P1

IMPLEMENTING AN ENHANCED RECOVERY PROGRAMME FOR ADOLESCENT IDIOPATHIC SCOLIOSIS SURGERY

M. Addy, E. Broomfield, T. J. W. Dawes, M. George

Great Ormond Street Hospital, London, UK

Background:

Recovery from posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be slowed by pain, gastrointestinal symptoms and delayed mobilisation.

Enhanced recovery programmes (ERP) for this patient group are heterogeneous(1) but may reduce length of stay without increasing complications(2,3).

Problem:

There was no standardised peri-operative care pathway for patients with AIS undergoing PSF at our institution. Our seven-day planned admission was longer than reported elsewhere(2,3).

We aimed to improve functional recovery by reducing opioid related side effects and accelerating mobilisation.

Strategy for change:

Thirty consecutive cases were retrospectively reviewed to define the pre-intervention peri-operative management and outcomes. Patient anthropometrics (age, sex, weight, ASA status), surgical characteristics (instrumented levels, operative duration, post-operative drop in serum haemoglobin) and anaesthetic management were recorded. Post-operative trajectory was defined by analgesia use, pain scores, gastrointestinal symptoms (nausea, vomiting, constipation (BNO > 3 days)), and time to enteral intake, urinary catheter removal, mobility outcomes and hospital discharge.

A ward-based ERP was developed in conjunction with the multidisciplinary team focusing on patient and family education and expectation management, multi-modal analgesia regimes and post-operative protocolised daily targets for all aspects of care.

The first fifty consecutive patients post implementation were followed prospectively with two interim safety reviews.

Data were stored securely on Microsoft Excel, analysed using GraphPad Prism and are reported as mean (SD) for normal and median (IQR) for skewed data. Data were compared using unpaired t-tests and Mann-Whitney tests respectively.

Measure of improvement:

The pre- and post-ERP groups were comparable for patient and surgical characteristics except for longer operative time in the latter (349 (64) vs 305 (52) minutes, p=0.002).

Compliance with the ERP interventions was higher for the anaesthetic protocol and post-operative prescribing for days 0-1 (both 89%) than ward-based prescribing from day 2 onwards (43%).

In the ERP group, parenteral morphine was used for a shorter time (45 (41-51) vs 49 (46-69) hours, p=0.004) with a lower total dose (1.1 (0.9-1.4) vs 1.8 (1.5-2.3) mg.kg-1, p<0.001). Pain scores were similar but with less nausea (54 vs 93%), vomiting (64 vs 73%) and constipation (22 vs 60%). All measured timepoints were improved including urinary catheter removal (1 (1-1) vs 3 (2-4) days, p<0.001), physiotherapy discharge (3 (3-4) vs 4 (3-5) days, p<0.001) and length of stay (5 (5-6) vs 6 (6-7) days, p<0.001).

Lessons learnt:

Enhanced recovery is feasible in this patient group, improving functional recovery and reducing length of stay.

Compliance with the post-operative medication regime fell from day 2. An electronic prescribing bundle to facilitate the prescription of the full regime on day 0 is being developed.

Message for others:

The Spinal Clinical Nurse Specialists have taken ownership of the ERP, which has facilitated ongoing staff engagement and education.

References:

1. Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform. 2021;9(4):893-904.
2. Koucheki R, Koyle M, Ibrahim GM, Nallet J, Lebel DE. Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta-analysis of 2456 adolescent idiopathic scoliosis cases. Eur Spine J. 2021 Dec;30(12):3457-3472.
3. Subramanyam R, Muhly WT, Goobie SM. Enhanced recovery: The evolution of pediatric spinal fusion care. Pediatr Anesth. 2020;30(10):1066-1067.