1. Multidisciplinary Perioperative Home for Complex Spine Surgery Reduces Delays and Cancellations on Day of Surgery John W Robben, MD 1, M. Saif Siddiqui, MD 1 James Layton, MD 1, Taranjit Sangari, MD 1, Richard McCarthy, MD 2, Frances McCullough, RNP, MNSc 2 1 Division of Pediatric Anesthesiology, University of Arkansas for Medical Science 2 Department of Orthopedic Surgery, University of Arkansas for Medical Science

2. Financial Disclosures John W Robben, MD – no disclosures Saif Siddiqui, MD – no disclosures James Layton, MD –no disclosures Taranjit Sangari, MD – no disclosures Richard McCarthy, MD – Consultant for Medtronic Frances McCullough, RNP, MNSc – no disclosures

3. Outline Hypothesis Design Introduction Methods Results Conclusion

4. Hypothesis Preoperative multidisciplinary conferences discussing patients undergoing complex spine surgery will reduce delays and cancellations on the day of surgery

5. Design Retrospective review

6. Introduction Perioperative care of patients undergoing surgery for complex scoliosis requires multiple disciplines of medical and surgical specialties Patients with scoliosis secondary to neuromuscular disease or syndromes often have pathology of multiple organ systems that need optimization perioperatively Patients with higher ASA physical status classification have increased morbidity and mortality 1

7. Methods Monthly conferences were held to discuss and optimize the perioperative course of complex spine patients Services represented included pediatric anesthesiology, critical care, cardiology, pulmonology, and orthopedic surgery Cases are reviewed monthly and recommendations for perioperative tests and perioperative care were planned Cases from the previous month were presented and reviewed

8. Results 45 complex spine patients with diagnosis of cerebral palsy, history of transplants, muscular dystrophy, thoracic insufficiency syndrome, and genetic abnormalities were presented Multidisciplinary perioperative management was discussed Patients were risk stratified Perioperative transfusion guidelines were developed Invasive and noninvasive cardiovascular monitors were recommended based upon risk stratification Patients were risk stratified into low, moderate, or high risk based on

9. Results continued There have been no delays or same day cancellations of patients presented at the multidisciplinary complex spine case conference for the past year

10. Transfusion and Cardiovascular Monitoring HIGH RISK Large bore PIVs Cell saver Arterial line Central line 2 hot lines 2 pressure bags Activation of Massive Transfusion Protocol Amicar infusion Vasopressor of choice in-line Non-invasive cardiac output monitor – ECOM (if ≥ 6.5 mm ETT is appropriate) – Vigileo (if a 6.0 mm ETT or smaller is required) Masimo Rainbow Pulse Oximeter Consider cerebral NIRS PT/PTT/INR/fibrinogen at beginning of case INTERMEDIATE RISK Large bore PIVs Cell saver Arterial line +/- Central line 1-2 hot line(s) 2 pressure bags Blood bank aware of potential for Massive Transfusion Protocol PRBCs available Amicar infusion Consider having a vasopressor available Consider non-invasive cardiac output monitor (ECOM, Vigileo) Consider Masimo Rainbow Pulse Oximeter LOW RISK Large bore PIVs Cell saver PRBCs available Arterial line 1 hot line 1 pressure bag +/-Amicar infusion

11. Conclusion A multidisciplinary perioperative home for complex spine surgery reduces delays and cancellations on the day of surgery

12. References 1 J Neurosurg Spine. 2011 Apr;14(4):470-4. doi: 10.3171/2010.12.SPINE10486. Epub 2011 Feb 4