparative evaluations were made across clinical, surgical, laboratory, and quality of life parameters. Following propensity score matching, 156 patients were analyzed. Within the initial 3 days following surgery, the ERAS cohort demonstrated lower pain intensity and exhibited higher daily oral intake compared to their counterparts in the control group. A mere 14.1% of patients in the ERAS group experienced a peak body temperature exceeding 38.5°, illustrating a significantly lower incidence compared to the 33.3% recorded in the control group. The ERAS cohort displayed expedited timeframes for the onset of initial bowel function and postoperative discharge when contrasted with the control group. Levels of IL-6 assessed on the third day post-surgery were markedly reduced in the ERAS group in comparison to the control group. Noteworthy is the similarity observed in postoperative hemoglobin and albumin levels measured on the first and third postoperative days between the two groups. Assessments of quality of life using SF-36 and SRS-22r questionnaires revealed comparable scores across all domains in the ERAS group when juxtaposed with the control cohort. ERAS protocol has demonstrated a capacity to bolster early perioperative recovery, alleviate postoperative stress responses, and uphold favorable quality of life outcomes in children undergoing corrective surgery for congenital scoliosis.
Collapse
Affiliation(s)
- Li Su
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China
| | - Feiran Wu
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China
| | - Hui Wang
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China.
| |
Collapse
|
2
|
Hey G, Mehkri Y, Mehkri I, Boatright S, Duncan A, Patel K, Gendreau J, Chandra V. Enhanced Recovery After Surgery Pathways in Pediatric Spinal Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 190:329-338. [PMID: 39089650 DOI: 10.1016/j.wneu.2024.07.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Pediatric spinal fusion surgery is a complex procedure that poses challenges in perioperative management. The enhanced recovery after surgery (ERAS) approach is an evidence-based, multidisciplinary strategy to optimize patient care in an individualized, multidisciplinary way. Despite the benefits of ERAS protocol implementation, the role of ERAS in pediatric spine surgery remains understudied. This systematic review and meta-analysis aims to evaluate the current literature regarding pediatric spinal surgery ERAS protocols and their ability to decrease the length of stay, pain, time-to-stand, and complications. METHODS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Statistical analyses were performed using Cochrane's RevMan (version 5.4). RESULTS Seventeen studies totaling 2733 patients were included in this analysis. Patients treated in an ERAS protocol had significant reductions in length of stay (P < 0.001), time-to-stand (P < 0.001), total complications (P = 0.02), and estimated blood loss (P = 0.001). CONCLUSIONS ERAS protocol implementation can significantly enhance outcomes for pediatric patients receiving spinal surgery. Consequently, ERAS protocols have the potential to lower healthcare expenses, increase access, and set a new standard of care. Future research should be conducted to expand pediatric ERAS protocols to a diverse range of spinal pathologies and assess the long-term advantages of this practice.
Collapse
Affiliation(s)
- Grace Hey
- University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Yusuf Mehkri
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ilyas Mehkri
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Avery Duncan
- Mercer University, School of Medicine, Savannah, Georgia, USA
| | - Karina Patel
- Mercer University, School of Medicine, Savannah, Georgia, USA
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Vyshak Chandra
- Lillian S. Wells Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| |
Collapse
|
3
|
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
|
4
|
