Transcript Integrated Perioperative Care: Major Non-Cervical Spine

INTEGRATED PERIOPERATIVE
CARE:
MAJOR NON-CERVICAL
SPINE PATHWAY
OHSU Anesthesiology & Perioperative Medicine
Grand Rounds November 30th, 2015

Overview of IPC Major Non-Cervical Spine Pathway

Preoperative changes

Intraoperative management for Pathway patients

Multimodal analgesia

Antifibrinolytics

Hemotherapy
SUMMARY

Preoperative Optimization
•
Iron Deficiency Anemia
•
Pain & Expectations Management (CPC visit)

Intraoperative Management

Postoperative Management & Active Recovery following hospital
discharge
INTEGRATED PERIOPERATIVE CARE

1.
Instrumentation spanning ≥ 3 levels

2. Surgery involving anterior and posterior approach or
planned multi-stage procedure, independent of the number of
levels of instrumentation

3.
Estimated Blood Loss ≥ 1000mL

4.
Duration of procedure ≥ 6 hours

5.
Complex revision surgery, major osteotomies, or corpectomy

6. Significant, regular opioid use for more than 3 months or
history of psychiatric disorder related to drug abuse
QUALIFYING CRITERIA
IPC MAJOR SPINE PATHWAY

Assigned when the surgeon places request to surgery scheduler

Epic flag or notification still being determined

Matt Healy will contact scheduled anesthesia team on the day
prior to surgery (for the next several months at least)
IDENTIFYING IPC PATHWAY PATIENTS
(HOW WILL I KNOW I HAVE AN IPC
PATIENT)

Multimodal Preoperative Medications (AVOID duplicate
administration)
•
Acetaminophen 1000 mg PO (for patients > 50 kg)
•
Gabapentin 600 mg PO (or home dose, if higher)
•
Consider Pregabalin 300 mg PO if gabapentin intolerance/mild side
effect
•
Morning home dose of opioid
•
Please do not administer NSAIDs pre-op
•
Please review & implement any CPC recommendations
DAY OF SURGERY: PREOP
IPC MAJOR SPINE PATHWAY

Neuromuscular blockade for intubation: communicate with
surgery and neuromonitoring teams regarding whether prepositioning MEPs are planned

Lung protective ventilation strategy

Arterial line & central line (triple lumen preferred unless
inadequate large bore PIV access/clinical judgment suggests
introducer)

Invest in maintaining normothermia: maintain room temp > 70 F
until patient is draped or warmed, consider placing convective
warmer during line placement
DAY OF SURGERY: INTRAOP
IPC MAJOR SPINE PATHWAY

Neuromonitoring: MEP (< 1/3 MAC), SSEP (< 1/2 MAC), EMG

If propofol requirement is high (> 200 mcg/kg/min), consider
dexmedetomidine (0.3 – 0.5 mcg/kg/hr base on lesser of IBW or actual body
weight) as anesthetic & analgesic adjunct

Also consider remifentanil as adjunct, particularly if TIVA required (signals,
pre-op myelopathy, acute neurologic injury)

Ketamine 0.5 mg/kg (up to 50 mg) bolus at induction followed by infusion at
4 mcg/kg/min (up to 40 mg/hr total dose) (unless contraindicated)

If extubating, redose APAP IV within 1 hour prior & (unless contraindicated)
discuss ketorolac 30 mg IV with surgery team—evidence suggests low dose
ketorolac does not increase bleeding, non-union or pseudoarthrosis

Contact APS—will follow all IPC spine pathway patients post-op, ask them to
place order for post-op ketamine infusion if indicated
ANESTHESIA MAINTENANCE &
INTRAOP PAIN MANAGEMENT

Fluid restrictive strategy—large volume resuscitation associated with
increased pulmonary complications in spine surgery*, morbidity and
hospital LOS

Primarily LR, limit NS to 1 liter total then switch to Normosol if needed
for transfusion

Fluid boluses above maintenance to maintain hemodynamic goals
should be guided by PPV (>10% may predict volume responsiveness)

Goal lactate < 2.0

CVP should be within 4 cm of H2O of patient’s baseline

Vasoconstrictors may be required to maintain hemodynamic goals
and limit excessive volume administration, goal is to wean off by
conclusion of case
VOLUME MANAGEMENT

PRBCs: transfuse for hct < 24 at any point, hct < 26 with ongoing
bleeding & anticipated further blood loss

FFP: INR ≥ 1.6 at any point, INR > 1.3 and surgical
oozing/expected ongoing bleeding

PRBC:FFP 1:1 delivery after 3rd unit PRBC or as indicated
clinically/labs

Platelets: < 100,00 (ongoing bleeding), 1 pack for every 6 units
PRBCs

Cryoprecipitate: one pool if Fibrinogen < 150,000

Massive Transfusion Activation: EBL > 3000 ml total, > 1000 ml in
one hour, or uncontrolled hemodynamic instability
BLOOD MANAGEMENT


Antifibrinolytics (all patients, unless contraindicated)
•
Surgery team should order pre-op
•
TXA: 10 mg/kg bolus (1 gram max) over 30 minutes prior to incision, 1
mg/kg/hr infusion
Target < 180 mg/dL, consider initiating treatment of CBG > 160
mg/dL
ANTIFIBRINOLYTICS & BLOOD
GLUCOSE MANAGEMENT

Email with these details as well as references

Ongoing communication to Anesthesia teams caring for IPC
Major Spine Pathway Patients

Further information on Epic notification

Please direct questions, concerns or questions to Matt Healy or
Peter Schulman
LOOKING FORWARD