Error traps in adolescent idiopathic scoliosis surgery: Part two
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. Error traps can be viewed as circumstances that result in common mistakes and undesirable consequences due to knowledge gaps and thought process errors. Harmon et al.1 highlight 4 error traps in the perioperative management of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery, namely, “proper patient positioning, avoidance of neuromonitoring interference with a quickly metabolized anesthetic for a rapid wake-up test, limiting intraoperative bleeding and proper fluid balance, and designing an effective analgesic regimen to maximize patient recovery.” In yesterday’s PAAD we discussed patient positioning and avoidance of neuromuscular monitoring interference. In today’s, we discuss the final two, namely, failure to prevent excessive bleeding, decrease transfusion, and maintain intravascular volume and avoidance of excessive postoperative pain and poor recovery outcomes. Myron Yaster MD
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
Failure to prevent excessive bleeding, decrease transfusion, and maintain intravascular volume.
The authors point out that multiple approaches have been employed to reduce intraoperative blood loss and the incidence of allogenic blood product transfusion. These include intraoperative administration of antifibrinolytics, autologous red cell salvage, restrictive transfusion strategies, identification and correction of preoperative anemia (including with the use of preoperative erythropoietin and supplemental iron), meticulous surgical hemostasis, topical hemostatic agents, acute normovolemic hemodilution, and avoidance of excessive hemodilution.1,2 Of these, we’d like to highlight their discussion of tranxexamic acid (TXA), which has been discussed in several previous PAADs. While TXA dosing has bedeviled us as well as the Pedi Crisis app committee for the past several years, Hammon et al. provide a concise overview of TXA dosing studies and their limitations, concluding with an expert consensus recommendation of a loading dose of 30 mg/kg (up to a maximum of 2 g) and an infusion dose of 10 mg/kg/h of TXA. This recommendation, which is in keeping with current use at my (CM) institution, is consistent with pharmacokinetic data and recommendations previously provided by Goobie and colleagues.3
When should we transfuse? Is there a hemoglobin transfusion trigger? Assuming hemodynamic stability, Harmon et al.1 point out the need to balance potential complications of transfusion such as immunosuppression and transfusion related lung injury with the potential benefits, including improved oxygen carrying capacity in a patient undergoing major surgery. Unfortunately, there is no evidence-based transfusion trigger in children,4 while in adults transfusion triggers remain controversial – a transfusion hemoglobin trigger of 7 g/dL has been associated with a decrease in blood transfusion, hospital stay, and postoperative infection while improved postoperative outcomes and fewer wound infections were noted if hemoglobin remained > 9 g/dL intraoperatively and > 8g/dL postoperatively.1,5,6
Failure to optimize post procedure recovery using enhanced recovery after surgery (ERAS) approaches and preoperative optimization:
Over the past two decades, design and implementation of enhanced recovery after surgery (ERAS) protocols has become an important advance in the perioperative management of surgical patients. Pioneered by the surgeon Dr. Henrik Kehlet,7-9 ERAS is a holistic, multidisciplinary, multimodal, comprehensive, evidence-based, perioperative care model that aims to minimize the stress of surgery and enable patients to recover more quickly through the maintenance of normal physiology. By implementing standardized paradigms for pain control, infection prevention, perioperative fluid and feeding management, and early postoperative mobilization, ERAS protocols can hasten recovery after surgery without increasing complications or reducing patient satisfaction A key component to this approach (which we will discuss in more detail below) is the use of multimodal analgesia in which different modes and/or classes of analgesics targeting different mechanisms are employed to achieve additive or, at times, synergistic analgesic effects. In doing so, the perioperative use of opioids can be reduced or eliminated. Why is this reduction of opioids so important? Because opioid-related adverse effects on bowel motility, breathing and mobility can impede recovery and increase hospital length of stay.
