Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY.
Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.
Spine (Phila Pa 1976). 2020 Aug 15;45(16):E1039-E1046. doi: 10.1097/BRS.0000000000003495.
Retrospective cohort study.
We sought to determine if there was an association between enhanced recovery after surgery (ERAS) implementation level and complication risk, length of stay, and cost of hospitalization.
ERAS protocols aim to minimize the stress response of surgery by promoting early mobilization, oral intake, as well as improvement of analgesia. Implementation of ERAS protocols in spine surgeries has been limited to mostly single-institution studies, and no population-based data exist on the impact of the level of implementation of various ERAS components on outcomes.
In this study we identified 265,576 posterior lumbar fusion surgeries from 2006 to 2016. The main effect was the application of eight ERAS-related practices: (1) multimodal analgesia, (2) tranexamic acid, (3) antiemetics, (4) steroids, (5) early physical therapy, (6) avoidance of urinary catheters, (7) avoidance of patient-controlled analgesia, (8) avoidance of wound drains. Patients were classified by levels of ERAS implementation: "High," "Medium," and "Low" ERAS implementation if they received more than five, three to five, or less than three ERAS components, respectively. Mixed-effects models measured associations between ERAS implementation categories and complications, length and cost of hospitalization; odds ratios (OR, or average ratios for continuous outcomes), and 99.4% confidence intervals (CI) were reported.
Overall, 13.3%, 62.8%, and 24.4% of cases were categorized as "High," "Medium," and "Low" ERAS implementation, respectively. After adjusting for study variables, "Medium" and "High" (compared with "Low") ERAS implementation levels were significantly associated with incrementally improved outcomes regarding "any complication" (OR 0.84 CI 0.80-0.88 and OR 0.77 CI 0.71-0.84), cardiopulmonary complications (OR 0.75 CI 0.68-0.73 and OR 0.69 CI 0.59-0.80), length of stay (average ratio 0. 94 CI 0.93-0.94 and average ratio 0.91 CI 0.90-0.91), and hospitalization cost (average ratio 0.99 CI 0.98-0.99 and average ratio OR 0.95 0.95-0.96).
In a cohort undergoing posterior lumbar spine fusion the level of utilization of ERAS protocol components was independently associated with incrementally improved complication odds as well as reduced length of stay and a small decrease in overall hospitalization cost.
回顾性队列研究。
我们旨在确定手术后恢复强化（ERAS）实施水平与并发症风险、住院时间和住院费用之间是否存在关联。
ERAS 方案旨在通过促进早期活动、口服摄入以及改善镇痛来最小化手术的应激反应。ERAS 方案在脊柱手术中的实施仅限于大多数单中心研究，尚无关于各种 ERAS 成分实施水平对结果影响的基于人群的数据。
在这项研究中，我们从 2006 年至 2016 年确定了 265576 例后路腰椎融合术。主要效果是应用八项 ERAS 相关实践：（1）多模式镇痛，（2）氨甲环酸，（3）止吐药，（4）皮质类固醇，（5）早期物理治疗，（6）避免使用导尿管，（7）避免使用患者自控镇痛，（8）避免使用伤口引流管。如果患者接受了超过 5 项、3 至 5 项或少于 3 项 ERAS 成分，则分别将他们分类为“高”、“中”和“低”ERAS 实施水平。混合效应模型测量了 ERAS 实施类别与并发症、住院时间和费用之间的关联；比值比（OR，或连续结果的平均比值）和 99.4%置信区间（CI）报告。
总体而言，分别有 13.3%、62.8%和 24.4%的病例被归类为“高”、“中”和“低”ERAS 实施水平。调整研究变量后，与“低”ERAS 实施水平相比，“中”和“高”ERAS 实施水平与并发症（OR 0.84，CI 0.80-0.88 和 OR 0.77，CI 0.71-0.84）、心肺并发症（OR 0.75，CI 0.68-0.73 和 OR 0.69，CI 0.59-0.80）、住院时间（平均比值 0.94，CI 0.93-0.94 和平均比值 0.91，CI 0.90-0.91）和住院费用（平均比值 0.99，CI 0.98-0.99 和平均比值 OR 0.95，0.95-0.96）的改善呈显著相关。
在接受后路腰椎融合术的队列中，ERAS 方案组件的使用水平与并发症几率的逐步改善以及住院时间的缩短和整体住院费用的小幅下降独立相关。
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