Hengartner AC, Elsamadicy AA, Jonnalagadda A, Craft S, Sherman JJZ, Reeves BC, Fernandez T, Hobbs J, Koo AB, DiLuna M, Tuason DA. Impact of a quality improvement initiative and monthly multidisciplinary meetings on outcomes after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2024; 12:1043-1051. [PMID: 38493442 DOI: 10.1007/s43390-024-00859-2] [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: 08/21/2023] [Accepted: 03/05/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Several studies have demonstrated the benefits of enhanced recovery after surgery (ERAS) protocols for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumented fusion (PSIF). However, there are relatively few studies investigating the effect of regular multidisciplinary team meetings on level selection, surgical performance parameters, and patient outcomes after PSIF for AIS. The aim of this study was to assess changes in intra- and postoperative outcomes following multidisciplinary team meeting implementation for patients undergoing PSIF for AIS. METHODS The medical records of 96 adolescents (10 to 18 years old) diagnosed with AIS and undergoing PSIF at a major academic institution from 2017 to 2022 were retrospectively reviewed. A quality improvement (QI) initiative was implemented in February 2020, including institution of monthly multidisciplinary conferences focusing on preoperative indications, level selection, postoperative review of surgical performance parameters for previous cases, and discussion and optimization of postoperative ambulation and pain control protocols. Patients were placed into "Pre-QI" (treated pre-February 2020) and "Post-QI" (treated post-February 2020) cohorts. Patient demographics, comorbidities, deformity characteristics, intraoperative variables, ambulation status, postoperative complications, length of stay (LOS), and unplanned readmission rates were assessed. RESULTS Of the 96 study patients, 44 (45.8%) were in the Pre-QI cohort, and 52 (54.2%) were in the Post-QI cohort. Mean major curve was not significantly different between the two cohorts (Pre-QI: 58.0 ± 7.3° vs Post-QI: 57.9 ± 14.5°, p = 0.169). The Pre-QI cohort had a greater mean minor curve degree (Pre-QI: 42.7 ± 11.8° vs Post-QI: 36.8 ± 12.4, p = 0.008). The Pre-QI cohort had significantly greater mean spinal levels fused (Pre-QI: 11.7 ± 1.7 vs Post-QI: 10.4 ± 2.6, p = 0.009), significantly greater mean estimated blood loss (Pre-QI: 1063.6 ± 631.5 ml vs. Post-QI: 415.8 ± 189.9 ml, p < 0.001), significantly greater mean operative time normalized to levels fused (Pre-QI: 0.6 ± 0.1 h/level fused vs Post-QI: 0.4 ± 0.1 h/level fused, p < 0.001), and a significantly greater proportion of patients with intraoperative drain placement (Pre-QI: 93.2% vs Post-QI: 5.8%, p < 0.001). The Post-QI cohort had significantly shorter time to postoperative ambulation (Pre-QI: 2.1 ± 0.9 days vs Post-QI: 1.3 ± 0.5 days, p < 0.001). A significantly greater proportion of patients in the Pre-QI cohort developed any postoperative complication (Pre-QI: 72.7% vs Post-QI: 34.6%, p < 0.001), and mean LOS was significantly greater among Pre-QI patients (Pre-QI: 4.5 ± 1.1 days vs Post-QI: 3.2 ± 0.8 days, p < 0.001). Discharge disposition (p = 0.758) and 30-day unplanned readmissions (p = 0.207) were similar between the cohorts. CONCLUSIONS Our findings suggest that monthly multidisciplinary pediatric spine team meetings may improve patient care. Further studies exploring the incorporation of QI implementation with frequent multidisciplinary team meetings into existing ERAS protocols are merited.
Collapse
Affiliation(s)
- Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Anshu Jonnalagadda
- Department of Orthopedics, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Tiana Fernandez
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Joshua Hobbs
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Dominick A Tuason
- Department of Orthopedics, Yale University School of Medicine, New Haven, CT, 06520, USA.
| |
Collapse
|
5
|
Gilbertson LE, Muhly WT, Montana MC, Chidambaran V, DiCindio S, Sadacharam K, Wilder RT, Whyte SD, Hifko A, Sponseller PD, Frankville DD. A survey of practice in the anesthetic management of adolescent idiopathic scoliosis spine fusion by the North American Pediatric Spine Anesthesiologists Collaborative. Paediatr Anaesth 2024; 34:645-653. [PMID: 38578166 DOI: 10.1111/pan.14895] [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: 11/16/2023] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Adolescent Idiopathic Scoliosis (AIS) affects 2%-4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management. AIMS To examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon. METHODS A web-based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital. RESULTS Thirty-one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7-93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3-89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3-100) and an arterial line (100%; 95% CI 88.8-100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6-99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7-93.3). CONCLUSION Most anesthesiologists (87.1%; 95% CI 80.6-99.9) report the use of some form of an anesthesia-based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.
