1. INTEGRATED PERIOPERATIVE CARE: MAJOR NON-CERVICAL SPINE PATHWAY OHSU Anesthesiology & Perioperative Medicine Grand Rounds November 30 th, 2015

2. SUMMARY  Overview of IPC Major Non-Cervical Spine Pathway  Preoperative changes  Intraoperative management for Pathway patients  Multimodal analgesia  Antifibrinolytics  Hemotherapy

3. INTEGRATED PERIOPERATIVE CARE  Preoperative Optimization Iron Deficiency Anemia Pain & Expectations Management (CPC visit)  Intraoperative Management  Postoperative Management & Active Recovery following hospital discharge

4. QUALIFYING CRITERIA IPC MAJOR SPINE PATHWAY  1. Instrumentation spanning ≥ 3 levels  2. Surgery involving anterior and posterior approach or planned multi-stage procedure, independent of the number of levels of instrumentation  3. Estimated Blood Loss ≥ 1000mL  4. Duration of procedure ≥ 6 hours  5. Complex revision surgery, major osteotomies, or corpectomy  6. Significant, regular opioid use for more than 3 months or history of psychiatric disorder related to drug abuse

5. IDENTIFYING IPC PATHWAY PATIENTS (HOW WILL I KNOW I HAVE AN IPC PATIENT)  Assigned when the surgeon places request to surgery scheduler  Epic flag or notification still being determined  Matt Healy will contact scheduled anesthesia team on the day prior to surgery (for the next several months at least)

6. DAY OF SURGERY: PREOP IPC MAJOR SPINE PATHWAY  Multimodal Preoperative Medications (AVOID duplicate administration) Acetaminophen 1000 mg PO (for patients > 50 kg) Gabapentin 600 mg PO (or home dose, if higher) Consider Pregabalin 300 mg PO if gabapentin intolerance/mild side effect Morning home dose of opioid Please do not administer NSAIDs pre-op Please review & implement any CPC recommendations

7. DAY OF SURGERY: INTRAOP IPC MAJOR SPINE PATHWAY  Neuromuscular blockade for intubation: communicate with surgery and neuromonitoring teams regarding whether pre- positioning MEPs are planned  Lung protective ventilation strategy  Arterial line & central line (triple lumen preferred unless inadequate large bore PIV access/clinical judgment suggests introducer)  Invest in maintaining normothermia: maintain room temp > 70 F until patient is draped or warmed, consider placing convective warmer during line placement

8. ANESTHESIA MAINTENANCE & INTRAOP PAIN MANAGEMENT  Neuromonitoring: MEP (< 1/3 MAC), SSEP (< 1/2 MAC), EMG  If propofol requirement is high (> 200 mcg/kg/min), consider dexmedetomidine (0.3 – 0.5 mcg/kg/hr base on lesser of IBW or actual body weight) as anesthetic & analgesic adjunct  Also consider remifentanil as adjunct, particularly if TIVA required (signals, pre-op myelopathy, acute neurologic injury)  Ketamine 0.5 mg/kg (up to 50 mg) bolus at induction followed by infusion at 4 mcg/kg/min (up to 40 mg/hr total dose) (unless contraindicated)  If extubating, redose APAP IV within 1 hour prior & (unless contraindicated) discuss ketorolac 30 mg IV with surgery team—evidence suggests low dose ketorolac does not increase bleeding, non-union or pseudoarthrosis  Contact APS—will follow all IPC spine pathway patients post-op, ask them to place order for post-op ketamine infusion if indicated

9. VOLUME MANAGEMENT  Fluid restrictive strategy—large volume resuscitation associated with increased pulmonary complications in spine surgery*, morbidity and hospital LOS  Primarily LR, limit NS to 1 liter total then switch to Normosol if needed for transfusion  Fluid boluses above maintenance to maintain hemodynamic goals should be guided by PPV (>10% may predict volume responsiveness)  Goal lactate < 2.0  CVP should be within 4 cm of H 2 O of patient’s baseline  Vasoconstrictors may be required to maintain hemodynamic goals and limit excessive volume administration, goal is to wean off by conclusion of case

10. BLOOD MANAGEMENT  PRBCs: transfuse for hct < 24 at any point, hct < 26 with ongoing bleeding & anticipated further blood loss  FFP: INR ≥ 1.6 at any point, INR > 1.3 and surgical oozing/expected ongoing bleeding  PRBC:FFP 1:1 delivery after 3 rd unit PRBC or as indicated clinically/labs  Platelets: < 100,00 (ongoing bleeding), 1 pack for every 6 units PRBCs  Cryoprecipitate: one pool if Fibrinogen < 150,000  Massive Transfusion Activation: EBL > 3000 ml total, > 1000 ml in one hour, or uncontrolled hemodynamic instability

11. ANTIFIBRINOLYTICS & BLOOD GLUCOSE MANAGEMENT  Antifibrinolytics (all patients, unless contraindicated) Surgery team should order pre-op TXA: 10 mg/kg bolus (1 gram max) over 30 minutes prior to incision, 1 mg/kg/hr infusion  Target 160 mg/dL

13. LOOKING FORWARD  Email with these details as well as references  Ongoing communication to Anesthesia teams caring for IPC Major Spine Pathway Patients  Further information on Epic notification  Please direct questions, concerns or questions to Matt Healy or Peter Schulman