Orthopaedic Patients Having Spinal Surgery

Transcription

1 1.0 Introduction: Purpose: This pathway is developed by an interdisciplinary clinical team at SickKids using research, clinical experience and consensus agreement. It is a general guideline and does not represent a professional care standard governing providers obligations to patients. Care may be revised to meet individual patient needs. At this time, due to limited published research evidence, all recommendations are considered Level C: Expert Opinion, except when noted otherwise. Target Population: Inclusion: Children aged 3 18 years old requiring surgery by an orthopaedic surgeon for a spinal deformity such as scoliosis or kyphosis. These deformities may be idiopathic, congenital or neuromuscular in nature or from a secondary cause such as Marfan's. Surgery will generally consist of surgical correction of the spinal deformity using metal implants which are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the spine segments which have been operated on are fused as one bone. All patients will undergo Intraoperative neurophysiological monitoring (IONM) throughout the surgical procedure. In some cases, a spinal orthosis (eg. Cheneau or Milwaukee Brace) may be required post-operatively for a specified time or for an ongoing basis. Exclusion: Target Users: Patients may be removed from this pathway if there are significant postoperative complications (eg wound infection, changes to spinal cord/neuromonitoring, difficulty with extubation). Surgeons, residents, fellows, nurses, physiotherapists, and orthotists. otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 1 of 6

2 2.0 Definitions Definitions are from the Scoliosis Research Society unless otherwise stated Scoliosis - a lateral curvature of the spine Idiopathic Scoliosis - defined radiographically as a lateral curvature of the spine greater than or equal to 10º Cobb with rotation or unknown etiology Congenital Scoliosis - scoliosis due to congenitally anomalous vertebral development Neuromuscular Scoliosis (NM) - a scoliosis due to either a neurologic or muscular disorder Early Onset Scoliosis - lateral (side to side) curve of the spine that is diagnosed at ages 0-9 years; incudes infantile and juvenile idiopathic scoliosis and congenital scoliosis Late Onset Scoliosis - lateral (side to side) curve of the spine that is diagnosed at age greater or equal to 10 years Kyphosis - a posterior convex angulation of the spine EOS 2D/3D imaging system - digital radiography system that performs "uninterrupted full-body, weight bearing digital 2D and 3D imaging in a single scan with a low radiation dose" (National Institute for Health and Clinical Excellence, 2011, p.3) Intraoperative Neurophysiological Monitoring (IONM) is the use of physiological techniques 1) to assess neural integrity and/or 2) to map or neuro-navigate within at-risk neural structures during surgical procedures. otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 2 of 6

3 3.0 Clinical Practice Recommendations Pre-Operative Management Complete education about surgery and recovery phase Patient attends pre-operative teaching session completed by Ortho Clinic nurse Family to meet Ortho Nurse Practitioner on pre-op day Family to review About Kids Health information on spinal surgery Complete required pre-op tests on pre-op teaching day Blood work, CBC, Ferritin, Cross & Type Focused Physical Exam: height & weight, musculoskeletal assessment if necessary to determine baseline Spine X-rays EOS 3ft PA & LATERAL** (& possibly side benders) Clinical photos (Pre-op & 6 months Post-op) Pre-Anaesthesia Consult and ICU consult as indicated Determination of Post-op bed placement including recommendations from pre-anaesthesia clinic (ie children with co-morbid conditions, established on BIPAP, will require OICUPICU bed post-op) Patient/family advised of pre-op bath. Wipes to be used upon arrival. Refer to standard work document Pre-operative Medical Care and Tests Discuss options for receiving blood intra and postoperatively with patient/family If indicated based on curve type and severity (determined at time of booking): complete echo, CT/MRI, Pulmonary Function Tests and any additional blood work # of units of blood requested by the surgeon to be available intra-op will be based on: type of scoliosis (idiopathic, congenital or neuromuscular), planned approach to surgery is anterior or posterior, and number of vertebral levels to be fused. (Grade A) Patient and family provided with contact information for SickKids Patient Blood Management Co-ordinator Patient should be prescribed a treatment dose of an iron supplement See e-formulary for dosing. Refer to dietician if patient is below 3 rd percentile or BMI 10% to assist with weight gain prior to surgery to optimize pre-operative nutrition. Consult Thrombus team if patient has DVT/PE risk i.e. obesity, estrogen containing birth control, obesity, immobility, spinal cord injury Determine post-op bed placement with Anesthesia and note on surgical booking sheet (5A,OICU or PICU) Complete pre-op medical record Post-operative Care Complete post-op order set **Radiographs of the entire thoracic and lumbar spine and the iliac crests should be taken with patients standing erect with elbows fully flexed and relaxed fists on clavicles (fists-on-clavicles position), and holding their breath. [Grade B] In general PA radiographs are more valid and reliable than lateral radiographs. Printable Version otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 3 of 6