Collapse
Affiliation(s)
- Laura E Gilbertson
- Department of Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael C Montana
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sabina DiCindio
- Department of Anesthesiology, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Kesavan Sadacharam
- Department of Anesthesiology, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Robert T Wilder
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Simon D Whyte
- Department of Anesthesiology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Alan Hifko
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Paul D Sponseller
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - David D Frankville
- Anesthesia Services Medical Group, Rady Children's Hospital of San Diego, San Diego, California, USA
| |
Collapse
|
6
|
Abdulmajeed A. Effectiveness of a Preoperative Bowel Preparation Protocol for Patients With Adolescent Idiopathic Scoliosis to Decrease Postoperative Gastrointestinal Morbidities and the Hospital Length of Stay. Global Spine J 2024:21925682241249107. [PMID: 38767157 DOI: 10.1177/21925682241249107] [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] [Indexed: 05/22/2024] Open
Abstract
STUDY DESIGN Randomised controlled trial. OBJECTIVE This study aimed to determine the effectiveness of a preoperative bowel preparation protocol comprising bisacodyl to minimize postoperative gastrointestinal morbidities and the hospital length of stay for patients with adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Patients who undergo scoliosis correction surgery frequently experience postoperative gastrointestinal morbidities and a prolonged hospital length of stay. Emesis, paralytic ileus and constipation are the most common gastrointestinal morbidities. Opioid medication is a well-known risk factor for gastrointestinal complications after scoliosis correction surgery. METHODS Eighty-seven patients (22 boys [25.3%] and 65 girls [74.7%]) with a mean age of 17.7 years (standard deviation [SD], ±2.2 years) diagnosed with adolescent idiopathic scoliosis were enrolled in this study and randomized into 2 groups. Group A comprised 44 patients who received a preoperative bowel preparation comprising bisacodyl. Group B comprised 43 patients who did not receive any preoperative medication. Demographic data, height, weight, medical and surgical comorbidities, Risser status, number of instrumented levels and preoperative opioid consumption of all patients were evaluated. RESULTS Group A experienced fewer postoperative abdominal symptoms than group B. The mean hospital length of stay was 4.1 days (SD, ±.6 days; median, 4 days; range, 3-5 days) for group A; however, it was 5.3 days (SD, ±.8 days; median, 5 days; range, 4-7 days) for group B (P = .01). CONCLUSION The use of a bowel preparation protocol before scoliosis correction surgery for patients with adolescent idiopathic scoliosis can effectively decrease postoperative gastrointestinal morbidities and the hospital length of stay.
Collapse
Affiliation(s)
- Alzakri Abdulmajeed
- Department of Orthopaedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
- Department of Spine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
7
|
Zhang H, Liu H, Zhang X, Zhao M, Guo D, Bai Y, Qi X, Shi H, Li D. Short-term outcomes of an enhanced recovery after surgery pathway for children with congenital scoliosis undergoing posterior spinal fusion: a case-control study of 70 patients. J Pediatr Orthop B 2024; 33:258-264. [PMID: 37339529 DOI: 10.1097/bpb.0000000000001105] [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: 06/22/2023]
Abstract
Increasing evidence demonstrates the advantages of an enhanced recovery after surgery (ERAS) protocol; however, few studies have evaluated ERAS in pediatric patients. This study aimed to evaluate the effect of ERAS in pediatric patients with congenital scoliosis. Seventy pediatric patients with congenital scoliosis underwent posterior hemivertebra resection and fusion with pedicle screws and were prospectively randomly assigned to the ERAS group ( n = 35) and control group ( n = 35). ERAS management comprised 15 elements including a shortened fasting time, optimized anesthesia protocol, and multimodal analgesia. The control group received traditional perioperative management. Clinical outcome was evaluated by hospital stay, surgery-related indicators, diet, pain scores, laboratory tests, and complications. The surgical outcome showed a similar correction rate in the ERAS group (84.0%) and control group (89.0%; P = 0.471). The mean fasting time was significantly shorter in the ERAS group than in the control group. Compared with the control group, the ERAS group had significantly shorter mean times to postoperative hospital stay, first anal exhaust and defecation, significantly lower mean pain scores in the first 2 days postoperatively ( P < 0.05), and a significantly lower mean interleukin-6 concentration on postoperative day 1 ( P < 0.001). The incidence of complications was similar in the ERAS group and control group ( P > 0.05). The ERAS protocol is effective and safe for pediatric patients with congenital spinal deformity and may significantly improve the treatment efficacy compared with traditional perioperative management methods. Levels of Evidence: III.
Collapse
Affiliation(s)
- Hanwen Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haonan Liu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xuejun Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Mengqi Zhao
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Dong Guo
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Yunsong Bai
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xinyu Qi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haixia Shi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Duoyi Li
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| |
Collapse
|
8
|
Segal KR, Gomez JA, Schulz JF, Alvandi LM, Fornari ED. The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management. Hosp Pediatr 2023; 13:1001-1009. [PMID: 37850258 DOI: 10.1542/hpeds.2023-007232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance. METHODS This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores. RESULTS A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85). CONCLUSIONS As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.
