Idiopathic Spine Protocol

Acute Pain Service: Idiopathic Spine Protocol (≥50kg) 

Updated 5/3/2021 

Preoperative Preparation: 

1. Neurontin Load: Preoperative Load of Neurontin 15mg/kg up to 1200mg (Rusy, 2010 May 1)  

1. Round Load Dosing down to most feasible dosing structure. 

1. If <50kg then 600mg   (two 3oomg pills) 

2. If  75kg>Weight≥50kg   then 800mg  (two 400mg Pills) 

3. If Weight ≥75kg then 1100mg (two 400mg pills and one 300mg) 

2. Liquid concentration is 250mg/5mL 

3. Pills arrive in 100mg/300mg forms 

4. Single Dose isn’t enough (Mayell A1, 2014 Dec). Continues Postop 

5. Side effects 

1. Nausea, Dizziness, Fatigue, Swelling of Extremities, Somnolence 

6. Exclusionary Group 

1. Chronic Renal Insufficiency  

2. Concomitant Psychotropic Medication 

3. Depressed Baseline Mental Status 

2. Midazolam Premedication:   Optional 

Intraoperative Procedure: 

Caveat: These protocols are for healthy routine patients undergoing idiopathic scoliosis surgery. Patients come in many flavors and a protocol cannot account for every variable. Use clinical judgement and use this as a guide to care for your Scoliosis patients.  

1. Setup in addition to standard 

1. 4 syringe pumps 

2. 1 hot line 

3. 1 arterial line transducer 

4. 3, 2-1 y connecters 

5. 4 syringe pump tubing 

6. Airway equipment for ET Intubation 

7. Ophthalmic Lubricant 

8. 2 bite blocks (one across either jaw line to prevent dental damage from EP’s) 

9. I-stat with 4-6 CG8 Cartridges 

10. Appropriate Prone View or Prone Pillow 

11. Cell Salvage Availability 

12. Neuro-monitoring Availability 

13. Standard Pharmacy Order: Norepinephrine 3.2mcg/ml, Remifentanil 100mcg/mL, Tranexamic Acid 10mg/mL, Methadone 10mg/1mL prepared syringe, Relistor Injectable 12mg/0.6mL Vial  

2. Monitors 

1. Standard ASA Monitors 

2. Arterial Transducer Bag 

3. Motor Evoked Potentials (MEP)  

4. Somatosensory Evoked Potentials (SSEP) 

3. Laboratory  

1. iStat CG8 to be followed every hour until closure has begun 

1. Trend Hg and Base Deficit 

2. Type and Cross (4 units pRBC Cooler). Draw second confirmation tube within 5 minutes of first  

3. For EBL>1 Blood Volume check coagulation labs and consider ordering 2 units FFP thawed 

4. Lines 

1. Arterial Access for MAP Monitoring in conjunction with neuro-monitoring 

2. Peripheral Access: 1 large bore and secondary peripheral for infusions 

3. Central Access/PICC Line:  

1. Consider if patient going to ICU on Vasopressors 

2. Consider if patient has prior cardiac anomalies 

3. Consider if unable to obtain sufficient large bore IV Access 

4. Consider if the patient is consented for studies involving prolonged venous sampling 

5. Anesthetic 

1. General Anesthetic with TIVA when neuro-monitoring present 

1. Volatile agent approved for induction. 

1. Transition to TIVA ASAP 

2. Neuromuscular blockers to facilitate intubation 

1. Avoid if possible 

2. Recommend short acting or reversible agents when able (Sux/Roc) 

3. Should baseline signals be an issue consider reversal (neo/glycol or Sugammadex)  

3. Relistor SC Injection (Methyl-Naltrexone) 

1. Dosing: 

1. 0.15mg/kg <40kg 

2. 8mg SC 40-60kg 

3. 12mg SC 60-110kg 

2. Recommended Sites:  

1. Either Upper Arm 

2. Abdomen 

3. Either Anterior Thigh 

4. TIVA Protocol (Bold Drugs Are First Line. Residents and CRNAS will set up these drugs unless discussed with attending prior) 

