Introduction: Osteotomy in spine surgery can be used as a marker of increased case complexity and duration. During these cases, patients undergo prone positioning and major fluid shifts, which can contribute to airway edema and decrease ease of reintubation. Although intraoperative emergence and extubation is desirous to avoid prolonged mechanical ventilation and to promptly assess neurological status, the decision to do so should be made after balancing risks and benefits. There is a paucity of evidence on variables associated with delayed extubation after major spine surgery. In this study, cases involving osteotomy were used as a proxy for complex spine surgery and predictors of delayed extubation were analyzed.
Methods: A retrospective, cross-sectional IRB-approved study was performed using a prospectively maintained database containing preoperative and intraoperative variables for 17223 spine surgery procedures between 01/2006 and 11/2016. Preoperative and intraoperative variables included patient demographics, comorbidities, airway risk factors, fluid administration, estimated blood loss, involved personnel, anesthesia time, and prone positioning. The database was queried for cases involving osteotomy and the electronic medical record was manually reviewed to affirm that cases met inclusion criteria. Statistical analysis was performed with R (Version 3.4.1).
Results: A total of 238 cases met the inclusion criteria. 55 patients (23%) were kept intubated after osteotomy surgery. The variables independently associated with delayed extubation were infused crystalloid volume (p = 0.025), administered total fresh frozen plasma (FFP) (p = 0.037), and number of anesthesiologist attending handoffs (p = 0.005).
Conclusions: The present study strongly suggests that crystalloid volume administered, fresh volume plasma administered, and number of handoffs are independently associated with delayed extubation in major spine surgery. These results can better inform the preoperative identification and optimization of patients for complex spine surgery with the goal of improving preoperative planning and developing a high-risk spine pathway to reduce morbidity and cost of care.
Patient Care: This study demonstrates the importance of comparing the risks and benefits of post-surgical extubation. This study has strong implications for the preoperative identification and optimization of patients for complex spine surgery, and identifies a need for a high-risk spine pathway, similar to the existing fast track cardiac pathway. A standardized protocol to pre-select high risk spine surgery patients and facilitate early extubation can improve efficiency of care, reduce cost, and improve outcomes.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Identify preoperative and intraoperative predictors of delayed extubation in complex spine surgery
2) Describe the importance of comparing the risks and benefits of post-surgical extubation after complex spine surgery
3) Develop strategies to pre-select high risk spine surgery patients and optimize outcomes
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