175. Opioid sparing anesthesia for adult spinal deformity surgery reduces postoperative pain, length of stay, ICU stay, opioid consumption and opioid-related complications: a propensity matched analysis

Abstract

<h3>BACKGROUND CONTEXT</h3> The US opioid crisis highlights the dire need to reduce opioid exposure with alternative approaches. Prior studies report that 25% of opioid naive patients are still on opioids two years after spinal fusion surgery. Currently, opioids are a primary component of anesthesia during spinal surgery. We developed an opioid sparing anesthesia (OSA) protocol for adult spinal deformity (ASD) surgery to mitigate opioid exposure. <h3>PURPOSE</h3> The purpose of this study is to compare recovery kinematics and in-hospital opioid consumption of patients undergoing corrective surgery for ASD using OSA compared to traditional anesthesia techniques (Non-OSA). <h3>STUDY DESIGN/SETTING</h3> Retrospective, single-center propensity-matched observational cohort. <h3>PATIENT SAMPLE</h3> Opioid naive patients undergoing > 5 level lumbar fusion at a single multisurgeon tertiary level spine center. <h3>OUTCOME MEASURES</h3> Intraoperative and in-hospital opioid consumption, opioid related complications, emergence time, post-anesthesia care unit (PACU) time, pain score (0 to 10) on transfer in and transfer out of PACU, hospital length of stay (LOS), ICU admission. <h3>METHODS</h3> Opioid naive patients undergoing > 5 level lumbar fusion for were identified. Patients receiving OSA were propensity-matched to non-OSA patients based on sex, smoking status, BMI, ASA grade, surgical invasiveness, number of levels fused, and revision vs primary procedure. OSA has several components from preoperative, intraoperative and emergence. Preoperatively patients received an oral regimen of cyclobenzaprine (10 mg), gabapentin (300-600mg), acetaminophen (650mg-1gm), optional midazolam and antiemetic. Intraoperative induction with bolus doses of lidocaine, diprivan, rocuronium, succinylcholine, ketamine, magnesium, dexmedetomidine and esmolol as needed. Regional block for anterior spine fusion (transversus abdominis) when performed. Maintenance intraoperatively included inhalational and or infusion or boluses of diprivan, dexmedetomidine and esmolol. Emergence entailed reversal of muscle relaxant and antiemetics. The control arm (Non-OSA) included preoperative optional midazolam and antiemetic only. Intraoperatively induction was with bolus doses of lidocaine and fentanyl. Maintenance intraoperatively included inhalational, infusion or bolus doses of diprivan, fentanyl or hydromorphone. Emergence included reversal of muscle relaxant, antiemetics, fentanyl and/or hydromorphone. All patients (OSA and Non-OSA) had a postoperative opioid escalation protocol while in the hospital. <h3>RESULTS</h3> Of 45 OSA patients meeting inclusion criteria, 43 were successfully propensity-matched to 43 non-OSA patients. There were no differences in baseline demographic or surgical parameters. Opioid consumption was reduced intraoperatively (3.6 vs 53.2MME, p=0.000), on POD 1 (67.4 vs 111.6MME, p=0.030), and each POD with decreased total consumption (241.3 vs 453.9MME, p=0.022) in OSA patients compared to NonOSA patients. OSA patients had reduced opioid-related complications (1 vs 9, p=0.015) and less patients required blood transfusion (1 vs 28, p=0.000) despite similar EBL (570 vs 692cc, p=0.294). Emergence time (17.4 vs 14.3min, p=0.374) and PACU time (113.8 vs 142.6min, p=0.077) was similar between cohorts. There was a shorter LOS for OSA patients (4.3 vs 6.2 days, p=0.009) and less ICU admissions (4 vs 14, p=0.015). Pain score on transfer in (4.6 vs 7.6, p=0.000) and out (4.2 vs 6.2, p=0.002) of PACU was lower for OSA patients as well. <h3>CONCLUSIONS</h3> Our results show that OSA in ASD surgery improves immediate postoperative recovery kinetics by reducing the need for ICU, blood transfusion, pain scores, and LOS. Opioid-related complications and total opioid consumption were reduced as well. OSA appears to be an attractive alternative to opioid-dependent anesthesia protocols in ASD surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.