For adolescents undergoing posterior spinal fusion, ERAS protocols include preoperative, intraoperative and postoperative components. Preoperatively, patient education, psychological preparation, physical therapy, administration of iron and multivitamin supplements, and chlorhexidine wash play a role. Intraoperatively, the use of power tools and dual surgeons, limiting fluid excessive fluid administration, and administration of intrathecal morphine may all be components. And postoperatively, early mobilization and physical therapy, early enteral feeding and administration of bowel regimens, early discontinuation of urinary catheters and other drains, and multimodal analgesia are addressed.1
Focusing here on multimodal analgesia, opioids remain a mainstay of intraoperative anesthetic management, in part because they do not negatively affect neurometric monitoring. That said, there are multiple intra- and postoperative opioid regimens with wide variability across different institutions. Some include oral and/or intravenous methadone, intrathecal or epidural morphine, sufentanil, and/or postoperative patient-controlled analgesia. Short-acting opioids, notably remifentanil, are preferred by some intraoperatively to allow for rapid wake up and emergence but avoided by others due to concerns regarding the potential for acute opioid tolerance and hyperalgesia. Methadone-based analgesia and intrathecal opioids may decrease overall opioid consumption, but require further study and can be associated with other risks (e.g., refractory hypotension with intrathecal morphine administration).
Non-opioid analgesic adjuvants commonly administered include acetaminophen, ibuprofen, ketorolac, the gabapentenoids, and ketamine. Furthermore, local anesthetics can be given locally via wound infiltration, epidurally, via nerve blocks (e.g., erector spinae), or systemically by continuous intravenous infusion (i.e., lidocaine). Administration of these medications can be opioid sparing but their use is variable. Interestingly, perioperative NSAIDs were once avoided because of concerns for potential bleeding and bone healing problems, but this is no longer the case.10 How to combine acetaminophen and an NSAID is not clear. Should they be given together? Or alternating on every 6 hour regimen (12-6-12-6 and 9-3-9-3)? Intravenous ketamine given by infusion (0.1 mg/kg/hour) has not shown consistent benefits or opioid reduction.11 Indeed, in our experience ketamine even at low doses, may be too sedating and in some patients may affect potoperative mobility and thereby delay hospital discharge.
But why is pain control so important? As Hammon et al. point out, “Pain begets pain.” Since poor pain control during the two weeks following PSF surgery is a predictor of poor recovery, it is crucial that patients receive effective perioperative pain management as well as appropriate follow-up with physical therapy and referral to pain clinics when indicated. Further, risk identification and stratification using screening aids such as the Pediatric Pain Screening Tool may help allow for the use of targeted preemptive strategies. These include behavioral interventions, sleep hygiene, and education to set realistic (but positive) expectations about the pain experience after spinal fusion surgery that may improve postoperative outcomes after surgery.
What do you use in your practice? Do you use methadone? Ketamine? Gabapentenoids? How do you dose acetaminophen and ibuprofen? Send your thoughts to Myron who will post in a Friday Reader response.
References
1. 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
2. Oetgen ME, Litrenta J: Perioperative Blood Management in Pediatric Spine Surgery. J Am Acad Orthop Surg 2017; 25: 480-488
3. Goobie SM, Faraoni D: Tranexamic acid and perioperative bleeding in children: what do we still need to know? Curr Opin Anaesthesiol 2019; 32: 343-352
4. 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
5. 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
6. 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
7. Kehlet H, Mogensen T: Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 1999; 86: 227-30
8. Kehlet H, Wilmore DW: Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-41
9. Joshi GP, Kehlet H: Postoperative pain management in the era of ERAS: An overview. Best Pract Res Clin Anaesthesiol 2019; 33: 259-267
10. Vitale MG, Choe JC, Hwang MW, Bauer RM, Hyman JE, Lee FY, Roye DP, Jr.: Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications. Spine J. 2003; 3: 55-62
11. Minoshima R, Kosugi S, Nishimura D, Ihara N, Seki H, Yamada T, Watanabe K, Katori N, Hashiguchi S, Morisaki H: Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: a randomized controlled trial. Acta Anaesthesiol Scand 2015; 59: 1260-8