Collapse
|
9
|
Jeandel C, Ikonomoff T, Bertoncelli CM, Lo Cunsolo L, Vergillos Luna M, Monticone M, Clement JL, Rampal V, Solla F. Enhanced recovery following posterior spinal fusion for adolescent idiopathic scoliosis: A medical and economic study in a French private nonprofit pediatric hospital. Orthop Traumatol Surg Res 2023; 109:103626. [PMID: 37086946 DOI: 10.1016/j.otsr.2023.103626] [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: 10/07/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION Little data exist on the efficacy of enhanced recovery after surgery (ERAS) protocols in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). HYPOTHESIS ERAS reduces hospital costs (HC) and length of stay (LOS) without increasing pain or complications. MATERIALS AND METHODS This was a retrospective comparative medical and economic study of 2 cohorts of patients who underwent PSF for AIS: a prospective group who underwent surgery with an ERAS protocol without a specially assigned care coordinator from 2020 to 2021 (n=30) and a retrospective group (control) who received standard care from 2017 to 2018 (n=30). The key amendments to the ERAS protocol were reduced preoperative investigations, opioid-sparing analgesia, ambulation starting on postoperative day (POD) 1, early resumption of oral diet, and early transition to oral analgesics. Moreover, an intensive care unit (ICU) stay, surgical drainage, and the postoperative CT scan were no longer routine. The discharge criteria were the same for both groups: normal bowel function, independent walking, pain Visual Analog Scale (VAS)<3 without strong opioids, and no signs of complications. The endpoints were: decreased HC (calculated by subtracting the costs of hospital days and complementary exams that were not carried out) and LOS, complications, and postoperative pain according to the VAS on POD 1, POD 3, and discharge. All means were reported with the standard deviation. RESULTS The mean age of patients undergoing surgery (14.5±1.7 years), sex ratio, curve type according to the Lenke classification, mean Cobb angle (54±12°), and the number of instrumented vertebrae (9±2) were similar in both groups (p>0.5). The HC decreased on average by 3029€ per patient. The mean LOS was 5±0.9 days in the ERAS group versus 6.5±0.6 days in the control group (p<0.001). The VAS scores on POD 1 and POD 3 were lower in the ERAS group. One postoperative complication was noted in each group. CONCLUSION Implementing an ERAS protocol without a specifically assigned care coordinator for patients with AIS undergoing PSF significantly decreased HC, LOS, and early postoperative pain. LEVEL OF EVIDENCE III; retrospective comparative study.
Collapse
Affiliation(s)
- Clément Jeandel
- Orthopédie infantile, hôpital Lenval, 57, avenue Californie, 06200 Nice, France
| | - Tania Ikonomoff
- Anesthésie pédiatrique, hôpital Lenval, 57, avenue Californie, 06200 Nice, France
| | | | - Lucas Lo Cunsolo
- Orthopédie infantile, hôpital Lenval, 57, avenue Californie, 06200 Nice, France
| | | | - Marco Monticone
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Jean-Luc Clement
- Orthopédie infantile, hôpital Lenval, 57, avenue Californie, 06200 Nice, France
| | - Virginie Rampal
- Orthopédie infantile, hôpital Lenval, 57, avenue Californie, 06200 Nice, France
| | - Federico Solla
- Orthopédie infantile, hôpital Lenval, 57, avenue Californie, 06200 Nice, France; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| |
Collapse
|
10
|
Zacha S, Szwed A, Miegoń J, Skonieczna-Żydecka K, Andrzejewska A, Modrzejewska E, Horecki M, Jarosz K, Biernawska J. Novel Interdisciplinary Enhanced Recovery after Surgery Protocol Implementation in Paediatric Orthopaedics. J Pers Med 2023; 13:1417. [PMID: 37763184 PMCID: PMC10532497 DOI: 10.3390/jpm13091417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
The enhanced recovery after surgery (ERAS) protocol is not routine management in paediatric orthopaedics. Cultural differences or assumptions about the financing of medical care in different countries encourage creative adaptation of general assumptions in local communities. The aim of this study was to compare the quality of the perioperative period before and after the introduction of an interdisciplinary protocol adopted to organisational conditions. A group of 4098 children were included in the "before-after" observational study. The data of 1553 patients (BEFORE group) were analysed in terms of compliance with the enhanced recovery after surgery protocol guidelines and the time and cost of hospitalisation over a 20-month period. A novel interdisciplinary protocol was developed, including an education and training app called BackOnFeet (BOF®), standardised hospital management, and the introduction of methods novel to Poland (intraoperative nerve cryoanalgesia in children). A further 2545 patients (AFTER group) were reassessed over a period of 20 months. It was found that the groups differed in hospitalisation time (p < 0.001), type of procedures, and percentage ratio of costs incurred to revenue generated. The usefulness of the BOF® app as an effective educational tool was demonstrated. The optimisation of perioperative management in paediatric orthopaedics based on novel tools and the interdisciplinary ERAS protocol is possible and brings tangible benefits in psychological, organisational, and financial terms.
