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Table 1 Lumbar spinal fusion ERAS protocol

From: Enhanced recovery after surgery (ERAS) program for lumbar spine fusion

Stage Location Action
Preoperative Neurosurgical clinic visit ▪ 1–2-level lumbar fusion patients identified to be included in the project
▪ Neurosurgery Spine Booking Checklist completed and surgery scheduled with the comment “lumbar fusion ERP”
▪ Patient given information letter and materials including diabetes education and smoking cessation
▪ Patients received a “pain questionnaire” and if any patient selects “on chronic and current benzodiazepines or opioids,” they will be considered high risk for pain and the acute pain service will be made aware
Booking office ▪ The following appointments are made:
 § Preoperative services
 § OR for surgery
 § Postoperative wound check (14 days) and surgical (30 days) follow-up
▪ A surgical packet will be sent to the patient with the following:
 § Cover letter explaining the contents and what to expect at POS and PSA
 § Instructions for taking or stopping medications
 § Directions to pre-operative services and ambulatory surgery unit
 § Postoperative discharge instructions
 § Social support services information
 § Discharge needs assessment form—to be returned pre-operatively
 § Pre-operative pain questionnaire-to be returned pre-operatively
▪ Assistant will add the lumbar fusion ERP checklist to the surgical packet that is sent to pre-operative services
Preoperative services ▪ History and physical-required
▪ Anesthesia consult-required and to be performed by an anesthesiologist, qualified MD, or physician extender
▪ Required testing includes T&S, CBC, PT/PTT, INR, UA, and for diagnosed diabetic patients HgbA1C
▪ HgbA1c of ≥ 9 will postpone the surgical date by at least 2 months and will be re-evaluated prior to rebooking
▪ Incentive spirometry, OSA and CPAP education, NPRS education
▪ Pre-operative antibiotic ordered—Ancef 2 g (3 g if > 120 kg), Clindamycin 900 mg, or Vancomycin 15 mg/kg
Perioperative Ambulatory surgery unit ▪ If identified as a “high-risk pain” the “pain liaison” will visit the patient prior to OR
▪ Acetaminophen 975 mg PO, gabapentin 900 mg PO prior to OR
▪ High-risk patients administer 40 mg aprepitant for PONV
OR for surgery ▪ Antibiotics will be dosed and given less than 1 h prior to incision and re-dosed as appropriate
▪ All patients regardless of diabetic status will receive dexamethasone 8 mg IVP
▪ High-risk patients with known chronic pain may receive ketamine 30 mg with induction
▪ Follow intra-op protocol as prescribed including hourly attending anesthesia to neurosurgeon communication
 § Should include progress of surgery, fluid status, hemodynamics, pressure point evaluations, EBL
PACU ▪ Assess patient temperature
All patients receive PCA and methocarbamol 1500 mg PO or IV
▪ Pain liaison will visit the patient if identified as “high-risk pain”
Postoperative Floor ▪ Nursing staff will notify neurosurgery if there are any medically necessary deviations from the protocol.
▪ PT/SW/NS to meet Monday–Friday to review patients’ discharge progress
POD#0 ▪ All patients will receive stool softeners and laxatives delineated in the power plan
▪ Diet as tolerated
▪ Continue IVF’s until tolerating good oral intake
▪ Reinforce incentive spirometry
POD#1 ▪ Discontinue Foley catheter at 0600
▪ Celecoxib 200 mg Q12H PO, gabapentin 300 mg Q8H PO, and acetaminophen 975 mg Q6H PO to be continued for 1 week
▪ Acute pain assessment for the transition to oral medications
▪ Mobilize out of bed and reinforce incentive spirometry
▪ PT evaluation for rehabilitation needs
▪ SW/Case management evaluation for support services and discharge planning
POD#2 ▪ If appropriate discontinue surgical drain and continue to mobilize
▪ Discharge if appropriate
Follow Up Neurosurgical Clinic Visit ▪ Follow-up phone call post-discharge day 1
▪ Wound check visit 2 weeks after discharge
▪ Regularly scheduled follow-up at 1 month, 3 months, 6 months, and 1 year
  1. The data in italics are the important interventions for measured outcomes
  2. POS preoperative services, PSA presurgical admission, OSA obstructive sleep apnea, CPAP continuous positive airway pressure, NPRS numeric pain rating scale, PONV postoperative nausea/vomiting, IVP IV push, EBL estimated blood loss, PCA patient-controlled analgesia, PT physical therapy, SW social work, NS neurosurgery