Implementation of an enhanced recovery pathway in Australia after posterior spinal fusion for adolescent idiopathic scoliosis delivers improved outcomes.

PURPOSE: Traditionally, spinal surgery for Adolescent Idiopathic Scoliosis (AIS) has seen long hospital length of stay (LOS) and slow mobility progression. Postoperative enhanced recovery pathways (ERP) for this population in North America and Asia have successfully reduced LOS and hospital costs without increasing complications. This study assessed if ERP introduced in an Australian center achieves similar results. METHODS: A pre-post intervention study compared a historical AIS cohort having a posterior spinal fusion (PSF) who received conventional care (CC) (2013-2014) with prospectively assessed ERP recipients (2016-2018) separated by 1-year implementation period. Patient characteristics, surgical details, postoperative analgesia, mobilization, LOS and complication outcomes were collected. RESULTS: The 32 CC and 61 ERP recipients had similar demographics. ERP recipients had 44% decreased LOS (mean LOS 3.5 ± 0.9 days vs. CC 6.3 ± 0.9 days, p < 0.001) as all ERP milestones were achieved sooner including transition to oral analgesia (MD - 2 days, 95% CI 1.8-2.3), oral intake (MD - 2.3 days, 95% CI 2.0-2.6) and mobilization, with fewer physiotherapy sessions (5.2 vs 8, p < 0.001). Postoperative in-hospital costs were 50.2% less for ERP vs CC (AUD $8234 vs $16,545). Due to small sample size, no differences between the groups were detectable for complications (4.9% vs 6.3%) or readmission (1.6% vs 3.1%). CONCLUSION: An ERP for AIS after PSF in this Australian center improved functional recovery reducing LOS and by associated postoperative inpatient costs. Other Australian hospitals should consider an ERP for this population with larger-scale audit to assess impact upon complications. LEVEL OF EVIDENCE: III.

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single-event multilevel surgery.

AIM: To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery. METHOD: Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]). RESULTS: There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001). INTERPRETATION: Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.

Difficulties with assessment and management of an infant's distress in the postoperative period: Optimising opportunities for interdisciplinary information-sharing.

OBJECTIVES: The importance of accurate paediatric patient assessment is well established but under-utilised in managing postoperative medication regimens. METHODS: Data for this case report were collected through observations of clinical practice, conduct of interviews, and retrieval of information from the medical record. This case report involving a hospitalised 1-year-old boy demonstrates the difficulties associated with assessing and managing postoperative distress, including pain and other clinical conditions related to the surgical procedure. RESULTS: Postoperatively, there were difficulties in managing pain and an episode of over-sedation, occasioning opiate reversal with naloxone. In addition, he had decreasing oxygen saturation and increased work of breathing. X-ray showed changes consistent with either atelectasis or aspiration, and he was commenced on antibiotics. The patient experienced respiratory distress and required intervention from the medical emergency team. CONCLUSION: This case demonstrated the importance of comprehensive assessment and careful consideration of alternative causes of an infant's distress using the results of assessment tools to aid decision-making. Communication moderates effective patient care, and more favourable outcomes could be achieved by optimising interdisciplinary information-sharing.

Audit of extrapleural local anaesthetic infusion in neonates following repair of tracheo-oesophageal fistulae and oesophageal atresia via thoracotomy.

In order to reduce postoperative opioid requirement, extrapleural local anaesthetic infusion dosing recommendations and guidelines for extrapleural catheter insertion were developed in our institution for 'extubatable' neonates requiring short-gap neonatal tracheo-oesophageal fistula/oesophageal atresia repair (via thoracotomy) and audited prospectively. Data audited included patient characteristics, analgesia details and ventilation duration. We divided patients into two groups: group 1 - term patients (=36 weeks gestational age) with birth-weights =2.5 kg; group 2 - pre-term patients (<36 weeks gestational age), with birth weights <2.5 kg and those with co-morbidities. There were 26 neonates in group 1 and 11 in group 2. All received extrapleural infusions of bupivacaine or levobupivacaine: the majority (90%) =300 µg.kg(-1).hour(-1) (median duration 43 hours, range 1.5 to 72 hours); 36% required morphine infusion and 39% were ventilated (median duration 34 hours, range 3 to 140 hours). In group 1, 24% required morphine infusion compared with 64% in group 2. Most group 1 patients (77%) were extubated immediately postoperatively; 20% had short duration ventilation (median 15 hours, range 11 to 37 hours); one required longer-term ventilation (231 hours). 82% of group 2 were ventilated for a median of 72 hours (range 3 to 140 hours). Review of patients' co-morbidities facilitated guideline revision. These now specify use in neonates requiring short-gap tracheo-oesophageal fistula/oesophageal atresia repair who are term at =36 weeks gestational age and =2.5 kg birth-weight, anticipated as ready for extubation either immediately or shortly after surgery.