Collapse
Affiliation(s)
- Sławomir Zacha
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, SPSK nr 1 Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Aleksander Szwed
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, SPSK nr 1 Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Jakub Miegoń
- Department of Anaesthesiology and Intensive Therapy, SPSK No 1 Pomeranian Medical University, 71-252 Szczecin, Poland; (J.M.); (J.B.)
| | | | - Agata Andrzejewska
- Department of Anaesthesiology and Intensive Therapy, SPSK No 1 Pomeranian Medical University, 71-252 Szczecin, Poland; (J.M.); (J.B.)
| | - Elżbieta Modrzejewska
- Department of Paediatric Orthopaedics and Musculoskeletal Oncology, SPSK nr 1 Pomeranian Medical University, 71-252 Szczecin, Poland
| | - Marcin Horecki
- Department of Infectious Diseases, Tropical Diseases and Acquired Immunodeficiencies, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Konrad Jarosz
- Department of Clinical Nursing, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Jowita Biernawska
- Department of Anaesthesiology and Intensive Therapy, SPSK No 1 Pomeranian Medical University, 71-252 Szczecin, Poland; (J.M.); (J.B.)
| |
Collapse
|
11
|
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
|
12
|
Barnett SA, Song BM, Bauer M, Nungesser ME, Leonardi C, Heffernan MJ. Minimalistic approach to enhanced recovery after pediatric scoliosis surgery. Spine Deform 2023; 11:841-846. [PMID: 36935474 PMCID: PMC10261149 DOI: 10.1007/s43390-023-00675-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/25/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen. METHODS AIS patients aged 10-18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon's practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement. RESULTS A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p < 0.0001). Narcotic requirement was similar between groups (p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p < 0.0001). 83% of the ERP group had LOS ≤ 3 days compared to 0% in the SRP group, whose mean LOS was 4.2 days. There was no difference in complications between the groups (2.2% vs 6.0%, p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23). CONCLUSION In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.
Collapse
Affiliation(s)
- Scott A Barnett
- Children's Hospital New Orleans, LSU Health Sciences Center, New Orleans, LA, USA
| | - Bryant M Song
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Matthew Bauer
- Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | - Claudia Leonardi
- School of Public Health, LSU Health Sciences Center, New Orleans, LA, USA
| | - Michael J Heffernan
- Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, USA.
- Jackie and Gene Autry Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #69, Los Angeles, CA, 90027, USA.
| |
Collapse
|
13
|
Rapid recovery pathway without epidural catheter analgesia for surgical treatment of adolescent idiopathic scoliosis: a comparative study. Spine Deform 2023; 11:373-381. [PMID: 36152234 DOI: 10.1007/s43390-022-00587-5] [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: 03/25/2022] [Accepted: 09/10/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE To assess effectiveness of a rapid recovery pathway (RRP) without epidural catheter analgesia (ECA) or intravenous patient controlled analgesia (PCA) in accelerating recovery and decreasing opioid consumption in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF). METHODS A retrospective cohort study included collection of demographics, ECA use, IV PCA, postoperative opioid consumption, postoperative pain scores, and reoperation rate. Opioid consumption was calculated using morphine milligram equivalents (MME). Hospital length of stay (HLOS) and first reported ambulation with physical therapy (PT) were also recorded. RESULTS 53 patients were included, with 18 in the RRP group. Patient characteristics were comparable between the groups, except in ECA use and BMI. The RRP group consumed less total MME from postoperative day (POD) 0 to 2 (mean difference 61.6 MME; 95% CI 37.1-86.1 MME; p < 0.001). In addition, the RRP group had significantly shorter HLOS (2.5 vs 4.0 days; p < 0.001). There were no differences in VAS scores between the two groups. A subset analysis comparing patients who did and did not receive ECA showed that ECA resulted in overall higher inpatient MME and HLOS. A prediction model was developed using multiple regression based on the different medications used for multimodal analgesia (MMA) in the RRP. CONCLUSIONS An RRP without the use of ECA or IV PCA can provide adequate analgesia in patients with AIS undergoing PSF while lowering inpatient narcotic consumption and accelerating immediate postoperative recovery.
