Good morning, thank you for being here for this. How many people in your own institutions are hearing more and more about ERAS protocols? Okay, how many of you have a good understanding of what it is? Okay, so this is, the reason I'm talking about this is because I'm one of those surgeons that had very little interest in these protocols and not very interested in this side of medicine. I'm more interested in the procedures and doing the surgeries and doing the talks about how we develop these procedures. And when we started doing this at one of our centers, I started to see the benefits of this and I thought, you know, this is a topic that we need to get on because we're very far behind. If you start to look where these technologies started and what people are looking at, it started in Europe about 20 years ago and it's really hit most of the specialties and spine is one of the last for it to really start engaging in this process. And what is ERAS? Well, it's Enhanced Recovery After Surgery. It is a wastebasket term for anything that you do that tries to look at making the patient care and the outcomes better than it started. So the point is is that at one institution, they may have something that they call their ERAS protocol and that can be very different than another institution. It's not the same thing. It can be stuff that's done in the clinic preoperatively when you start to talk about patients about nutrition, calcium, vitamin D levels, health, diabetes, glucose control. It can start at that point and then apply to what you do preoperatively to the patients as far as infection goes, when you give your antibiotics and then it can extend beyond the operation itself. So the term has become a true wastebasket term for everything that we do to try and make patients have better outcomes. And to do this, you really need to use evidence-based medicine. And we are starting to get to the point where we're seeing anecdotal results with what we're doing, so we're starting to collect the data. And what's really interesting is the biggest barrier we've had is some of the anesthesiologists because they're not comfortable with a lot of the intraoperative drips that we're gonna use that really help with their patient's postoperative pain control. And so we need the data to show these anesthesiologists, hey, look at these outcome improvements in order to get them on board. Because if we don't, they can very easily turn and say, well, all that's great, but there's nothing that says that that actually improves their outcome. The goals are, as we stated, you wanna reduce morbidity and mortality and then optimize pain control. And this is an interesting one because I think we all know how the pendulum with pain management has changed over decades, right? Probably 10, 15 years ago, none of us were treating pain well enough. We were told by governments and hospitals, we need to give more opioids and if a patient has pain after surgery, it's our fault and we need to give them more medicine. Well, then we created a generation of addicts and now they're mad at us for having given all these patients all these opioids. And so now in these ERAS protocols, there's a lot of movement towards looking at ways to reduce opioid use and see if you can achieve better pain control without the use of the opioid. So it's kind of interesting how this is developing and some of the drugs that are used to help do that. Then there's all things like DVT prevention, infection, blood management strategies, and I'm gonna try and hit as many of these as we can in the time allotted. So we sort of started with our first protocol was pain control, okay? We think that's the most important thing. That's what patients touch a lot. That's their life and if you can make their pain better after surgery and reduce their opioid needs, I think that becomes obvious to everyone that there's a benefit there. Now, secondarily, if their pain's better controlled, then their length of stay improves and then the biggest thing that I think comes to the fact that one in 15 surgical patients prescribed opioids will become chronic users. And I think that is a very important detail for us as doctors and us as surgeons is while it may never be our intention to contribute to that, it's a fact of the addictive properties of these medicines that we use. And if we can stay away from that or at least reduce the usage so it's easier for patients to not use them once their pain is improving, I think that's going to help us at the end of the day. You know, there are costs associated with all of the, what they call the opioid-related adverse events. There's costs with respiratory depression, pneumonia that can develop, GI motility issues. We've all seen that with our patients who have had an ALIF and you're telling them to get up and move and to stop taking so much narcotics so their bowels wake up and so they don't get an ILEUS and you have one of those patients who's got an NG tube for a week or two in the hospital and it destroys all of your data that you need to start collecting because we're all starting to have to collect this. And then there's the urinary retention issues and the interesting one is the opioid-induced hyperalges and we'll get into that a little bit. So what have we seen so far? We're seeing, and these are some national statistics, but you can see the cost of hospitalization, length of stay, the mortality rates, and 30-day admission in patients who are having these opioid-related adverse events. So there is data that says that there are consequences of our use of opioids. And so how do we minimize this use? Well, that's where we start to get into all the different adjunctive medications, the NMDA antagonists, the COX-2 inhibitors, the anticonvulsants, the gabapentin that we'll gloss over because