Error traps in adolescent idiopathic scoliosis surgery: Part one
Myron Yaster MD and Constance L. Monitto MD
Over the past 2 years Pediatric Anesthesia has published a series of articles under the umbrella of “error traps and a culture of safety in pediatric anesthesiology.” Many of these articles have also been selected for the journal’s featured article of the month podcast. Having previously co-authored an article for this series (CM),1 I can attest that the concept of an error trap as it is understood in human quality and safety literature has been applied somewhat broadly throughout this series at the authors’ discretion. That said, error traps can be viewed as circumstances that result in common mistakes and undesirable consequences due to knowledge gaps and thought process errors.2 Some of the articles in this series have addressed the role of cognitive errors in promulgating these situations,3 while others have focused on remedying knowledge gaps by providing an educational review of a topic. As such, these articles often deliver clinical pearls not traditionally found in textbooks that can be passed down to trainees by experienced teachers.
Today’s PAAD by Hammon et al.4 takes the educational review approach as it tries to improve the reader’s knowledge regarding the perioperative management of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery.
Admittedly, the management of patients with scoliosis was one of my (MY) favorite challenges as a practicing clinical pediatric anesthesiologist as the management of perioperative blood loss and postoperative pain were the focus of my early career as a clinical researcher.5 For this reason, I really looked forward to today’s article and was not disappointed. Whether you’re an experienced pediatric anesthesiologist or a “newbie,” this is a terrific review article with an encyclopedic reference list that I highly recommend reading in its entirety. Because of the enormous amount of information contained in the article, this review has been split it into two parts. The second will appear tomorrow. Finally, many of the error traps and issues discussed in today’s article have been discussed in previous PAADs, including one on “Intraoperative fluid management in scoliosis” published on Oct 10, 2023. But first, a word about orthopedic surgeons from Dr. Glaucomflecken.
Original article
Hammon, DE, Chidambaran, V, Templeton, TW, Pestieau, S. Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Pediatr Anesth. 2023; 33: 894-904. doi:10.1111/pan.14735
Complex, common, and often prolonged (> 4 hours), posterior spinal fusion is one of the most challenging surgeries routinely performed on generally healthy adolescents. As such, the risks are particularly high. Harmon et al.4 highlight four perioperative error traps that can contribute to adverse patient outcomes. These include failure to properly position the prone patient, to appropriately maintain neurologic monitoring, to maintain proper fluid balance and minimize/address intraoperative bleeding, and to optimize preoperative preparation and postoperative recovery, including avoiding excessive postoperative pain. These are summarized as a checklist in Table 2 of the article and reprinted below. Unfortunately, it is beyond the scope of the PAAD to discuss all of these error traps in detail, but we will highlight some of the key points.
Positioning the prone patient. Improper positioning of the patient undergoing posterior spinal fusion can result in neurologic injuries due to malalignment of the cervical cranial axis and associated vascular compromise, upper extremity nerve traction injuries, and pressure injuries, especially on pressure points on the face, chest and genitals. In addition, postoperative visual loss (POVL) remains a rare but significant injury associated with prone positioning, with an incidence of 3.09 per 10,000 spinal fusion procedures. Aside from direct compression, POVL is associated with long surgical duration, significant blood loss, and administration of large volumes of crystalloid solutions.6 Finally, the turn from supine to prone at the beginning of the case and prone back to supine at the end can result in catastrophic and completely avoidable problems including loss of intravenous, arterial and central venous lines, and bladder catheters, and inadvertent extubation. The authors suggest and we wholeheartedly agree that it is best to disconnect as many lines as feasible during these turns, reconnecting them once the patient is positioned and ventilation resumed and endotracheal tube position is confirmed. One important omission from this section, however, is how to deal with cardiac arrest in the prone position.