Collapse
|
14
|
Joarder I, Taniguchi S, Mendoza A, Snow ME. Defining "successful" treatment outcomes in adolescent idiopathic scoliosis: a scoping review. 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; 32:1204-1244. [PMID: 36847911 DOI: 10.1007/s00586-023-07592-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/07/2023] [Accepted: 02/07/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis that affects children aged 10-18 years old, manifesting in a three-dimensional spinal deformity. This study aimed to explore outcome measures used in defining AIS treatment success. Particularly, analyzing the extent of qualitative and quantitative (radiographic and quality of life domains) measures to evaluate AIS and whether AIS treatment approaches (surgical, bracing and physiotherapy) influences outcomes used as proxies of treatment success. METHODS EMBASE and MEDLINE databases were used to conduct a systematic scoping review with 654 search queries. 158 papers met the inclusion criteria and were screened for data extraction. Extractable variables included: study characteristics, study participant characteristics, type of study, type of intervention approach and outcome measures. RESULTS All 158 studies measured quantitative outcomes. 61.38% of papers used radiographic outcomes whilst 38.62% of papers used quantitative quality of life outcomes to evaluate treatment success. Irrespective of treatment intervention utilized, the type of quantitative outcome measure recorded were similar in proportion. Moreover, of the radiographic outcome measures, the subcategory Cobb angle was predominantly used across all intervention approaches. For quantitative quality of life measures, questionnaires investigating multiple domains such as SRS were primarily used as proxies of AIS treatment success across all intervention approaches. CONCLUSION This study identified that no articles employed qualitative measures of describing the psychosocial implications of AIS in defining treatment success. Although quantitative measures have merit in clinical diagnoses and management, there is increasing value in using qualitative methods such as thematic analysis in guiding clinicians to develop a biopsychosocial approach for patient care.
Collapse
Affiliation(s)
- Ishraq Joarder
- Faculty of Medicine, University of British Columbia, #908 - 2233 Allison Road, Vancouver, BC, V6T 1T7, Canada.
| | - Seika Taniguchi
- Faculty of Medicine, University of British Columbia, #908 - 2233 Allison Road, Vancouver, BC, V6T 1T7, Canada
| | | | | |
Collapse
|
15
|
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
|
16
|
Martin BD, Gordish-Dressman H, Mirzada A, Kelly SM, Pestieau SR, Cronin J, Oetgen ME. A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency. Spine Deform 2023; 11:643-649. [PMID: 36681754 PMCID: PMC9867539 DOI: 10.1007/s43390-022-00639-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/30/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes. METHODS 367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests. RESULTS Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed. CONCLUSION Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.
