Robert W. Gould

Standardizing care for high-risk patients in spine surgery: the Northwestern high-risk spine protocol.

Study Design. Review article of current literature on the preoperative evaluation and postoperative management of patients undergoing high-risk spine operations and a presentation of a multidisciplinary protocol for patients undergoing high-risk spine operation. Objective. To provide evidence-based outline of modifiable risk factors and give an example of a multidisciplinary protocol with the goal of improving outcomes. Summary of Background Data. Protocol-based care has been shown to improve outcomes in many areas of medicine. A protocol to evaluate patients undergoing high-risk procedures may ultimately improve patient outcomes. Methods. The English language literature to date was reviewed on modifiable risk factors for spine surgery. A multidisciplinary team including hospitalists, critical care physicians, anesthesiologists, and spine surgeons from neurosurgery and orthopedics established an institutional protocol to provide comprehensive care in the pre-, peri-, and postoperative periods for patients undergoing high-risk spine operations. Results. An example of a comprehensive pre-, peri-, and postoperative high-risk spine protocol is provided, with focus on the preoperative assessment of patients undergoing high-risk spine operations and modifiable risk factors. Conclusion. Standardizing preoperative risk assessment may lead to better outcomes after major spine operations. A high-risk spine protocol may help patients by having dedicated physicians in multiple specialties focusing on all aspects of a patients care in the pre-, intra-, and postoperative phases.

Acute spinal cord injury

Spinal cord injury (SCI) is a potentially devastating injury, which can affect a multitude of systems. The most common etiologies are motor vehicle crashes, assault, falls, and sporting injuries. Other potential causes of loss of spinal function include neoplastic, vascular compromise, or genetic predisposition such as ankylosing spondylitis. Anatomically, the spinal cord is divided into the cervical, thoracic, lumbar, and sacral levels. At each of these levels originate spinal nerves that maintain various physiologic functions. The level of injury will dictate the loss of what physiologic functions. Owing to this, the higher the level of injury, the more catastrophic the impediments would be. These physiologic functions include not only the neuromuscular system but also cardiovascular, respiratory, metabolic and nutritional systems. Currently, there are over 250,000 people living with SCI in the United States. On average, there are about 10,000 new cases per year in the United States. About half of these injuries are at the cervical level and 40% of these will require some level of mechanical ventilation. Furthermore, 5% of those who require mechanical ventilation will require long-term mechanical ventilation. Owing to gains in medical care the average life expectancy of those with spinal cord injuries has increased over the last 40 years with an increase in those discharged ventilator dependent. Owing to this, the anesthesiologist should be familiar with the acute and chronic management of SCI.

Predicting major adverse cardiac events in spine fusion patients: Is the revised cardiac risk index sufficient?

Study Design. Observational cohort study. Objective. To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more. Summary of Background Data. Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients. Methods. After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance. Results. The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity. Conclusion. The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery. Level of Evidence: 3

The Implementation and Efficacy of the Northwestern High Risk Spine Protocol

OBJECTIVE The aims of this study were to determine the efficacy and feasibility of implementation of the intraoperative component of a high risk spine (HRS) protocol for improving perioperative patient safety in complex spine fusion surgery. METHODS In this paired availability study, the total number of red blood cell units transfused was used as a surrogate marker for our management protocol efficacy, and the number of protocol violations was used as a surrogate marker for protocol compliance. RESULTS The 548 patients (284 traditional vs. 264 HRS protocol) were comparable in all demographics, coexisting diseases, preoperative medications, type of surgery, and number of posterior levels instrumented. However, the surgical duration was 70 minutes shorter in the new group (range, 32-108 minutes shorter; P < 0.0001) and the new protocol patients received a median of 1.1 units less of total red blood cell units (range, 0-2.4 units less; P = 0.006). There were only 7 (2.6%) protocol violations in the new protocol group. CONCLUSIONS The intraoperative component of the HRS protocol, based on two Do-Confirm checklists that focused on 1) organized communication between intraoperative team members and 2) active maintenance of oxygen delivery and hemostasis appears to maintain a safe intraoperative environment and was readily implemented during a 3-year period.

Monitoring in the Intensive Care Unit

Neurologic illness is complex and often complicated by adverse effects on the cardiopulmonary system. Studies have shown improved outcomes for patients treated in a dedicated Neurologic Intensive Care Unit (NICU) likely secondary to specialized nursing care, neurointensivist teams, and protocolized management of complex neurologic illness [1]. The common types of hemodynamic monitors within any intensive care unit (ICU) include temperature monitoring, blood pressure measurements, electrocardiography, respiratory and ventilatory parameters, as well as measurements of volume status and cardiac output [2, 3]. Neuromonitoring within the NICU is conducted with transcranial Doppler, intracranial pressure (ICP) monitors, cerebral oxygen monitors, and electroencephalograms [4]. This discussion is presented in the context of a few case descriptions to exemplify the complexities of managing patients with severe neurologic disease.

Pain control in the critically ill patient

Abstract The interplay of pain, anxiety, and delirium makes the achievement of patient comfort in the critically ill challenging. Assessment of pain, anxiety, and delirium is hence central to the management of patient care in the critically ill. Such an assessment will help direct therapy appropriately and provide a more patient-centered treatment based on the underlying pathology. Importantly, the underlying pathophysiology in critically ill patients may limit therapeutic options for pain, anxiety, and delirium necessitating careful selection of treatment options.