A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion

Gornitzky, Alex L.; Flynn, John M.; Muhly, Wallis T.; Sankar, Wudbhav N.

doi:10.1016/j.jspd.2016.01.001

Cited by 203 publications

(93 citation statements)

References 38 publications

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“…Preoperative gabapentin administration has been studied in a randomized controlled trial19 and as part of a rapid recovery pathway (RRP) for spinal fusion 20. Mayell et al 19 demonstrated that patients who received a single preoperative dose of gabapentin did not show significant improvement in opioid consumption or pain scores in this population.…”

Section: Discussionmentioning

confidence: 99%

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

Kars

Mori

Ahn

et al. 2019

Reg Anesth Pain Med

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IntroductionOpioid-induced hyperalgesia (OIH) and acute opioid tolerance have been demonstrated extensively in patients undergoing adolescent idiopathic scoliosis (AIS) repair. Remifentanil infusion has been strongly linked to both tolerance and OIH in these patients; however, the impact of using an intraoperative fentanyl infusion has not been well studied. This study aims to determine if patients undergoing operative management of AIS have decreased opioid consumption and pain scores when an intraoperative fentanyl infusion is used as compared with a remifentanil infusion.MethodsThis is a retrospective chart review of patients with AIS who underwent posterior spinal fusion. During the period January 2012–June 2013, patients received remifentanil infusion as part of total intravenous anesthesia. From July 2013 to June 2015, remifentanil was replaced by fentanyl as standard protocol. The remifentanil cohort included 37 patients and the fentanyl cohort included 25 patients. The primary outcome was the total opioid consumption (morphine equivalents) in the first 24 hours postsurgery. Secondary outcomes included mean postoperative pain score in the first 24 hours postsurgery, postoperative opioid consumption 24–48 hours after surgery, time to extubation, time to assisted ambulation, length of stay, and incidence of postoperative nausea and vomiting.ResultsCompared with the remifentanil group, the fentanyl group had significantly higher postoperative opioid usage during the first 48 hours and significantly higher postoperative mean pain score during the first 24 hours. There was no difference between the two groups in mean pain score for 24–48 hours, extubation time, time to assisted ambulation, length of stay, or postoperative nausea and vomiting.DiscussionDespite concerns for hyperalgesia and acute tolerance, remifentanil is widely used for intraoperative opioid infusions for surgical correction of AIS. This retrospective study examined a practice change from intraoperative remifentanil to intraoperative fentanyl as a potential approach to avoid OIH. Surprisingly, patients receiving fentanyl intraoperatively showed increased postoperative opioid use and pain scores in the first 24 hours postsurgery compared with the prior cohort receiving remifentanil. Substitution of fentanyl for remifentanil during surgical correction of AIS does not appear to solve the problem of OIH or acute tolerance. Prospective studies are needed to confirm this unexpected result.

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Section: Discussionmentioning

confidence: 99%

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

Kars

Mori

Ahn

et al. 2019

Reg Anesth Pain Med

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“…One additional study, was not picked up by the search but was known to the lead author, and highly relevant, and so was added to the review. 32 Of the five pertinent articles, one described the implementation of ERAS to a whole elective spinal surgery service, 32 two papers examined idiopathic scoliosis surgery, 33,34 one looked at lumbar spinal fusion, 35 and one described a series of lumbar and cervical spinal decompression patients. 36 The paper examining the adoption of ERAS to a whole elective spinal service was based in the UK, and had the hospital had organisational experience of adopting ERAS to hip and knee replacement patients.…”

Section: The Application Of Eras To Spine Surgerymentioning

confidence: 99%

“…The two studies looking at the implementation of ERAS for adolescent idiopathic scoliosis surgery, also indicated that ERAS can be successfully introduced to this pathway, and that LOS can be reduced to 3-4 days. 33,34 In one study mean length of stay was reduced by 1.7 days to 4 days after the rapid recovery pathway was fully introduced for 84 patients. 34 In this paper, the authors present the details and results of a systematic quality improvement journey, with clear details of the historical pathway, the transition period, and the implementation of ERAS.…”

Section: The Application Of Eras To Spine Surgerymentioning

confidence: 99%

“…This illustrates and confirms the link found previously in ERAS pathways, that high process compliance is linked to improved outcomes, 5 and that compliance to 80% or more of the elements of the ERAS protocol is required to improve outcomes. 37 Gornitzky et al 33 and Muhly et al 34 both conclude that a standardised multi-modal analgesic strategy, can facilitate early discontinuation of intravenous opioids whilst achieving effective pain control to allow early mobilisation and accelerated recovery. The two papers, were performed by the same group and include an analgesic regime including preoperative gabapentin and acetaminophen, intraoperative methodone and acetaminophen, and postoperative PCA and diazepam supplemented with gabapentin, acetaminophen, and ketorolac; with ambulation and full diet from day 1 post-op.…”

Section: The Application Of Eras To Spine Surgerymentioning

confidence: 99%

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Enhanced recovery after surgery (ERAS)—Concepts, components, and application to spine surgery

Wainwright

Wang

Immins

et al. 2018

Seminars in Spine Surgery

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This article describes the concept of Enhanced Recovery after Surgery (ERAS) and its application to spine surgery. ERAS is a multimodal approach designed to reduce the surgical stress response and accelerate recovery following surgery. It is a multi-disciplinary, patient centred approach that employs an evidenced-based pathway of standardised care. It has been proven across a range of surgical pathways but has yet to be defined and adopted in spine surgery. ERAS pathways are needed in spine surgery. Patient recovery is often long, painful, expensive, and a highly variable experience. Consequently, ERAS programs will find great utility in this subspecialty. Introduction:Enhanced Recovery after Surgery (ERAS) is a multimodal approach to patient care 1 introduced to prepare patients for surgery, reduce the impact of surgery, and enable patients to recover faster. It has been adopted across a wide variety of surgical procedures in many nations, and there is consistent evidence to show that it improves recovery, reducing length of hospital stay without increasing complications, readmissions, or compromising the patient experience. [2][3][4] ERAS rationale:The concept of ERAS was developed by a team of academic surgeons based in Europe at the start of this century. 5 The initial focus was on modulating and reducing the surgical stress response to major general surgical procedures. A combination of hormonal and inflammatory responses to the trauma of surgery contributes to insulin resistance; a major factor that affects surgical outcome. 6 By

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“…Its analgesic efficacy is similar to that of morphine, and it can help reduce the incidence of opioid-associated postoperative nausea and vomiting. 53 Other options for intravenous nonopiate analgesia include low-dose ketamine infusions, intermittent diazepam, 54,55 and butorphanol 56 injections.…”

Section: Surgical Site Infectionmentioning

confidence: 99%

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

George

Koka

Gan

et al. 2017

Can J Anesth/J Can Anesth

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A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion

Abstract: Implementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.

Cited by 203 publications

References 38 publications

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

Enhanced recovery after surgery (ERAS)—Concepts, components, and application to spine surgery

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

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