Collapse
Affiliation(s)
- Benjamin D. Martin
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, 111 Michigan Avenue, Washington, DC 20010 USA
| | - Heather Gordish-Dressman
- grid.239560.b0000 0004 0482 1586Research Center for Genetic Medicine, Children’s National Hospital, Washington, DC USA
| | - Ariana Mirzada
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Shannon M. Kelly
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, Washington, DC USA
| | - Sophie R. Pestieau
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Jessica Cronin
- grid.239560.b0000 0004 0482 1586Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, Washington, DC USA
| | - Matthew E. Oetgen
- grid.239560.b0000 0004 0482 1586Division of Orthopaedic Surgery & Sports Medicine, Children’s National Hospital, Washington, DC USA
| |
Collapse
|
17
|
Yao Y, Li G, Li J, Liu S, Chen Y, Deng J, Wei Y, Gao L, Wang D, Zeng H. Short-Term Outcomes of Enhanced Recovery after Surgery (ERAS) for Ankle Fracture Patients: A Single-Center Retrospective Cohort Study. Orthop Surg 2023; 15:766-776. [PMID: 36660923 PMCID: PMC9977597 DOI: 10.1111/os.13621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) has been successfully adopted for the improvement of medical quality and efficacy in many diseases, but the effect thereof for ankle fracture patients can vary. The aim of the present study was to explore the short-term postoperative outcomes of ERAS among ankle fracture patients. METHODS The present study was a retrospective cohort study conducted between January 2019 and May 2019. One hundred and sixty ankle fracture participations (58 males and 102 females, aged 41.71 ± 14.51 years) were included. The participants treated with open reduction and internal fixation were divided into two groups (non-ERAS vs. ERAS) depending on whether ERAS was applied. Postoperative outcomes included American Orthopedic Foot and Ankle Society (AOFAS) score, length of stay (LOS), hospital cost, complications, and consumption of opioids. To assess the association between the groups and outcomes, generalized estimating equation (GEE) modeling and multivariable linear regression analysis were performed. RESULTS The average follow-up periods of the participations were 24 months postoperatively. No significant differences were detected between the non-ERAS group and ERAS group with respect to the demographic of patients in terms of gender, age, Danis-Weber classification of fracture, dislocation of ankle joint, and comorbidity (P > 0.05). Significant differences in terms of a higher AOFAS score were found in the ERAS group compared with the non-ERAS group (6.73, 95% CI, 5.10-8.37, p < 0.001) at 3 months postoperatively (PO3M) and (4.73, 95% CI, 3.02-6.45, p < 0.001) at 6 months postoperatively (PO6M). However, similar AOFAS scores were found at 12 months postoperatively (PO12M) (0.28, 95% CI, -0.32 to 0.89, P > 0.05) and at 24 months postoperatively (PO24M) (0.56, 95% CI, -0.07 to 1.19, P > 0.05). Additionally, the GEE analysis and group-by-time interaction of AOFAS score revealed that the ERAS protocol could facilitate faster recovery for ankle fracture patients, with higher PO3M and PO6M (both P < 0.05). At the same time, significant differences in terms of a shorter length of stay (-3.19, 95% CI, -4.33 to -2.04, P < 0.01) and less hospital cost (-6501.81, 95% CI, -10955.21 to -2048.42, P < 0.01) were found in the ERAS group compared with the non-ERAS group. CONCLUSION By reducing LOS and hospital cost, the ERAS protocol might improve the medical quality and efficacy. The present study can provide a realistic evaluation and comparison of the ERAS protocol among ankle fracture patients, and ultimately guide clinical decision making.
Collapse
Affiliation(s)
- Yuefeng Yao
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Guoqing Li
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Jing Li
- Renal Division, Peking University Shenzhen HospitalPeking UniversityBeijingChina
| | - Su Liu
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Yixiao Chen
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Jiapeng Deng
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Yihao Wei
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Liang Gao
- Center for Clinical MedicineHuatuo Institute of Medical Innovation (HTIMI)BerlinGermany
| | - Deli Wang
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| | - Hui Zeng
- Department of Bone & Joint SurgeryPeking University Shenzhen HospitalShenzhenChina,National & Local Joint Engineering Research Center of Orthopaedic BiomaterialsPeking University Shenzhen HospitalShenzhenChina
| |
Collapse
|
18
|
Ding H, Hai Y, Guan L, Liu Y, Pan A, Han B. The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study. Front Surg 2022; 9:989119. [PMID: 36277279 PMCID: PMC9581125 DOI: 10.3389/fsurg.2022.989119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Methods Results Conclusions
Collapse
Affiliation(s)
| | - Yong Hai
- Correspondence: Yong Hai Li Guan
| | - Li Guan
- Correspondence: Yong Hai Li Guan
| | | | | | | |
Collapse
|
19
|
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
|
20
|
Blood loss estimation during posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2022; 10:581-588. [PMID: 34784000 DOI: 10.1007/s43390-021-00440-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Blood loss (BL) during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) may be estimated using a variety of unproven techniques. Patient care and research on BL are likely impacted by a lack of standardization. A novel FDA-approved blood volume (BV) analysis system (BVA-100 Blood Volume Analyzer) allows rapid processing with > 97% accuracy. The purpose of this study was to investigate common methods for BL estimation. METHODS BV assessment was performed with the BVA-100. After obtaining a baseline sample of 5 mL of blood, 1 mL of I-131-labeled albumin was injected intravenously over 1 min. Five milliliter blood samples were then collected at 12, 18, 24, 30, and 36 min post-injection. Intravenous fluid was minimized to maintain euvolemia. Salvaged blood was not administered during surgery. BL was estimated using several common techniques and compared to the BV measurements provided by the BVA-100 (BVABL). RESULTS Thirty AIS patients were prospectively enrolled with major curves of 54° and underwent fusions of 10 levels. BL based on the BVA-100 (BVABL) was 519.2 [IQR 322.9, 886.2] mL. Previously published formulas all failed to approximate BVABL. Multiplying the cell saver volume return by 3 (CS3) approximates BVABL well with a Spearman correlation coefficient and ICC of 0.80 and 0.72, respectively. An extrapolated cell salvage-based estimator also showed high intraclass correlation coefficient (ICC) and Spearman coefficients with less bias than CS3. CONCLUSION Published formulaic approaches do not approximate true blood loss. Multiplying the cell saver volume by 3 or using the cell salvage-based estimator had the highest correlation coefficient and ICC. LEVEL OF EVIDENCE Prospective cohort Level 2.