Failure to maintain neurologic monitoring signals: One of the many challenges of anesthetizing a patient for posterior spinal fusion surgery is that we must provide an anesthetic “cocktail” that does not interfere with neurometric monitoring while simultaneously maintaining an adequate depth of anesthesia – and being ready at a moment’s notice to wake the patient up! Every institution has its own recipe. All allow opioids, but due to their effects on SSEP amplitude and latency, some medications, such as half a MAC of a vapor anesthetic, may be allowed by neuromonitoring folks at one institution but strictly forbidden at others. Going a step further, greenhouse gases aside, nitrous oxide, which decreases SSEP amplitude but not latency, is routinely provided to adults at my (CM) institution during neuromonitoring, but often avoided one floor up in the pediatric operating rooms. Unfortunately, while propofol and dexmedetomidine may have little impact on SSEPs, they can produce a depth of anesthesia that delays rapid wakeup if signals are lost. Although not discussed in this article, the routine use of intraoperative EEG monitoring may help in guiding the use of these drugs in the future.7
What to do if signals are lost is worth an entire PAAD in its own right. We were pleased that the authors advocated for discussion among the surgical, anesthesia and neuromonitoring teams as a first step as well as the use of the Society for Pediatric Anesthesia’s PediCrisis app V 2 Loss of Evoked Potentials checklist. If you don’t have the app you can and should download it now via the SPA website – and may want to consider adding it as an online resource to the anesthetic records at your institution.
We will discuss error trap three: “Failure to prevent excessive bleeding, decrease transfusion, and maintain intravascular volume” and four: :”Failure to optimize post procedure recovery using enhanced recovery after surgery (ERAS) approaches and preoperative optimization” in tomorrow’s PAAD.
Please send your thoughts and comments to Myron, who will post in a Friday Reader response..
References
1. Vecchione TM, Agarwal R, Monitto CL: Error traps in acute pain management in children. Paediatr Anaesth 2022; 32: 982-992
2. Stiegler MP, Neelankavil JP, Canales C, Dhillon A: Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012; 108: 229-35
3. Sohn L, Peyton J, von Ungern-Sternberg BS, Jagannathan N: Error traps in pediatric difficult airway management. Paediatr Anaesth 2021; 31: 1271-1275
4. Hammon DE, Chidambaran V, Templeton TW, Pestieau Sophie R: Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery. Pediatric Anesthesia 2023; 33: 894-904
5. Yaster M, Simmons RS, Tolo VT, Pepple JM, Wetzel RC, Rogers MC: A comparison of nitroglycerin and nitroprusside for inducing hypotension in children: a double-blind study. Anesthesiology 1986; 65: 175-179
6. Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, Domino KB: The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology 2006; 105: 652-9; quiz 867-8
7. Yuan I, Xu T, Kurth CD: Using Electroencephalography (EEG) to Guide Propofol and Sevoflurane Dosing in Pediatric Anesthesia. Anesthesiol Clin 2020; 38: 709-725
8. Oetgen ME, Litrenta J: Perioperative Blood Management in Pediatric Spine Surgery. J Am Acad Orthop Surg 2017; 25: 480-488
9. Long TR, Stans AA, Shaughnessy WJ, Joyner MJ, Schroeder DR, Wass CT: Changes in red blood cell transfusion practice during the past quarter century: a retrospective analysis of pediatric patients undergoing elective scoliosis surgery using the Mayo database. Spine J 2012; 12: 455-62
10. Alfonso AR, Hutzler L, Lajam C, Bosco J, Goldstein J: Institution-Wide Blood Management Protocol Reduces Transfusion Rates Following Spine Surgery. Int J Spine Surg 2019; 13: 270-274
11. Barrie U, Youssef CA, Pernik MN, Adeyemo E, Elguindy M, Johnson ZD, Ahmadieh TYE, Akbik OS, Bagley CA, Aoun SG: Transfusion guidelines in adult spine surgery: a systematic review and critical summary of currently available evidence. Spine J 2022; 22: 238-248