DOCUMENT CONTROL PAGE Title Title: UNDERGOING SPINAL DEFORMITY SURGERY Version: 2 Reference Number: Supersedes Supersedes: all other versions Description of Amendment(s): Revision of analgesia requirements Originator or modifier Originated By: Designation: Consultant Paediatric Anaesthetist & Consultant Paediatric Intensivist Modified by: As above Designation: As above Approval Approval by: Sub Committee Approval Date: [if required] Application All Patients Patients Patients Children only All staff Staff Group (Medical & Nursing) Other (Insert) Circulation Review Issue Date: June 2008 Circulated by: Circulation list of anaesthetists, PICU intensivists and nursing staff, Children s Pain Team, Orthopaedic spinal team, Liebert ward. Issued to: All of above Review Date: June 2010 Responsibility of: UNDERGOING SPINAL DEFORMITY SURGERY Page 1 of 7
POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT Circulation List: For Information Central Manchester and Manchester University Hospitals NHS Trust is committed to promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity. Refer to section 8 for more detail on undertaking equalities impact assessment. This document must be disseminated to all relevant staff, refer to section 10: Dissemination and Implementation The Policy must be posted on the intranet: Date Posted: UNDERGOING SPINAL DEFORMITY SURGERY Page 2 of 7
GUIDELINES FOR THE POST-OPERATIVE MANAGEMENT OF CHILDREN UNDERGOING SPINAL DEFORMITY SURGERY INTRODUCTION These guidelines have been drawn up to help trainee medical and nursing staff looking after these children during the post-operative period. The aim of these guidelines is to standardise the post-operative care (pain, fluid and transfusion management) and improve the communication between senior colleagues and other staff. Children undergoing this type of surgery fall broadly into one of two categories. The first is those with idiopathic scoliosis and the second being those whom have some form of neuromuscular disease or other underlying disorder. In general, children in the idiopathic group are healthy adolescents while those in the other group have some form of systemic disease. WHERE WILL THESE CHILDREN BE NURSED AND WHO WILL LOOK AFTER THEM? The majority of children will be nursed post-operatively in the High Dependency Unit (HDU). Some children with pre-existing co-morbidity will require planned admission to the PICU. Occasionally some children due to unanticipated intra-operative complication will require admission to the PICU For children managed on HDU the lead clinician will be the consultant spinal surgeon. If there are any questions relating to the management of these children, then the nursing staff or surgical F2 s should seek advice from either the spinal fellow/orthopaedic ST if it is a surgical problem or the on-call anaesthetic ST if it is related to fluid or pain management. Anaesthetic STs are not to be called for day to day management issues. During the working day advice on pain management should be sought from the Acute Pain team. If for whatever reason these personnel are unable to help then advice should be sought directly from the consultant spinal surgeon and/or the consultant anaesthetist who is in charge of the patient. The lead clinician for those children managed initially in the Paediatric Intensive Care Unit (PICU) will be the consultant intensivist. The intensive care trainee should seek advice from the consultant intensivist in the first instance. Consultation with the spinal surgeon / anaesthetist may be required. POST-OPERATIVE ANALGESIA Owing to the nature of the surgery these children will require a significant amount of analgesia during the initial post-operative period. Analgesia will be provided using both Morphine (0-35microgram/kg/hr) and Ketamine (1-3 microgram/kg/minute) for the first 48-72 hour (see appendix 1). In addition an epidural or intrapleural block may be used to supplement the analgesia. Paracetamol will be prescribed and given regularly. UNDERGOING SPINAL DEFORMITY SURGERY Page 3 of 7
Non-steroidal anti-inflammatory drugs should only be started if the child is complaining of severe pain despite the aforementioned analgesia and the coagulation tests are within acceptable limits (1-1.5 x normal range). For those children who are ventilated for a short time (overnight), it should not be necessary to completely turn off the morphine infusion to extubate these children. We know from those children who are not intubated and ventilated that significant amounts of morphine are required to provide effective analgesia. Similarly, if the epidural has been started then this should be kept running and only switched off if there is evidence of any neurological deficit or hypotension. As mentioned previously, these children require significant amounts of analgesia and it is not unusual for these children to require morphine infusions up to 35 microgram/kg/hr on the HDU. Epidural catheters should normally be removed by the third post-operative day. FLUID MANAGEMENT AND BLOOD TESTS All children will have undergone prolonged major surgery with significant intraoperative blood loss and will continue to lose significant fluid into the wound in the post-operative period (third space loss). It is not unusual for large volumes of fluid to be required both intra-operatively and post-operatively following this type of surgery. Blood Tests All patients should have the following blood tests on admission to the High Dependency or Intensive Care Unit: Full blood count Urea and electrolytes Clotting screen Arterial blood gases Blood sugar. All these blood tests should be repeated in the following morning. A daily FBC and U&E should be done for the first 3 days. Other tests should only be done if clinically indicated. FLUID THERAPY FOR NON-VENTILATED PATIENTS These children will have a significant amount of fluid shift into traumatised tissue and additional losses through wound drains (third space loss) in the postoperative period. They will require significant amounts of fluid replacement during this time. The following fluid replacement therapy is suggested: For the first 48 h: 100% maintenance fluid (e.g. for 40 kg child = 80 ml/hr 0.9% saline / 5% dextrose with 10 mmol/l of potassium chloride) +10 ml/kg of gelofusine over 30 min if the age appropriate mean blood pressure is low or urine output is less than 0.5 ml/kg for more than 2 consecutive hours Avoid human albumin solution as a colloid replacement in idiopathic patients where possible CVP trends should be used to guide fluid requirement when available UNDERGOING SPINAL DEFORMITY SURGERY Page 4 of 7
