Goal-Directed Fluid Therapy Based on Stroke Volume Variation in Patients Undergoing Major Spine Surgery in the Prone Position: A Cohort Study

Intraoperative fluid management in adult spinal deformity surgery: variation analysis and association with outcomes

PURPOSE

To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS).

METHODS

Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes.

RESULTS

Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004).

CONCLUSION

Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes.

LEVEL OF EVIDENCE

III.

Influence of blood loss on cerebral oxygen saturation in paediatric patients undergoing surgery for scoliosis correction: A retrospective observational study

AIM

Surgery for congenital scoliosis correction in children is often associated with considerable blood loss. Decrease in regional oxygen saturation (rScO2) can reflect insufficient cerebral perfusion and predict neurological complications. This retrospective observational study explored the relationship between blood loss during this surgery and a decrease in rScO2 in children.

METHODS

The following clinical data of children aged 3-14 years who underwent elective posterior scoliosis correction between March 2019 and July 2021 were collected: age, sex, height, weight, baseline rScO2, basal mean invasive arterial pressure (MAP), preoperative Cobb angle, number of surgical segments, preoperative and postoperative haemoglobin level, percentage of lowest rScO2 below the baseline value that lasted 3 min or more during the operation (decline of rScO2 from baseline, D-rScO2%), intraoperative average invasive MAP, end-tidal carbon dioxide pressure, fluid infusion rate of crystalloids and colloids, operation time, and percentage of total blood loss/patient's blood volume (TBL/PBV).

RESULTS

A total of 105 children were included in the study. Massive haemorrhage (TBL/PBV ≥50%) was reported in 53.3% of patients, who had significantly higher D-rScO2 (%) (t = -5.264, P < 0.001) than those who had non-massive haemorrhage (TBL/PBV <50%). Multiple regression analysis revealed that TBL/PBV (β = 0.04, 95% CI: 0.018-0.062, P < 0.05) was significantly associated with D-rScO2%.

CONCLUSIONS

Intraoperative massive blood loss in children significantly increased D-rScO2%. Monitoring should be improved, and timely blood supplementation should be performed to ensure maintenance of the blood and oxygen supply to vital organs, improve the safety of anaesthesia, and avoid neurological complications.

The Effect of Colloids versus Crystalloids for Goal-Directed Fluid Therapy on Prognosis in Patients Undergoing Noncardiac Surgery: A Meta-Analysis of Randomized Controlled Trials

Background

Goal-directed fluid therapy (GDFT) contributes to improvements in intraoperative fluid infusion based on objective parameters and has been widely recommended in clinical practice. In addition, increasing evidence reveals that GDFT can improve the prognosis of surgical patients. However, considering the individual characteristics of colloids and crystalloids in clinical use, it is uncertain as to which type of fluids administered is associated with better outcomes in the condition of GDFT.

Objectives

To evaluate the effect of colloids versus crystalloids under GDFT on prognosis in patients undergoing noncardiac surgery. Data Sources. Randomized controlled trials (RCTs) from PubMed, EMBASE, Ovid MEDLINE, CNKI, Cochrane library, and reference lists of relevant articles.

Methods

Two investigators independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was a composite of postoperative complications. The secondary outcomes were (1) mortality at the follow-up duration; (2) postoperative complications of several organ systems, including cardiac, pulmonary, digestive, urinary, nervous system, and postoperative infection events; and (3) hospital and ICU length of stay. Heterogeneity was assessed by the I 2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data.

Results

Of 332 articles retrieved, 15 RCTs (involving 2,956 patients undergoing noncardiac surgery) were included in the final analysis. When the data were pooled, patients in the colloids and crystalloids group revealed no difference in postoperative composite complications (OR = 0.84, 95% CI = 0.51-1.38, P=0.49) under GDFT. Regarding the secondary outcomes, patients in the colloids group were associated with fewer digestive system complications (OR = 0.64, 95% CI = 0.41-0.98, P=0.04). However, no difference was found in mortality (OR = 1.37, 95% CI = 0.72-2.58, P=0.34), complications of the cardiac system (OR = 1.49, 95% CI = 0.66-3.37, P=0.34), pulmonary system (OR = 0.89, 95% CI = 0.62-1.28, P=0.53), urinary system (OR = 1.05, 95% CI = 0.61-1.80, P=0.87), nervous system (OR = 1.04, 95% CI = 0.55-1.98, P=0.90), postoperative infection events (OR = 0.89, 95% CI = 0.75-1.07, P=0.22), length of hospital stay (difference in mean = -0.71, 95% CI = -1.49-0.07, P=0.07), and ICU stay (difference in mean = -0.01, 95% CI = -0.20-0.18, P=0.95) between patients receiving GDFT with colloids or crystalloids.

