Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach

Study Design: Single-center prospective cohort. Objectives: To evaluate a multidisciplinary led, structured protocol for reducing surgical site infections (SSIs) in pediatric scoliosis surgery. Methods: Following a spike to 8.6% in local annual infection rate, a multidisciplinary team was convened to identify interventions. The team consisted of spinal surgeons, infectious diseases consultants, physiotherapists, specialist nurses, and theatre managers. A protocol was initiated, including preoperative skin decontamination; standardized operative site prepreparation; betadine-soaked swabs sutured to wound edges; blood loss minimization; 3 L0.9% saline pulsed-lavage; defined protocol of glove changes; antibiotic regime of preoperative gentamicin, intraoperative subfascial vancomycin powder, 48-hour cefuroxime; and intraoperative normothermia. A 4-year audit was initiated of all patients aged ≤18 years undergoing corrective spinal deformity surgery. Institutional board review was not required. Results: Between January 1, 2014 and January 1, 2018, 414 operations were performed on 355 patients: male:female = 1:2.2, mean age 13.7 years (range 2.5-17.9), 233 idiopathic (mean operated vertebral levels 12), 122 neuromuscular (mean operated vertebral levels 14), 66 growing rod procedures, 41 multistage procedures. The mean number of operated vertebral levels both overall and in infected cases was 13 (range 2-17). Nine SSIs occurred in 8 patients at 3 months (4 neuromuscular), resulting in an overall SSI per operation of 2.2%. Conclusion: A multidisciplinary approach with standardized measures significantly reduced SSIs in the unit’s pediatric scoliosis surgery.

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“…This expedited hemostasis reduces both blood loss as well as operative time, another potential factor in developing an SSI. 5 …”

Section: Discussionmentioning

confidence: 99%

“…However, there is a growing consensus that the most effective means of reducing the risk of SSIs is a broad based, multidisciplinary approach. 4 - 6…”

Section: Introductionmentioning

confidence: 99%

Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit

Tipper

Chiwera

Lucas

2019

Global Spine Journal

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“…Bellaire et al14 had a pre-ERAS average LOS of 4.9 reducing this further to 4 with an ERAS that included decreased time to the imitation of oral food and pain medication. The LOS in the Bellaire and colleagues study is already (before intervention) lower than the average in any other studies, illustrating this institution's dedication to rapid discharge as several other studies in other categories originate for the same institution 4,14,21…”

Section: Discussionmentioning

confidence: 70%

“…The LOS in the Bellaire and colleagues study is already (before intervention) lower than the average in any other studies, illustrating this institution's dedication to rapid discharge as several other studies in other categories originate for the same institution. 4,14,21 In 2015 Pearsall et al 22 examined barriers to the adoption of ERAS, here they identified the lack of education at all levels of the team involved in the patient's care as a major barrier. In our study, it could seem as adopting the general principle ideas of ERAS can have a large impact on other patient categories.…”

Section: Discussionmentioning

confidence: 99%

The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis

Tøndevold

Bari

Andersen

et al. 2023

Journal of Pediatric Orthopaedics

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Introduction: Enhanced recovery after surgery (ERAS) protocols are often specific to a specific type of surgery without assessing the overall effect on the ward. Previous studies have demonstrated reduced length of stay (LOS) with ERAS protocols in patients with adolescent idiopathic scoliosis (AIS), although the patients are often healthy and with few or no comorbidities. In 2018, we used ERAS principles for patients undergoing AIS surgery with a subsequent 40% reduced LOS. The current study aims to assess the potential collateral effect of LOS in patients surgically treated for neuromuscular scoliosis admitted to the same ward and treated by the same staff but without a standardized ERAS protocol. Methods: All patients undergoing neuromuscular surgery 2 years before and after ERAS introduction (AIS patients) with a gross motor function classification score of 4 to 5 were included. LOS, intensive care stay, and postoperative complications were recorded. After discharge, all complications leading to readmission and mortality were noted with a minimum of 2 years of follow-up using a nationwide registry. Results: Forty-six patients were included; 20 pre-ERAS and 26 post-ERAS. Cross groups, there were no differences in diagnosis, preoperative curve size, pulmonary or cardiac comorbidities, weight, sex, or age. Postoperative care in the intensive care unit was unchanged between the two groups (1.2 vs 1.1; P = 0.298). When comparing LOS, we found a 41% reduction in the post-ERAS group (11 vs 6.5; P < 0.001) whereas the 90-day readmission rates were without any significant difference (45% vs 34% P = 0.22) We found no difference in the 2-year mortality in either group. Conclusion: The employment of ERAS principles in a relatively uncomplicated patient group had a positive, collateral effect on more complex patients treated in the same ward. We believe that training involving the caregiving staff is equally important as pharmacological protocols.

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“…[27] Hence, an MAP >65 mmHg during dissection and a higher pressure goal of 75 mmHg are recommended during correction. [28] In Group I, there was almost no demand for nitroglycerine. The favorable surgical field allowed higher MAP that permits better tissues’ perfusion.…”

Section: Discussionmentioning

confidence: 99%

High-volume, multilevel local anesthetics–epinephrine infiltration in kyphoscoliosis surgery: Blood conservation

et al. 2019

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Introduction:Scoliosis surgery is usually associated with severe bleeding. Various systemic strategies for blood conservation were applied, while the local techniques get less attention. The preemptive use of sufficient volume for proper tissue infiltration at two levels was applied. The local epinephrine may control bleeding without reliance upon deliberate hypotension, permitting a higher tissue perfusion.Materials and Methods:This prospective study included 46 patients scheduled for posterior spinal fusion for scoliosis correction. Patients were randomized into two groups. group I received a cocktail of high volume (100 ml/each 10 cm of wound length) of local anesthetics and epinephrine tumescent infiltration at the subcutaneous (SC) followed by intramuscular level bilaterally. Group C received saline infiltration in the same technique. Statistically, data were analyzed according to its distribution using the t-test, Mann–Whitney, and Chi-square tests as appropriate.Results:There was a significant reduction in blood loss (38%), reduced blood and fluid transfusion (36% and 23%), and reduced operative time (23%), with higher surgeon satisfaction. The surgical field visibility (Fromme's scale) was much better during SC and muscular dissection in Group I, while it was fair during the bony work. The satisfactory field in spite of higher mean blood pressure in Group I greatly omitted the reliance upon deliberate hypotension.Conclusion:The high-volume multilevel infiltration of epinephrine cocktail can provide a significant blood and operative time conservation in kyphoscoliosis surgery.

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Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach

Cited by 22 publications

References 87 publications

Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit

Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit

The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis

High-volume, multilevel local anesthetics–epinephrine infiltration in kyphoscoliosis surgery: Blood conservation

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