4 Post-Operative Management Refer to: Care Pathway 4.0 Implementation Plan Education and awareness building by Orthopaedic Surgery program (surgeons, NPs, Fellows, Nurse educator) at: resident/fellow orientation and nursing staff orientation. Surgeons to communicate any updates in practice to Divisional colleagues. 5.0 Evaluation Plan Ortho Spinal Surgery Post-op order set utilization Length of Stay Correlation between Length of Stay and order set utilization 6.0 References 1. Alman, B. (2010). Overview and Comparison of Idiopathic, Neuromuscular, and Congenital Forms of Scoliosis. In Genetics & Development of Scoliosis. Kusumi, Dunwoodie Editors. Springer Science. 2. Bryant, R. A., & Nix, D. P. (2007). Acute Surgical and Traumatic Wounds. In Acute & Chronic Wounds Current Management Concepts. 3rd Edition. Mosby Elsevier. 3. Burrows, F. A., Shutack, D., & Crone, R. K. (1983). Inappropriate secretion of antidiuretic hormone in a postsurgical pediatric population. Critical Care Medicine, 11(7), Canavarro, K. (1946). Early post-operative ambulation. Annals of Surgery, 124(2), Guidelines for Preventing Health-care-associated Pneumonia. (2003). Recommendation of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 6. Harvey, C.V. (2005). Spinal Surgery Patient Care. Orthopaedic Nursing, 24(6), The Hospital for Sick Children Handbook of Pediatrics. (2009). 11th Edition. 8. Kelleher, Hoekelman. (2009). Fluids & Electrolytes in Clinical Practice. In T. K. McInerny, H. M. Adam, D. E. Campbell, & D. M. Kamat (Eds.), American Academy of Pediatrics Textbook of Pediatric Care (pp ). Chicago, United States: American Academy of Pediatrics 9. Linari, L. R., Schofield, L. C., & Horrom, K. A. (2011). Implementing a bowel program. Orthopaedic Nursing, 30(5), Lippincott Manual of Nursing Practice. (2010). 9th Edition. Ch. 32 & 54. Lippincott, Williams & Wilkins. 11. Mangram, A., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of surgical site infection, Hospital Infection Control Practices Advisory Commitee. Infection Control and Hospital Epidemiology, 20(4), ; quiz otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 4 of 6

5 12. Morris, B., Benetti, M., Marro, H., & Rosenthal, C. (2010). Clinical Practice Guidelines for Early Mobilization Hours After Surgery. Orthopaedic Nursing, 29(5), Murphu, R., Mooney, JF. (2016) Complications following spine fusion for adolescent idiopathic scoliosis. Current Review Musculoskeletal Medicine Raffini, L., Trimarchi, T., Beliveau, J., & Davis, D. (2011). Thromboprophylaxis in a pediatric hospital: A patient-safety and quality improvement initiative. Pediatrics, 127, e Rowan-Legg, A., & Canadian Paediatric Society, Community Paediatrics Committee. (2011). Managing functional constipation in children. Paediatric Child Health, 16(10), Scoliosis Research Society: SickKids Drug Handbook & Formulary. (2017). Surgical Prophylaxis for Neonates and Paediatric Patients, SickKids Department of Paediatric Laboratory Medicine Transfusion Medicine Shapiro, F., & Sethna, N. (2004). Blood loss in pediatric spine surgery. Eur Spine J, 13(Suppl 1), S6-S Short. V, Herbert G. et al (2015). Chewing Gum after surgery to help recovery in digestive system. Cochrane Database of Systemic Reviews. Issue The American Society of Neurophysiological Monitoring. (2013). Practice Guidelines for the Supervising Professional: Intraoperative Neurophysiological Monitoring. 22. Wright, J. G. (2007). A practical guide to assigning levels of evidence. JBJS, 89(5), Zolkipli, S., et al. (2012). Abnormal fatty acid metabolism in spinal muscular atrophy may predispose to perioperative risks. European Journal of Paediatric Neurology, 16(5), Guideline Group Membership: Janet Ahier, Nurse Practitioner Paediatrics, 5A Ward Orthopaedics Jeannette So, Evidence Analyst, Surgery Reinhard Zeller, MD Stephen Lewis, MD Fatma Rajwani, PT, Quality Management, Clinical Practice Guideline Coordinator Internal Reviewers: Cristina Franco, RN, 5A Clinical Support Nurse Braden Fielding, RN 5A, Staff Nurse Sabrina Boodham, Pharmacist Catharine Bradley, Physiotherapy Practitioner, Orthopaedic Clinic External Reviewers: Mike Dodds, Orthopaedic Surgeon, Dublin Ireland (former Sickkids Spine fellow) otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 5 of 6

6 Attachments: Scoliosis CPG Daily Care Goals.pdf Ortho Spinal Surgery_July 18.pdf pre_op care pathway_july 20.pdf otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to This Clinical Practice Page 6 of 6