Conclusion

There is no evidence of a benefit in using colloids over crystalloids under GDFT in patients undergoing noncardiac surgery, despite its use resulting in lower digestive system complications.

Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery

Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.

A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of the fluid therapy and hemodynamic monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

Enhanced recovery after microdiscectomy: reductions in opioid use, length of stay and cost

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are widely used worldwide. Recently, studies of the ERAS program in spinal surgery subspecialties have been reported. The aim of this study was to evaluate the impacts of ERAS in minimally invasive microdiscectomy (MD) surgery.

METHODS

This was a retrospective cohort study of patients undergoing MD at a single center. From March 2018 to March 2021, 286 patients were in the ERAS group. A total of 140 patients from March 2017 to February 2018 were in the conventional group. The outcomes included length of stay (LOS), the postoperative numeric rating scale (NRS), complications, 30-day readmission rate, 30-day reoperation rate and cost. Moreover, perioperative factors were also evaluated.

RESULTS

Compared with the conventional group, the LOS and cost were reduced in the ERAS group. There were no significant differences in the NRS, complication rate, 30-day readmission or reoperation rates between the groups. Furthermore, postoperative drainage volume, and postoperative opioid use were lower in the ERAS group.

CONCLUSIONS

The ERAS protocol for MD surgery reduces LOS, cost and opioid use and accelerates patient recovery.

Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes

Scoliosis surgery is a challenge for the entire team in terms of safety, and its accomplishment requires the utilization of advanced monitoring technologies. A prospective, single centre, non-randomised controlled cohort study, was designed to assess the efficacy of protocolised intraoperative haemodynamic monitoring and goal-directed therapy in relation to patient outcomes following posterior fusion surgery for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure management during the surgical procedure, whereas the intervention group (n = 35, mean age: 14 years) underwent minimally invasive haemodynamic monitoring. Arterial pulse contour analysis (APCO) devices were employed, along with goal-directed therapy protocol centered on achieving target mean arterial pressure and stroke volume. This was facilitated through the application of crystalloid boluses, ephedrine, and noradrenaline. The intervention group was subjected to a comprehensive protocol following Enhanced Recovery After Surgery (ERAS) principles. Remarkably, the intervention group exhibited notable advantages (p < 0.05), including reduced hospital stay durations (median 7 days vs. 10), shorter episodes of hypotension (mean arterial pressure < 60 mmHg-median 8 vs. 40 min), lesser declines in postoperative haemoglobin levels (-2.36 g/dl vs. -3.83 g/dl), and quicker extubation times. These compelling findings strongly imply that the integration of targeted interventions during the intraoperative care of AIS patients undergoing posterior fusion enhance a set of treatment outcomes.

The Impact of Intraoperative Haemodynamic Monitoring, Prediction of Hypotension and Goal-Directed Therapy on the Outcomes of Patients Treated with Posterior Fusion Due to Adolescent Idiopathic Scoliosis

A prospective, single-centre, non-randomised, case-control study aimed to evaluate the effectiveness of intraoperative haemodynamic monitoring, prediction of hypotension and goal-directed therapy on the outcomes of patients undergoing posterior fusion for adolescent idiopathic scoliosis (AIS). The control group (n = 35, mean age: 15 years) received standard blood pressure control during surgery, while the intervention group (n = 24, mean age: 14 years) underwent minimally invasive haemodynamic monitoring and goal-directed therapy. The intervention group showed significantly shorter durations of hypotension (mean arterial pressure < 60 mmHg), reduced hospital stays and smaller decreases in post-surgery haemoglobin levels. Additionally, the intervention group experienced shorter times from the end of surgery to extubation. These findings suggest that incorporating targeted interventions during intraoperative care for AIS patients undergoing posterior fusion can lead to improved outcomes.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

