RESUMO
BACKGROUND: 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. METHODS: 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. RESULTS: 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%, p = 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. CONCLUSIONS: 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.
RESUMO
Deliberate hypotension is an important technique for use in select anesthetics for procedures such as orthognathic surgery, specifically LeFort I maxillary osteotomy. We present a case report of an anesthetic involving deliberate hypotension for a 17-year-old female patient who presented for a LeFort I osteotomy, bilateral sagittal split of the mandible, and a genioplasty in order to correct a skeletal class III malocclusion. After reaching a steady-state general anesthetic, deliberate hypotension was induced solely with a bolus and subsequent continuous infusion of the ultrashort acting calcium channel blocker, clevidipine. The preoperative, intraoperative, and postoperative course and anesthetic management are discussed.