Blood transfusion if Hb < 7 g/dl for idiopathic patients and < 8.5 g/dl for the non idiopathic patients Review fluids every 12 hours Normal fluid maintenance from day 3 FLUID THERAPY FOR VENTILATED PATIENTS As according to PICU fluid management policy Avoid human albumin solution as a colloid replacement in idiopathic patients where possible INOTROPES Inotropes should be started to maintain the age appropriate mean blood pressure once the intravascular volume has been optimised. BLOOD AND BLOOD PRODUCT TRANSFUSION CRITERIA Idiopathic group It has been agreed between the consultant anaesthetists and surgeons that these children should not be transfused blood unless their haemoglobin is less than 7g/dl. Unlike the sick intensive care patients these young fit healthy patients can tolerate these levels of haemoglobin without any significant problems. If however, these children require a blood transfusion then their own AUTOLOGOUS blood should be given first if available. Non-idiopathic group These children should only receive a blood transfusion if the haemoglobin is below 8.5 g/dl. Transfusion of other blood products Clotting products should only be used if there is significant coagulopathy (i.e. clotting results > 2x normal) or active bleeding. MONITORING Arterial and central venous pressure monitoring The position of the central line will be confirmed peri-operatively with an xray as per trust protocol. All children will continue to have full invasive monitoring for the first 48 h following surgery. Neurological observations 1. The spinal surgeon will document in the operation notes, the patient s immediate postoperative neurological status. 2. For those patients that are sedated and ventilated postoperatively the intraoperative SSEP findings will be documented in the operation notes. 3. Upper and lower limb movement and sensation should be assessed hourly for the first 24 h and then 4 hourly for the next 48 h. Neurological assessment may not be possible or reliable in sedated and ventilated patients. The findings should be documented in the patient s notes and relayed to the spinal surgeon. 4. Patients should be reviewed daily by the spinal team and the neurological observations should be documented in the notes UNDERGOING SPINAL DEFORMITY SURGERY Page 5 of 7
OTHER ISSUES DVT prophylaxis whilst immobile Flowtron calf compression and or TED stockings for all patients Low molecular weight heparin (LMWH) for adolescents or children with a history of thromboembolism (eg. Clexane) Withhold LMWH prophylaxis while coagulopathic Mobilisation Following spinal fusion procedures the spine is stable postoperatively. Therefore unless otherwise instructed by the surgical team, all children can be sat up in bed following surgery. Children with idiopathic scoliosis should be encouraged to sit out of bed by day 2. If neurological deficit is present and spinal cord ischaemia is suspected then the patient should be nursed flat pending surgical review. Central venous catheter The central venous catheter should be removed by the 3 rd post-operative day unless on the PICU or otherwise instructed by the Consultant spinal surgeon. Authors: Dr D Patel (Cons Paediatric Anaesthetist) Dr JM Samuel (Cons Paediatric Intensivist) Date of Issue: June 2008 Review Date: June 2010 UNDERGOING SPINAL DEFORMITY SURGERY Page 6 of 7
Appendix 1 Children s Pain Team PROTOCOL FOR CONTINUOUS KETAMINE INFUSION (All drug doses to be prescribed on patient s medication prescription sheet.) Background Ketamine has an analgesic action both centrally and peripherally in the nervous system. It exerts strong adjuvant analgesic properties by inhibiting the binding of glutamate to the NMDA-R receptor. This mode of action is different to the action of opioid drugs such as Morphine and therefore the use of Ketamine in combination to Morphine can improve pain relief. Ketamine as a continuous infusion in combination with Morphine will reduce the need for high dosages of Morphine to be used and therefore will minimize side effects. Loading dose Before commencement of Ketamine infusion an intravenous bolus of 300micrograms/kg is recommended to load the patient and improve the effectiveness of the infusion. Dose: 3 milligrams per kilogram of Ketamine made up to 50mls with 0.9% Saline. Calculate three times the child s body weight to obtain the Ketamine dose. Draw up the Ketamine dose in milligrammes and make up to 50mls with 0.9% Saline. Rate: 1 3 mls/hr = 1 3 microgram/kg/min Example : 20 kg patient. Draw up 60mg of Intravenous Ketamine and make up to 50ml with 0.9% Saline. Set Infusion pump rate to deliver the solution at 1-3ml/hr. Dosage delivered is then: 1-3 micrograms /kg /min. Monitoring Infants under 6 months must have additional apnoea monitoring and be nursed in the HDU. Over 6 months children can be nursed on the ward. Rate and dosage is adjusted according to child s pain and sedation scores. All children must in addition to the normal ward observations be managed with a Morphine infusion observation chart and continuous PULSE OXIMETRY. If Ketamine is being used as the sole infusion regime a dedicated Ketamine observation chart and continuous Pulse Oximetery must be used. For safety reasons, if a dedicated IV line is not used an anti-reflux valve must be used to prevent back flow of the drug. Inform the on-call anaesthetist if: PAIN SCORE more than 6 on a scale of 0-10 SEDATION SCORE = 4, RESPIRATORY RATE below the level for the child s age (see observation form) OXYGEN SATURATION below level set by anaesthetist Dr.R.Walker/A. Adams/D.Lowthian/D.Jonas/C.Skelly. October 2007 Passed by Medicines Management November 2007 Review October 2009 UNDERGOING SPINAL DEFORMITY SURGERY Page 7 of 7