The Impact of Individualized Hemodynamic Management on Intraoperative Fluid Balance and Hemodynamic Interventions during Spine Surgery in the Prone Position: A Prospective Randomized Trial

Background and Objectives: The effect of individualized hemodynamic management on the intraoperative use of fluids and other hemodynamic interventions in patients undergoing spinal surgery in the prone position is controversial. This study aimed to evaluate how the use of individualized hemodynamic management based on extended continuous non-invasive hemodynamic monitoring modifies intraoperative hemodynamic interventions compared to conventional hemodynamic monitoring with intermittent non-invasive blood pressure measurements. Methods: Fifty adult patients (American Society of Anesthesiologists physical status I−III) who underwent spinal procedures in the prone position and were then managed with a restrictive fluid strategy were prospectively randomized into intervention and control groups. In the intervention group, individualized hemodynamic management followed a goal-directed protocol based on continuously non-invasively measured blood pressure, heart rate, cardiac output, systemic vascular resistance, and stroke volume variation. In the control group, patients were monitored using intermittent non-invasive blood pressure monitoring, and the choice of hemodynamic intervention was left to the discretion of the attending anesthesiologist. Results: In the intervention group, more hypotensive episodes (3 (2−4) vs. 1 (0−2), p = 0.0001), higher intraoperative dose of ephedrine (0 (0−10) vs. 0 (0−0) mg, p = 0.0008), and more positive fluid balance (680 (510−937) vs. 270 (196−377) ml, p < 0.0001) were recorded. Intraoperative norepinephrine dose and postoperative outcomes did not differ between the groups. Conclusions: Individualized hemodynamic management based on data from extended non-invasive hemodynamic monitoring significantly modified intraoperative hemodynamic management and was associated with a higher number of hemodynamic interventions and a more positive fluid balance.

Comparison of Goal-Directed Fluid Therapy using LiDCOrapid System with Regular Fluid Therapy in Patients Undergoing Spine Surgery as a Randomised Clinical Trial

Background

Goal-directed fluid therapy (GDFT) is a new concept to describe the cardiac output (CO) and stroke volume variation to guide intravenous fluid administration during surgery. LiDCOrapid (LiDCO, Cardiac Sensor System, UK Company Regd 2736561, VAT Regd 672475708) is a minimally invasive monitor that estimates the responsiveness of CO versus fluid infusion. We intend to find whether GDFT using the LiDCOrapid system can decrease the volume of intraoperative fluid therapy and facilitate recovery in patients undergoing posterior fusion spine surgeries in comparison to regular fluid therapy.

Methods

This study is a randomised clinical trial, and the design was parallel. Inclusion criteria for participants in this study were patients with comorbidities such as diabetes mellitus, hypertension, and ischemic heart disease undergoing spine surgery; exclusion criteria were patients with irregular heart rhythm or severe valvular heart disease. Forty patients with a previous history of medical comorbidities undergoing spine surgery were randomly and evenly assigned to receive either LiDCOrapid guided fluid therapy or regular fluid therapy. The volume of infused fluid was the primary outcome. The amount of bleeding, number of patients who needed packed red blood cell transfusion, base deficit, urine output, days of hospital length of stay and intensive care unit (ICU) admission, and time needed to start eating solids were monitored as secondary outcomes.

Results

The volume of infused crystalloid and urinary output in the LiDCO group was significantly lower than that of the control group (p = .001). Base deficit at the end of surgery was significantly better in the LiDCO group (p < .001). The duration of hospital length of stay in the LiDCO group was significantly shorter (p = .027), but the duration of ICU admission was not significantly different between the two groups.

Conclusion

Goal-directed fluid therapy using the LiDCOrapid system reduced the volume of intraoperative fluid therapy.

