O0821 Oct.3: 4:35pm - Zero Patient-Controlled Analgesia (PCA) is an achievable target for postoperative rapid recovery management of AIS patients

Studies have shown that narcotic substance addiction has been on a rise across all patient populations, including pediatrics . Narcotics have long been used in complex spine surgeries as a pain control method, and are often given in the form of patient controlled analgesia (PCA) during postoperative recovery and take home medication. The objective of this study was to report on one institution’s use of single bolus micro-dose intrathecal morphine (ITM) during Posterior Spinal Fusion (PSF) for Adolescent Idiopathic Scoliosis (AIS) and its comparison to patients whose pain was controlled with PCA.
In 2018, we instituted a rapid recovery pathway (RRP) for scoliosis patients undergoing PSF utilizing intrathecal micro dose ITM. Prior to this, PCA was the mainstay for postoperative pain management. In the ITM protocol, patients receive 1.5 mcg/kg ITM diluted in 1 cc saline administered preoperatively by anesthesiologists or intraoperatively by the surgeon. Postoperatively, patients received IV ketorolac at 0.5mg/kg Q6h, PO Tylenol (15 mg/kg q6h), PO Oxycodone (0.1 mg/kg q4), and IV Hydromorphone (15 mcg/kg) for breakthrough pain. At discharge PCA patients received 14-day prescriptions for 5mg Oxycodone q6 compared to just 7-day prescriptions in the ITM group.
AIS patients undergoing PSF from 2011 – 2019 were reviewed. PCA patients were included in Group 1 and ITM in Group 2. Perioperative data and patient requests for home prescription refills were analyzed and compared using Kruskal-Wallis and Chi-squared tests.
296 patients (PCA: 198; ITM:98). Perioperative major Cobb angles were similar between the two (55v54.9, p = 0.195), as well as levels fused (12v12, p = 0.481) and BMI (21.3 vs 21.2, p = 0.978). Group 1 averaged 2 days of PCA. 23.7% of patients in group 1 had a length of stay (LOS) greater than four days, which was significantly higher than the 12.6% of patients in group 2 (p < 0.001). Group 2 patients began ambulating significantly earlier with 89.6% patients out of bed by POD 2 compared to 81.6% in group 1 (p < 0.001). In addition, group 2 patients had significantly lower maximum pain scores with activity (5.8) compared to group 2 (7) (p < 0.001).
Foley catheters were removed earlier in group 2 (20v21, p = 0.002) and 70.5% of patients had their first fluid intake on POD 0 in group 2, significantly higher than 34.4% in group 1 (p < 0.001).
Time to first stool was similar (p = 0.935) as was postoperative emesis (p = 0.614). No patients had pruritus, respiratory depression, or required supplemental oxygenation.
This is the first study to show that use of micro-dose ITM with oral analgesics have adequate recovery, significantly better postoperative pain control and superior perioperative outcomes to PCA in the AIS population following PSF