Anesthesia for OutPatient Spine Surgery Michael A. Kellams, D.O.
DISCLOSURE None!
Hot Topics 2017 -Multimodal Analgesia/ERAS -TAP block -Inpatient procedures outpatient (Fusions)
Multimodal Analgesia -Using a complementary assortment of non-narcotic medications in the perioperative period to minimize the need for narcotics -Why? 1)Minimize unwanted side effects 2)Shorten and enhance recovery 3)Higher patient satisfaction 4)Reduce abuse potential
IS IT BAD POLYPHARMACY (ALCHEMY) TO GIVE A PATIENT A BUNCH OF DIFFERENT MEDICATIONS?
THE TEAM LIDOCAINE Local anesthetic. -Shown to reduce pain, nausea, ileus, opioid requirement, and LOS.(1) -1 mg/kg IV @ induction >>40 mcg/kg/m intraop>>0.5-1 mg/min PACU and for up to POD 2! KETAMINE NMDA Blocker (also opioid and Na+ channels) -0.5 mg/kg IV @ induction, 10 mcg/kg/min intraop. (2) OFIRMEV IV Acetaminophen (1000 mg preop)
THE TEAM (cont d) KETOROLAC NSAID (30 mg, 15mg if >65 yo. NOT in fusions)- a 10-yr metanalysis reported at ASA in 16 demonstrated lack of effect on renal function and bone healing with a 1-time dose intraop. (3) PRECEDEX Alpha agonist (dexmedetomidine) 0.5mcg/kg/min in IONM DIAZEPAM GABA activation. 0.05-0.1 mg/kg IV for post op muscle spasm DEXAMETHASONE Modulates pain, prevents nausea, improves cognitive function and overall well-being. (4)
Others that don't modulate pain MIDAZOLAM- Pre-op anxiolysis ONDANSETRON- Post-op nausea prevention SCOPOLAMINE- If they get car sick or have a hx of PONV PROPOFOL- Gotta induce with something! DESFLURANE/SEVOFLURANE- Gotta maintain with something (unless TIVA)
SEEN WORKING OUT AT THE ASA COMBINE Methadone! (5)
Others? GABAPENTIN Seems to NOT produce a clinically meaningful improvement in analgesia (6) CELEBREX & LYRICA I am not a fan of PO meds in the immediate preop period. BETA BLOCKERS Recent study out of Canada suggests Esmolol infusion reduced opioid consumption, PONV, and PACU LOS (7)
xx%
TAP Block Transversus Abdominis Plane - Carries somatic nerves T6-L1 to anterior abdominal wall
Why are we talking about TAP? -blocking these nerves allows us to successfully perform ALIF as OUTPATIENT -We also use bilateral facet injections in addition -( 15-16) 33 Outpt ALIF. TAP w/exparel + FB w/exparel -High pt satisfaction. Avg PACU pain score 2.8/10. Avg 24-hr pain score 2.9/10. -0 pts required admission, 0 pts had SSI, 0 Ileus -MUST have a PV Surgeon gain access!
INTANGIBLES ERAS - MMA is a big part along w/ pt education and perioperative nutrition PATIENT SELECTION - BIG factor is mindset FACILITY -right equipment, right setup for postop and possible transfer STAFF -EVERYONE has to be on board and have the skills
TAKE HOME MESSAGES MULTIMODAL ANALGESIA IS KEY COMPONENT OF ERAS AND SUCCESSFUL OUTPATIENT SPINE SURGERY THE ONLY THING THAT DOESN T CHANGE IS THAT THINGS ARE ALWAYS CHANGING. KEEP UP! EACH YEAR WE ARE TRANSITIONING MORE TRADITIONALLY INPATIENT SPINE SURGERIES TO OUTPATIENT SETTINGS- BETTER OUTCOMES, LESS COST, HIGHER PATIENT SATISFACTION
1) Perioperative Use of Intravenous Lidocaine, Dunn & Durieux- UVA, Anesthesiology V 126, pp 729-735 April 2017 2) Intraoperative Ketamine Reduces Perioperative Opiate Consumption in Opiate- Dependant Patients with Chronic Back Pain Undergoing Back Surgery, Loftus, et al - Dartmouth, Anesthesiology V 113, pp 639-645 September 2010 3) Literature Review Finds Ketorolac Side Effect Profile Largely Benign for Renal Function and Bone Healing, Lipana - Yale, ASA 2016, Abstract A2015 4) Postop Cognition in Elderly Improved With Dexamethasone, Valentin - São Paulo, ASA 2014, Abstract A2045 5) Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery, Murphy, et al - U. Chicago, Anesthesiology V 126, pp 822-833 April 2017 6) A Perioperative Course of Gabapentin Does Not Produce a Clinically Meaningful Improvement in Analgesia after Cesarean Section, Monks, et al, Toronto, Anesthesiology V 123, pp 320-326, August 2015 7) Intra-Op Beta Blockers Lower Post-Op Opioid Use, Nausea, Length of Stay, Yang- Montreal, CAS 2016, Abstract 151137
Thanks! Contact: Michael A Kellams, D.O. 2001 W 86th St St. Vincent Hospital Dept. of Anesthesia Indianapolis, IN 46260 6Kellams@gmail.com www.nasllc.org