Smith Justin, Probst Stephen, Calandra Colleen, Davis Raphael, Sugimoto Kentaro, Nie Lizhou, Gan Tong J, Bennett-Guerrero Elliott
1Department of Anesthesiology, Stony Brook University Medical Center, 101 Nicolls Rd, Stony Brook, NY 11794 USA.
2Department of Neurosurgery, Stony Brook University Medical Center, 101 Nicolls Rd, Stony Brook, NY 11794 USA.
Perioper Med (Lond). 2019 May 28;8:4. doi: 10.1186/s13741-019-0114-2. eCollection 2019.
There is a paucity of literature regarding the implementation of enhanced recovery after surgery (ERAS) protocols for open lumbar spine fusions. We implemented an ERAS program for 1-2-level lumbar spine fusion surgery and identified areas that might benefit from perioperative interventions to improve patient satisfaction and outcomes.
This institutionally approved quality improvement (QI) ERAS program for lumbar spine fusion was designed for all neurosurgical patients 18 years and older scheduled for 1 or 2 level primary lumbar fusions. The ERAS bundle contained elements such as multimodal analgesia including preoperative oral acetaminophen and gabapentin, postoperative early mobilization and physical therapy, and a prophylactic multimodal antiemetic regimen to decrease postoperative nausea and vomiting. No fluid management or hemodynamic parameters were included. Pre-ERAS and post-ERAS data were compared with regard to potential confounders, compliance with the ERAS bundle, and postoperative outcomes.
A total of 230 patients were included from October 2013 to May 2017. The pre-ERAS phase consisted of 123 patients, 11 patients during the transition period, and 96 serving as post-ERAS patients. The pre-ERAS and post-ERAS groups had comparable demographics and comorbidities. Compliance with preoperative and intraoperative medication interventions was relatively good (~ 80%). Compliance with postoperative elements such as early physical therapy, early mobilization, and early removal of the urinary catheter was poor with no significant improvement in post-ERAS patients. There was no significant change in the amount of short-acting opioids used, but there was a decrease in the use of long-acting opioids in the post-ERAS phase (14.6 to 5.2%, = 0.025). Post-ERAS patients required fewer rescue antiemetic medications in the recovery room compared to pre-ERAS patients (40 to 24%). There was no significant difference in postoperative pain scores or hospital length of stay between the two groups.
Implementing an ERAS bundle for 1-2-level lumbar fusion had minimal effect in decreasing length of stay, but a significant decrease in postoperative opioid and rescue antiemetic use. This ERAS bundle showed mixed results likely secondary to poor ERAS protocol compliance. Going forward, this QI project will look to improve post-operative ERAS implementation to improve patient outcomes.
关于开放性腰椎融合手术实施加速康复外科（ERAS）方案的文献较少。我们为1-2节段腰椎融合手术实施了一项ERAS计划，并确定了可能从围手术期干预中受益的领域，以提高患者满意度和手术效果。
这项经机构批准的用于腰椎融合的质量改进（QI）ERAS计划是为所有计划进行1或2节段原发性腰椎融合的18岁及以上神经外科患者设计的。ERAS方案包含多种要素，如多模式镇痛，包括术前口服对乙酰氨基酚和加巴喷丁、术后早期活动和物理治疗，以及预防性多模式止吐方案以减少术后恶心和呕吐。未包括液体管理或血流动力学参数。对ERAS实施前和实施后的数据就潜在混杂因素、对ERAS方案的依从性以及术后结果进行了比较。
2013年10月至2017年5月共纳入230例患者。ERAS实施前阶段包括123例患者，过渡期11例患者，96例作为ERAS实施后患者。ERAS实施前和实施后组在人口统计学和合并症方面具有可比性。对术前和术中药物干预的依从性相对较好（约80%）。对术后要素如早期物理治疗、早期活动和早期拔除导尿管的依从性较差，ERAS实施后患者无显著改善。短效阿片类药物的使用量没有显著变化，但在ERAS实施后阶段长效阿片类药物的使用有所减少（从14.6%降至5.2%，P = 0.025）。与ERAS实施前患者相比，ERAS实施后患者在恢复室需要的急救止吐药物更少（从40%降至24%）。两组术后疼痛评分或住院时间无显著差异。
为1-2节段腰椎融合实施ERAS方案对缩短住院时间影响甚微，但术后阿片类药物和急救止吐药物的使用显著减少。该ERAS方案结果喜忧参半，可能是由于对ERAS方案的依从性较差。展望未来，这个质量改进项目将致力于改善术后ERAS的实施情况以提高患者手术效果。