Enhanced Recovery After Surgery Protocol for Oblique Lumbar Interbody Fusion

BACKGROUND

Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it has not been widely utilized in spinal surgery. The study reported the development and implementation of an ERAS pathway for patients with lumbar spondylolisthesis undergoing oblique lumbar interbody fusion (OLIF).

METHODS

Seventy-six patients underwent OLIF surgery from January 2018 to December 2019 were enrolled. Thirty-seven patients were included in pre-ERAS group and 39 patients were included in ERAS group. Major outcomes that were collected included demographics, comorbidities, blood loss, operative time, length of hospital stay (LOS), cost, time to walk, blood transfusion, complications, Visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and factors affecting LOS were also recorded. The ERAS pathway and compliance with pathway elements were also recorded.

RESULTS

After ERAS implementation, the blood loss, LOS, the financial costs, and the time to walk were significantly lower in the ERAS group compared to the pre-ERAS group (all P < 0.05). There was no significant difference in operative time, complications, and blood transfusion between both groups. VAS and ODI between the two groups showed a significant difference during postoperative 3 days and postoperative 1 month (both P < 0.05). The preoperative time to walk was significant factors for hospital stay at the final follow-up.

CONCLUSION

Institution of an ERAS protocol for OLIF surgery appears to accelerate functional recovery, reduce length of stay and financial costs.

An enhanced recovery after surgery pathway: LOS reduction, rapid discharge and minimal complications after anterior cervical spine surgery

BACKGROUND

Enhance recovery after surgery (ERAS) is a new and promising paradigm for spine surgery. The purpose of this study is to investigate the effectiveness and safety of a multimodal and evidence-based ERAS pathway to the patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

The patients treated with the ACDF-ERAS pathway were compared with a historical cohort of patients who underwent ACDF before ERAS pathway implementation. Primary outcome was length of stay (LOS). Secondary outcomes included cost, MacNab grading, complication rates and 90-day readmission and reoperation. And perioperative factors and postoperative complications were reviewed.

RESULTS

The ERAS protocol was composed of 21 components. More patients undergoing multi-level surgery (n ≥ 3) were included in the ERAS group. The ERAS group showed a shorter LOS and a lower cost than the conventional group. The postoperative satisfaction of patients in ERAS group was better than that in conventional group. In addition, the rate of overall complications was significantly higher in the conventional group than that in the ERAS group. There were no significant differences in operative time, postoperative drainage, or 90-day readmission and reoperation.

CONCLUSIONS

The ACDF-tailored ERAS pathway can reduce LOS, cost and postoperative complications, and improve patient satisfaction without increasing 90-day readmission and reoperation.

Comparison of restrictive fluid therapy with goal-directed fluid therapy for postoperative delirium in patients undergoing spine surgery: a randomized controlled trial

Background

Postoperative delirium (POD) is a common phenomenon after spinal surgery. Intraoperative fluid management may affect POD. The aim of this study was to compare the effects of restrictive fluid therapy (RF) with those of goal-directed fluid therapy (GDT) on POD.

Methods

A total of 195 patients aged ≥ 50 years who underwent spinal surgery were randomly divided into two groups: the RF group and the GDT group. In group RF, a bolus of lactated Ringer’s solution was administered at a dose of 5 mL·kg^-1 before the induction of anesthesia, followed by a dose of 5 mL·kg^-1·h^-1 until the end of surgery. For patients in the GDT group, in addition to the initial administration of lactated Ringer’s solution at 5 mL·kg^-1, the subsequent fluid therapy was adjusted by using a continuous noninvasive arterial pressure (CNAP) monitoring system to maintain pulse pressure variation (PPV) ≤ 14%. The primary endpoint was the incidence of POD, assessed once daily with the Confusion Assessment Method-Chinese Reversion (CAM-CR) scale at 1–3 days postoperatively. The secondary endpoints were intraoperative fluid infusion volume, urine volume, mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), regional cerebral oxygen saturation (rSO₂) value, lactic acid value, and visual analog scale (VAS) pain score at 1–3 days after surgery. Moreover, postoperative complications and the length of hospital stay were recorded.

