Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key?

Enhanced Recovery After Surgery Pathways in Pediatric Spinal Surgery: A Systematic Review and Meta-Analysis

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.

Enhanced recovery following posterior spinal fusion for adolescent idiopathic scoliosis: A medical and economic study in a French private nonprofit pediatric hospital

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.

Impact of establishing a respiratory high dependency unit for SCAP patients on the therapeutic effect, prognosis, and expenditure: a retrospective case-control study

To explore the effects of establishing a high dependency unit (HDU) on the prognosis, outcome, and expenditure of patients with severe community-acquired pneumonia (SCAP). 108 SCAP patients were recruited from the respiratory intensive care unit (RICU) of the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. Of these, 87 qualified the study-selection criteria and were divided into HDU group (treated in HDU after discharge from RICU prior to transfer to normal unit) (n = 40) and normal group (not treated in the HDU) (n = 47). In the 87 patients, 40 were divided into HDU group, which meant they transferring to HDU when got stable while another 47 were divided into normal group which meant they staying longer in RICU and transferring to normal unit when got stable. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, duration of mechanical ventilation, hospital infection, intensive care unit syndrome, length of stay, and expenditure were compared between the two groups. The primary outcome was discharging from hospital while the secondary outcome was length of stay. There was no significant difference with respect to noninvasive ventilation time, oxygenation index, or APACHE II and SOFA scores at admission or discharge from RICU (P > 0.05). The mean invasive ventilation time (176 ± 160 h) of the HDU group was not significantly different from that in the normal group (206 ± 179 h). The period of sequential noninvasive ventilation in the HDU group (135 ± 82 h) was significantly shorter than that in the normal group (274 ± 182 h, P < 0.05). The HDU group had a shorter length of stay in hospital and RICU, and incurred lesser expenditure than patients in the normal group (P < 0.05). Patients in HDU group had almost the same therapeutic effect with shorter length of stay in hospital and RICU, and lesser expenditure.