Zero PCA as a Target for Postoperative Rapid Recovery Management in AIS Patients Michelle Kars 1Northwell
1 MD , Benita
Liao
1 MD ,
2 BS ,
2 BS ,
3 Dzaugis ,
Sayyida Hasan Jesse Galina Peter 2 2 Terry Amaral MD , Vishal Sarwahi MD
Aaron Atlas
2 BS ,
Yungtai Lo
4 PhD ,
Health, Department of Anesthesiology, 2Northwell Health, Department of Orthopaedic Surgery, 3Zucker School of Medicine at Hofstra/Northwell, 4Albert Einstein College of Medicine,
Background Studies have shown that opioid substance addiction has been on a rise across all patient populations, including pediatrics[1]. Opioids have long been used in complex spine surgeries as a measure of pain control and are often given in the form of patient controlled analgesia (PCA) during postoperative recovery as well as take home medication.
Hypothesis We hypothesize that the use of intrathecal single micro-dose Duramorph can replace the need for PCA in a rapid recovery pathway (RRP) protocol after scoliosis surgery
Methods Group 1: PCA •AIS patients undergoing PSF between 2011 – 2018 •Patients received IV Hydromorphone PCA (0.01 mg/kg) postoperatively for an average of 2 days Group 2: ITM (No PCA) •AIS patients undergoing PSF between 2018 – 2019 •Pts received 1.5 mcg/kg IT Morphine diluted in 1 – 1.5 cc saline, V Toradol d/c POD 2, PO Tylenol: 15 mg/kg q6, PO Oxycodone: 0.1 mg/kg q4, PO Diazepam: 0.05 mg/kg q6 with breakthrough IV Hydromorphone (15 mcg/kg) Pain scores, prescription refills, morphine equivalence were documented for both groups.
Results 296 AIS patients: 198 PCA, 98 ITM 221 Female, 72 Male
Table 1. Median and Interquartile Range of clinical data PCA [N = 198]
ITM [N = 98]
p
Levels Fused
12 (10 – 13)
12 (11 – 13)
0.481
BMI
21.3 (18.8 – 25.1)
21.2 (19.2 – 24.5)
0.978
Preoperative Major Cobb
55 (48 – 63.5)
54.9 (46.3 – 60.7)
0.195
Table 2. Median and Interquartile Range and Frequency of hospital stay data and postoperative return PCA [N = 198]
ITM [N = 98]
p
Length of Stay > 4 days 47 (23.7%)
12 (12.6%(
<0.001
Max Pain Score at Activity
5.8 (4.7 – 7.7)
<0.001
7 (6 – 6)
OOB POD 9n) 1 2
<0.001 86 (43.4%) 76 (38.3%)
62 (65.2%) 26 (27.4%)
30 Day Readmission
1 (0.5%)
0
n/a*
30 Day Return to ED
0
2 (2.1%)
n/a*
Table 3. Median and Interquartile Range and Frequency of perioperative intake and outtake
Foley Removal (hrs) 1st Fluid Intake within POD 0 1st Stool (hrs) Vomiting
PCA [N = 198] 21 (18 – 41) 68 (34.4%)
ITM [N = 98] 20 (17 – 23) 67 (70.5%)
p
76.9 (22.7 – 96.5)
64.9 (49.5 – 95.9)
0.935
82 (41.4%)
43 (45.2%)
0.614
0.002 <0.001
Table 4. Comparison of post-discharge pain medication and their morphine equivalence for PCA (14 –day prescription) and ITM (7 day prescription) patients. Figure 7: Independent CRISPR knockout of CDK4 or CDK6 PCA does not cause dropout in most breast cancer cell lines [N = studied.
198]
Total Morphine Equivalence 210 mg (ME) for Opioid Ex at discharge
ITM [N = 98]
P
105 mg
n/a*
Fig 1. Demonstration of intrathecal morphine being inserted into cerebrospinal fluid of lumbar spine. At our institution this is conducted by the anesthesiologist preoperatively or the surgeon intraoperatively.
Fig 2. Pre and post-operative radiographic images of a patient diagnosed with adolescent idiopathic scoliosis. The postoperative image was taken after the patient underwent posterior spinal fusion.
Discussion Micro-dose ITM patients had better postoperative recovery outcomes: •Lower pain scores, opioid use, earlier ambulation, oral intake, catheter removal and shorter LOS •Patients receiving ITM take fewer opioids following hospital discharge which avoids the risk of long-term opioid use post-surgery[2] •No patients had respiratory depression •No significant difference in constipation or emesis •No patient experienced pruritus during their hospital course
Conclusion This is the first study to show that use of micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to PCA in the AIS population following PSF. References:
Opioid Rx Refill (n)
34 (17.2%)
15 (15.8%)
0.868
Total Morphine Equivalence (ME) for Opioid Rx with Refill
420 mg
320 mg
n/a*
*Based on total dosage, therefore no p-value is required
1. Harbaugh CM, Lee JS, Hu HM, McCabe SE, et al. Persistent Opioid Use Among Pediatric Pediatric Patients After Surgery. Pediatrics. 2018; 141(1). 2. Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):456-466. doi:10.1097/AAP.0000000000000806