Results

The incidence of POD was lower in the GDT group than in the RF group (12.4% vs 4.1%; P = 0.035) in the first 3 days after spine surgery. Compared to group RF, group GDT exhibited a significantly increased volume of intraoperative lactated Ringer’s solution [1500 (interquartile range: 1128 to 1775) mL vs 1000 (interquartile range: 765 to 1300) mL, P < 0.001] and urine volume [398 (interquartile range: 288 to 600) mL vs 300 (interquartile range: 200 to 530) mL, P = 0.012]. Intraoperative MAP, CI and rSO₂ values were higher in the GDT group than in the RF group (P < 0.05). Moreover, the length of hospital stay [17.0 (14 to 20) days versus 14.5 (13 to 17.0) days, P = 0.001] was shorter in the GDT group than in the RF group.

Conclusions

GDT reduced the incidence of POD in middle- and old-aged patients undergoing spinal surgery possibly by stabilizing perioperative hemodynamic and improving the supply and demand of oxygen.

Trial registration

ChiCTR2000032603; Registered on May 3, 2020.

Changes in stroke volume induced by lung recruitment maneuver can predict fluid responsiveness during intraoperative lung-protective ventilation in prone position

Background

The present study aimed to evaluate the reliability of hemodynamic changes induced by lung recruitment maneuver (LRM) in predicting stroke volume (SV) increase after fluid loading (FL) in prone position.

Methods

Thirty patients undergoing spine surgery in prone position were enrolled. Lung-protective ventilation (tidal volume, 6–7 mL/kg; positive end-expiratory pressure, 5 cmH₂O) was provided to all patients. LRM (30 cmH₂O for 30 s) was performed. Hemodynamic variables including mean arterial pressure (MAP), heart rate, SV, SV variation (SVV), and pulse pressure variation (PPV) were simultaneously recorded before, during, and at 5 min after LRM and after FL (250 mL in 10 min). Receiver operating characteristic curves were generated to evaluate the predictability of SVV, PPV, and SV decrease by LRM (ΔSV_LRM) for SV responders (SV increase after FL > 10%). The gray zone approach was applied for ΔSV_LRM.

Results

Areas under the curve (AUCs) for ΔSV_LRM, SVV, and PPV to predict SV responders were 0.778 (95% confidence interval: 0.590–0.909), 0.563 (0.371–0.743), and 0.502 (0.315–0.689), respectively. The optimal threshold for ΔSV_LRM was 30% (sensitivity, 92.3%; specificity, 70.6%). With the gray zone approach, the inconclusive values ranged 25 to 75% for ΔSV_LRM (including 50% of enrolled patients).

Conclusion

In prone position, LRM-induced SV decrease predicted SV increase after FL with higher reliability than traditional dynamic indices. On the other hand, considering the relatively large gray zone in this study, future research is needed to further improve the clinical significance.

Trial registration

UMIN Clinical Trial Registry UMIN000027966. Registered 28th June 2017.

The Effect of Goal-Directed Fluid Therapy versus Standard Fluid Therapy on the Cuff Leak Gradient in Patients Undergoing Complex Spine Surgery in Prone Position

Objective  Cuff leak test is an effective and established maneuver to predict airway edema. Standard fluid therapy (SFT) based on conventional monitoring is often associated with postoperative airway edema after complex spine surgeries. We conducted this prospective randomized controlled study to compare the effect of SFT versus goal-directed fluid therapy (GDFT) on the cuff leak gradient (CLG) in patients undergoing complex spine surgery in prone position. Our secondary objectives were to compare the effect of SFT and GDFT on sore throat, hoarseness, and length of intensive care unit (ICU) and hospital stay.

Materials and Methods  Thirty consecutive American Society of Anesthesiologists physical status I and II patients (18–60 years), of either sex, scheduled for spine surgery in prone position with expected duration of surgery more than 5 hours were included. The patients were randomized into two groups of 15 each. Group S patients ( n  = 15) served as control group and received SFT intraoperatively, while patients in group G ( n  = 15) received GDFT. Standard anesthetic protocol was followed in both the groups. The CLG was defined as the difference between the cuff leak volume (CLV) after intubation (CLV _AI ) and before extubation (CLV _BE ).