everybody's familiar with that. And then some of the blocks that we've started doing. How many people have had at their institution perform TAP blocks when they do an ALIF? Okay. How many people are doing quadratus laborum blocks? All right. How many people are doing erector spiny blocks? Okay. So we're gonna go over some of those. There's a lot of blocks that are starting to develop that can really reduce postoperative pain for a lumbar fusion patient and really make a big difference. And with the use of lysosomal bupivacaine, which lasts 72 hours, you can get these patients out of the hospital very quick and they are more mobile during that early period of time where typically some of them are hurting enough that it's hard for them to get up and mobilize. So I'm gonna make sure we get to those medications then. Reducing perioperative opioids. How many people in here when you're about to operate on somebody who's a chronic narcotic user tell them you really want them to ramp down their narcotics leading up to surgery so you can control their pain better postoperatively? Yeah. So I mean, that's a common thing we do. That's basically, that is a part of the enhanced recovery after surgery. We all know what a nightmare it is to control chronic opioid pain patients after surgery and so we're trying to reduce that. So ketamine. This is one of the first things that we started using to try and reduce opioid consumption at our hospital and it's been very effective. And it's very good for chronic opioid users and we use it for our multilevel lumbar fusion. Some of our posterior cervical fusions. And so the question is when do you use it? Well, there's some literature out there and I've put some references in here. If anybody has an interest, I can share the references with you. For patients taking greater than 60 pills a month or more than 15 morphine equivalents. And so what we do is, and of course the contraindications to ketamine. The anesthesiologist really has to pay attention to all these things. So you've gotta make sure that they don't have some issue that could inhibit the use of this medication. So we have a dosing regimen. And again, this is all based on published literature but there's not a lot of literature on spine surgery with these medications. There is in other fields. And you can see that there's a intra-op dosing and then there's a post-operative dosing where we continue these trips for one to three days afterwards. The one downside is they're still hooked up to an IV pole but it's reducing their narcotic intake quite significantly in some cases. In addition to the ketamine drip, we're using the lidocaine infusion in surgery. How many of your anesthesiologists are doing lidocaine IV during your lumbar fusions? Okay. So that's one of the more common ones. And again, there's data out there that shows that there's up to six hours of post-operative pain relief for just using during intraoperative surgery and better pain scores associated with it. Very important, the cardiac are essentially the contraindications that we have to pay attention to. And again, there is a dosing regimen and a maximum of eight hours for using this. And one of the cautionary things is do not use this if you're using the lysosomal bupivacaine during the surgical procedure just because of the additive effect of those medications. The next medication we use is dexmedetomidine. Dexmed is what's short for it. I think the trade name is Presidex. Some of you may be more familiar with Presidex. And this is a alpha-2 adrenergic receptor agonist. And this also reduces opioid consumption in patients. Interestingly, it affects the post-op shivering that you see in a lot of patients in the recovery room and reduces stress responses by decreasing post-op cortisol levels. And so we've had some good success in using basically a combination of these three medications together, these three drips. So it's very common in our room in a lumbar fusion for the dexmed, the lidocaine, and all of those three medications we talked about in the ketamine to all be working together during an operation. Obviously, the contraindications and the adverse effects you have to pay attention to, and hopefully the anesthesiologist is really engaged. And a lot of this is driven by anesthesia. I mean, we have to buy into it and we have to let the anesthesiologist know that this is important to us because in our institution, the anesthesiologists don't go and post-op patients. They don't go to check on the floor how they're doing. They don't really ever check on them. And so if you want them to do these things, you kind of have to push them on it, at least at our institution, because they don't see the benefits. So they do their surgeries, put the patient to sleep, wake them up, see them in the recovery room. And then as far as they're concerned, they're done. So again, there's a loading dose and then we also continue a maintenance dose during the operation. I think gabapentin, I'm probably gonna skip because I think that's a very common medication for neurosurgeons. We're all very familiar with it. We give a preoperative dose of six to 900 milligrams and then we continue it for five days afterwards. And we've found some, again, benefits with utilization of these medicines. Tylenol, acetaminophen. I never really thought much of acetaminophen, mainly because it doesn't work for me. You do things as patients sometimes. If I need something, ibuprofen's always more helpful for me than acetaminophen's ever been. But it does have some help in that it works through the serotonin pathway by activating the cannabinoid receptor. So there is some actual pathway to where acetaminophen can be helpful. So we are giving a preoperative dose of 1,000 milligrams and then scheduling post-operative as well. Celebrex