1. Narcotic Options 

1. Remifentanil 0-0.2mcg/kg/min 

1. 100mcg/mL concentration  

2. 10 minute half life 

2. Sufentanil 0-0.3mcg/kg/hr  

1. 2.7hr Half-life with context sensitive half-life that is shorter. Recommend terminating once surgeons irrigating 

2. Discourage use with duramorph 

2. Sedative Hypnotics and Non-Narcotic Analgesics 

1. Propofol 0-250mcg/kg/min 

1. Dose decreases significantly within 40 minutes of Neurontin administration. Often can go as low as 75-100mcg/kg/min 

2. Ketamine 0-6mcg/kg/hr 

1. Increases Signal Amplitude 

2. Higher doses likely to delay extubation 

3.  Precedex 

1. 1mcg/kg load 

2. 0.5mcg/kg/hr gtt 

3. Controversial. Has potential to decrease MEP amplitude (Tobias 2008 Pediatric Anesthesia). Others have stated otherwise (Bithalk PK Journal of Neuroanesthesiology and Critical Care 2014)  

3. Vasopressors (Mandatory 1 on pump connected at start of case set to 9:00hr standby)  

1. Dopamine 5-20mcg/kg/min 

1. 3.2mcg/mL concentration 

2. Norepinephrine 0.05-2mcg/kg/min  

1. *No true upper bound  

3. Epinephrine 0.02-0.1 mcg/kg/min 

1. *No true upper bound 

4. Vasopressin 0.2-8mUnit/kg/minute 

1. *Used for refractory shock in conjunction with other vasopressors.  

4. Antifibrinolytic 

1. Tranexamic Acid 

1. 10mg/kg Bolus 

2. 10 mg/kg/hr gtt (ignore pump low warning) 

3. **Not to exceed 100kg ideal bodyweight  

2. Amicar 

1. 100mg/kg load  

2. 30mg/kg/hr  

3. **Not to exceed a 5 gram load (50kg) or 1.5gram/hr  (50kg)  

5. Adjunctive Medications 

1. Dexamethasone 0.5mg/kg to max 10mg IV (start of case 

1. Analgesic/Stridor/PONV 

2. Ondansetron  0.1mg/kg to max 4mg IV at end of case 

1. Anti-Emetic End of Case 

6. Fluids 

1. Fluids consist of Plasmalyte on Hot Line connected to largest bore IV 

2. Lactated Ringers on roller pump with infusions connected as close to the patient as possible.  

3. Albumin available for hypotension refractory to 20ml/kg bolus with corrected hemoglobin 

7. Blood Products 

1. Transfuse to Hg>7.0 

1.  higher when clinically indicated by refractory hypotension  

2. Hg>10 when signals compromised 

2. FFP 

1. INR>1.8 

2. Rapid Significant Blood Loss (Greater than 1 Blood Volume Expected) with no time for Coag evaluation 

3. Cryo/Factor/Concentrate 

1. As clinically indicated 

6. Intraoperative Methadone 

1. 100mcg/kg (to max 10mg) IV Push administered with initation of closure 

2. May titrated up to 200mcg/kg total after patient extubated and has exam (if uncomfortable) 

3. Call Pharmacy to stock in Pyxis at beginning of day 

4. Contraindications:  

1. Prolongued QT 

2. Renal Failure (Only for multiple doses)  

3. Hypersensitivity/Allergy 

7. Intrathecal Duramorph (Variant if methadone not an option) 

1. Dose administered by surgeon in the field (or preop by spinal if surgeon amenable)  

2. Dose at OU traditionally 7mcg/kg up to 500mcg of Duramorph due to in house analysis of non-idiopathic and idiopathic spines 

3. Higher doses utilized to 19mcg/kg (J. P. Rathmell, 2005) (Tripi PA, 2008 Sep ) 

4. Higher doses utilized in CHOP Study 500mcg regardless of idiopath with dosing range of 3-16mcg/kg (Stricker P, July 2012) 