Statistical Analysis and Results  CLG was significantly less in group G (group S, 137.12 mL; group G, 65.52 mL; p -value <0.001). Intravenous fluids, blood loss, and postoperative sore throat were comparatively lesser in group G, though not statistically significant. Postoperative hoarseness was significantly lower in group G ( p -value = 0.003). Duration of ICU stay in group G (19.43 hours) was significantly lower ( p -value = 0.009) than group S (24.64 hours), but length of hospital stay was comparable.

Conclusion  GDFT significantly reduces airway edema and consequently reduces CLG as compared with SFT in patients undergoing complex spine surgery in prone position. Postoperatively, it also reduces sore throat, hoarseness of voice, and duration of ICU stay.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Evidence-based standardization of the perioperative management of patients undergoing complex spine surgery can improve outcomes such as enhanced patient satisfaction, reduced intensive care and hospital length of stay, and reduced costs. The Society for Neuroscience in Anesthesiology and Critical Care (SNACC) tasked an expert group to review existing evidence and generate recommendations for the perioperative management of patients undergoing complex spine surgery, defined as surgery on 2 or more thoracic and/or lumbar spine levels. Institutional clinical management protocols can be constructed based on the elements included in these clinical practice guidelines, and the evidence presented.

Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study

STUDY DESIGN

Retrospective, comparative.

OBJECTIVE

The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.

SUMMARY OF BACKGROUND DATA

Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.

METHODS

Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.

RESULTS

A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).

CONCLUSION

Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

BACKGROUND

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

METHODS

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

RESULTS

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

CONCLUSIONS

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

OBJECTIVE

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.

METHODS

Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.

RESULTS

Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.

CONCLUSIONS

Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

[Expert consensus on the implementation of enhanced recovery after surgery in percutaneous endoscopic interlaminar lumbar decompression/discectomy (2020)]

In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients' functional training and perioperative education.

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions. ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal ERAS practices.

OBJECTIVE

The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the associated outcomes.

METHODS

A literature search on PubMed was conducted to identify clinical studies that implemented ERAS protocols for various spine procedures in the adult population. The search included English-language literature published through December 2019. Additional sources were retrieved from the reference lists of key studies. Studies that met inclusion criteria were identified manually. Data regarding the study population, study design, spine procedures, ERAS interventions, and associated outcome metrics were extracted from each study that met inclusion criteria.

RESULTS

Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative nutrition regimens. Perioperative elements include multimodal analgesia and minimally invasive surgery. Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid consumption. Although these trends were observed, there remained great variability among the ERAS protocols, as well as in the reported outcomes.

CONCLUSIONS

ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary based on the specific procedure.

CLINICAL RELEVANCE

This review contributes to the assessment of ERAS protocol implementation in the field of adult spine surgery.

Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review

Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.

Enhanced perioperative care and decreased cost and length of stay after elective major spinal surgery

OBJECTIVEThe purpose of this study was to compare total cost and length of stay (LOS) between spine surgery patients enrolled in an enhanced perioperative care (EPOC) pathway and patients receiving traditional perioperative care (TRDC).METHODSAll spine surgery candidates were screened for inclusion in the EPOC pathway. This cohort was compared to a retrospective cohort of patients who received TRDC and a concurrent group of patients who met inclusion criteria but did not receive the EPOC (no pathway care [NOPC] group). Direct and indirect costs as well as hospital and intensive care LOSs were analyzed between the 3 groups.RESULTSTotal costs after pathway implementation decreased by $19,344 in EPOC patients compared to a historical cohort of patients who received TRDC and $5889 in a concurrent cohort of patients who did not receive EPOC (NOPC group). Hospital and intensive care LOS were significantly lower in EPOC patients compared to TRDC and NOPC patients.CONCLUSIONSThe implementation of a multimodal EPOC pathway decreased LOS and cost in major elective spine surgeries.

The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 2

STUDY DESIGN

Structured literature review.

OBJECTIVES

To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery.

METHODS

Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies.

RESULTS

We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications.

CONCLUSION

Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care.

LEVEL OF EVIDENCE

Level II.