is another medication that we have found helpful. And I know that there's many institutions across the country using Celebrex pre- and post-operatively. Obviously, they're the patients that you need to be careful with and the contraindications for those patients in the utilization of that medication. So let's get to the blocks. So we've had some really good results with some of the different blocks we've done. We started with TAP blocks, which is the transversus abdominus plane. And that's where a lot of the innervation forms between the different layers of the abdominal muscular walls. That's where a lot of the innervation is. So basically, the anesthesiologist is taking a ultrasound and guiding a needle down into that plane and then injecting the lysosomal bupivacaine into that plane after an ALIF. And it's fascinating to watch that video of the medication filling that plane. And you can see the muscle layers separate. But it's very important they get into the right plane. Some anesthesiologists are better than others. I mean, we've all looked at ultrasounds. And sometimes, they're very clear. And sometimes, they're not. And we had a couple when we went back and looked at our data where one of the anesthesiologists had gotten into the wrong tissue plane. He was in between the external and internal, not between the internal and the transversus abdominus plane. So getting that injection into the right plane is very important. And we've seen significant improvements with opioid consumption to the point where we started doing same-day ALIFs at L5-S1. So if you have a healthy patient, when we're doing an L5-S1 ALIF and we do the blocks, our patients frequently will go home the same day as the operation because they're not having to take a lot of medications. They're getting up. They're comfortable and moving around. And we've looked at that retrospectively for the past two years. And we've had no adverse events so far doing that. I'm not a big fan of sending patients home the same day as an ALIF. But there are other people at the institution where I work at who kind of like that. But I still think that what we're seeing with these blocks has been very interesting. So that was where we started. And then we moved over to a newer block called the quadratus lumborum block, which basically is a little bit better than the TAP block because in addition to providing the analgesic to the abdominal wall innervation, it also affects the visceral innervation as well. So they're getting relief from all that intra-abdominal pain that patients get. And we're finding, again, this is anecdotal at this point, but it seems that the pain control is better. And so this is a picture of the plane and where the block needs to go. And they have two different areas where they block. And you can see those layers that they have to use an ultrasound to get into. So you can see the external, the internal, and the transversus abdominis. And before we were just putting the medication right into this plane here. And now what they're finding is if you can block right here by the quadratus and posterior in these two sections, there's much more innervation in these areas that can be affected. And it's getting better results. And this is a picture of that ultrasound. And so I think this is why some people are better than this than others. You could convince me of any of these things in telling me any of these. You can see the tissue planes between the internal, external, and the transversus abdominis. But when they start to get over here, it gets a little bit harder for me to be clear about it. But they're getting better and better at it. And the results are getting better as a result. So the lysosomal bupivacaine, is it worth the cost? Because that's one of the hospitals we work at refuses to let us use it, because it's $325 for a vial. And the other hospital said, yeah, we'll try that. And here's what we're seeing. When we look at our data, we're only seeing a decreased length of stay by half a day, essentially. So financially, it makes sense for the hospital and the cost of doing it. But it is not the miracle answer that we were hoping it would be. And it shows that our anecdotal impressions sometimes are not accurate. We think things are better than they actually are. And then you start looking it down, and you're like, well, that's a little bit better. I was hoping for more. Some of the future, it blocks the erector spinae plane blocks. Our anesthesiologists are starting to look at this, because they think that that may, with the innervated pathways of the posterior musculature, may be more or equal to the quadratus block. So we're going to start looking at those and comparatively and see what we find. And then there's some future modalities that are being discussed in the anesthesia literature about using magnesium as an NMDA antagonist and for reducing the opioid use. So are we achieving our goals? The answer is yes. But again, it's not a massive home run that we were hoping for. We're seeing incremental improvements. And a lot of this is fine tuning things. Well, how much of this medicine, how much of that, how many medicines can you give a patient? Because this is a lot of stuff that you're throwing at these people, all in the name of reducing some of their opioids and the opioid-related adverse events. And we are seeing benefit. I think we need to continue to refine these protocols based on experience. It's hard when you're doing seven or eight different things, saying, well, which one of these is really working? And so I think we're going to have to be a little bit more scientific about how we judge these protocols instead of just throwing the kitchen sink at everybody. And I think that's one of the areas where we're falling a little short at our institution. But