Collapse
|
21
|
Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202203000-00012. [PMID: 35285819 PMCID: PMC8920416 DOI: 10.5435/jaaosglobal-d-21-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022]
|
22
|
Enhanced Recovery Pathway in Adults Undergoing Elective Posterior Thoracolumbar Fusion Surgery: Outcomes Compared with a Traditional Care Pathway. Adv Orthop 2021; 2021:6204831. [PMID: 34567808 PMCID: PMC8461228 DOI: 10.1155/2021/6204831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/14/2021] [Accepted: 09/07/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Spine fusion surgery is an increasingly popular procedure, but the patient experience is variable and the cost is high. Enhanced recovery after surgery (ERAS) pathways can provide a standardized plan for spine fusion cases, improving quality of care and reducing costs. We report an early attempt at the implementation of such a pathway and compare it to a historical cohort. METHODS All adult patients undergoing elective posterior thoracolumbar spine fusion in 2019 and 2020 were included in the study. The ERAS protocol implementation started in January 2020. The study cohort was all cases performed in 2020-after implementation of ERAS-while the historical cohort was cases from 2019. Demographic and clinical data were collected and compared between the groups. RESULTS Ninety-three patients were included in the study. The study cohort (ERAS) included 42 patients, while the comparison group (pre-ERAS) included 51 patients. Demographic and preoperative clinical data were similar between the two groups. However, postoperative clinical data showed that ERAS resulted in less reliance on analgesics, earlier mobilization, and a reduced length of stay. Complication and readmission rates were unchanged. CONCLUSION ERAS can reduce costs while maintaining or improving clinical outcomes for spinal fusion surgery.
Collapse
|
23
|
Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases. 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 2021; 30:3457-3472. [PMID: 34524513 DOI: 10.1007/s00586-021-06984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 05/30/2021] [Accepted: 08/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways. METHODS Using major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed. RESULTS Fourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively. CONCLUSIONS Use of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction. LEVEL OF EVIDENCE III Meta-analysis of Level 3 studies.
Collapse
|
24
|
Brindle M, Heiss K. Commentary on early enteral feeding versus traditional feeding in neonatal congenital gastrointestinal malformation undergoing intestinal anastomosis: A randomized multicenter controlled trial of an enhanced recovery after surgery (ERAS) component. J Pediatr Surg 2021; 56:1485-1486. [PMID: 33858668 DOI: 10.1016/j.jpedsurg.2021.03.013] [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: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/17/2022]
Abstract
This is a Commentary on "Enhanced Enteral Feeding Versus Traditional Feeding in Neonatal Congenital Gastrointestinal Malformation Undergoing Intestinal Anastomosis: A Randomized Multicenter Controlled Trial of an Enhanced Recovery After Surgery (ERAS) Component" by Peng Y, Xiao D, Xiao S, et al.
Collapse
Affiliation(s)
- Mary Brindle
- Surgery and Community Health Sciences, University of Calgary, The EQuIS (Efficiency Quality Innovation and Safety), Alberta Children's Hospital, Director-Safe Surgery Safe Systems Program Ariadne Labs, Scientific Director-Province of Alberta Surgery Strategic Care Network, Calgary, Alberta, Canada.
| | - Kurt Heiss
- Emeritus of Surgery and Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, 6088 Millstone Run, Stone Mountain, GA 30087, USA.
| |
Collapse
|