we do see that there are some benefits to what we're doing. I'm going to pass over these things quickly. So that's the pain side of what we're talking about. Now, what are the other ones? How many people are using transexamic acid, TXA, for decreased blood loss in big operations? OK. Yeah, so there's certainly literature which shows that using this anti-fibroanalytic can reduce blood loss during a surgery and reduce the need for transfusions. And it's a safe and effective means for doing so. Obviously, there are a few contraindications to using it. But our experience clearly marries what we're seeing in the literature about decreased transfusion rate and decreased total blood loss. So we're using this for our T10 to the pelvis kind of cases. I'm going to skip over infection prevention because I think that most people are very much in tune with the preoperative dosing, making sure blood glucose levels are well-controlled, and keeping patients normothermic, and then cleaning them off before they come to the operating room. So I think there's a lot of information about infection prevention. And we have some data on that. So how do you get all this done? I mean, sometimes we all work in hospital systems. How many people have challenges when you want to do something new at your hospital that it takes an act of Congress to get anything done? OK, yeah. So we were running into this. We had a lot of ideas and things we wanted to do and couldn't get anything done at our hospital. So what we decided to do was build our own hospital. And so a group of spine surgeons in Indianapolis got together and basically built our own hospital for our patients. And now we can do all these things when we sit in a room and decide we're going to do them. And it's been extremely positive from a patient care standpoint. Our patients love it. And it's nice for us because if we think something's being done wrong, we can fix it immediately. If we think there's an opportunity to do something better, we can do it immediately. And it's been very successful from our perspective. And the patients love it. So I think that's a way, something that physicians should be looking at. And there's some limitations, obviously. OK, any questions? Or do you want to go through the next subject? Yeah, Lou. The questions are most meaningful right after the talk. OK. Great talk. So you presented a tap block, I think, part of the introducing tap block at one point. And I took it back immediately after. And the anesthesia, it seemed like it added an hour to getting the patient out of the room. Oh, we do it on the, oh, you mean, right. So let's do a tap block. I've got a colleague in the room. And they work absolutely great. I mean, there's no question. Does it take an hour for your anesthesiologist to do it, too, at your institution? Because it got to the point where. It took about 15 to 20 minutes. But what we were doing, in addition to the tap block, was we were then flipping the patient. And with the residual lysosomal boot pivot cane, the pain anesthesiologist then came in and put it in their facet joints. Because we think a lot of these ALIFs, when you really lift up the disk space, you stretch those facet capsules. And so we actually have some data that shows that the patients that we did the facet blocks actually had far better pain control than just the people who just got the tap block. But how do you walk it into your work world? For example, unless you have two rooms, if you have one room, you've torpedoed yourself. You've got three cases going because it's. I think that, yeah. I think that it's a trade-off. And I think you've got to find an anesthesiologist who's engaged. I think you have to have somebody who wants to do all this, who's excited about this. And we've got one of these guys. And he is much, much more efficient. It takes him about 15, 20 minutes to do the block. And so what I may do is, our spine hospital and our surgery center are next to each other. So I may do the ALIF at the spine hospital and then schedule a case at the surgery center and just walk right across the street and go to the surgery center while they're doing all that. And there was an abstract that was presented at the spine section about toroidal. Any thoughts on that? I mean, we've all been brainwashed to say, if we use something like toroidal, the patient's going to exsanguinate or have a post-op hematoma. And or present three months later with a pseudoarthrosis and never fuse. But they presented some data. What are your thoughts? I mean, it's the same as a COX-2 inhibitor. Yeah, so there is actual data on the COX-2s. And if they're used for a week after surgery, they have no impact on fusion. So there's good literature on that. As far as the bleeding, it's never bothered me. Like, when I'm doing a minimally invasive microdiscectomy and everything's dry at the end and the anesthesiologist says, can I get toroidal? I'm like, you can get whatever you want. I don't really care. That's never been an issue that I've been concerned with. And then in some cases, I'm doing something that's small and dry. And in other cases, I have a drain in. So if it has any impact, I'm not too worried about it. So that's never really bothered me. I know we have been brainwashed. I agree with that. I don't have good information as to whether the toroidal has the bleeding effect that we've been led to believe. Charlie, your thoughts on that? Exactly where you are. I mean, I was afraid of toroidal because of fusion rate. But now it's dramatically reduced to perioperative narcotic media. Yeah. Yes. Is Indiana Certificate a need-to? No. Yeah, good question. Any other questions? Okay, thank you.

Enhanced Recovery After Surgery

ERAS protocols

patient care

pain control

data collection

infection prevention strategies