5. Protocol Dose: To assist with onset dose of 10mcg of Sufentanil and 500mcg of Duramorph for all patients meeting protocol (idiopath>50kg) filled to 2mL volume with NSS. Pharmacy will prepare when asked (in advance) 

1. Pharmacy Prepared and Standard Dose to Reduce Dosing Errors 

2. Sufentanil assists with near immediate onset allowing for transition to Duramorph at 45min 

3. Even at extremes dose max is 10mcg/kg 

4. Pharmacy will make up (ask them to fill to 2cc with Saline) 

5. Duramorph alone 6-12hr delayed respiratory depression 

6. Lower intraoperative systemic requirements 

7. Peaks postoperatively  when strictly duramorph (45-75min onset) (Rathmell., 2005) 

8. Time for this onset is not in PACU or PICU or worse FLOOR 

9. No effect on signals (Stricker P, July 2012) 

6. When Morphine Allergy Present 

1. Preservative Free Hydromorphone at 2mcg/kg to max of 100mcg may be substituted for Preservative Free Morphine. 

8. Critical Components of Spine 

1. Induction – Ensure attending anesthesiologist present 

2. Initial Signals – Ensure attending aware, but presence not required 

3. Positioning-- (Kwee M, 2015) 

1. Bite blocks in place along either jawline. 

2. Eyes free from pressure 

3. Neck in neutral with occiput and T4 prominence at same level 

1. Exception thoracic scoliosis or severe lor/kyphosis 

4. Brachial plexus supported (upper arms not hanging) 

5. Abduction of arms <90 degrees.  

6. Bony prominences padded.  

7. Ensure Pannus (Belly) is free and without pressure 

8. Patients with larger breasts should have medial placement. 

1. Lateral associated with significantly more pain 

4. Insertion of first Rod –Ensure attending anesthesiologist is present. Timeout before placement to ensure optimization.  

1. Greatest likelihood of ischemic stress 

2. Optimize blood pressure prior to insertion 

5. Duramorph insertion –Ensure dose double checked by attending and only required dose handed off to surgeon 

1. 10 fold drug errors have occurred in the past 

6. Emergence –Ensure attending anesthesiologist present.   

9. Unable to Obtain Initial Signals 

1. Ensure attending anesthesiologist aware.  

2. First Evaluate management  

1. Residual NMB 

2. Residual Volatile 

3. HD Optimize to MAP >75 

4. Consider Patient Position as Cause 

3. If patient has no function and no signals may jointly decide with surgeon to proceed. Remember if no neuromonitoring TIVA is no longer required.  

4. If patient had previous function and no signals discuss aborting procedure whereas risks may be > benefits. 

10. Loss of Intraoperative Signals 

1. Announce change to surgeon and OR Staff.  

2. Call for second set of hands and ensure attending alerted/present 

1. Ask electrophysiologist when change occurred 

2. Ask at what level change occurred 

3. Ask electrophysiologist what change was (Latency, Amplitude, Complete Loss SSEP, Motor, or Both) 

1. Helps determine whether lead malfunction, nerve root impingement, or cord ischemia.  

2. Document change 

3. Determine if management changes (Drug) or hemodynamic changes occurred around time course. 

4. While surgeons address their contribution to signal loss 

1. Increase Spinal cord perfusion to a MAP of 75mmHG 

1. Triple Therapeutic Action Point 

1. Open Fluids and consider Colloid 

1. Stop when therapeutic endpoint has been reached 

2. Start in line pressor at starting dose for continuous map elevation. Titrate every 10 minutes to therapeutic endpoint (Set a timer. You are likely stressed and a poor judge of time) 

3. Bolus Pressor to temporize until infusion catches up 

1. Dose 10mg/kg Calcium Chloride  

1. if iCal < 1.3  

2. (once)  

2. Dose 0.5mcg/kg Phenylephrine  

1. if HR>75 

2. Repeat 3-5 minutes to desired effect (use timer)   

3. Escalate dose as needed 

3. If unable to use phenylephrine or Calcium bolus Epinephrine 0.5mcg/kg. 

1. Repeat 3-5 minutes to desired effect. Titrate dose up as needed.  

2. Optimize Hemoglobin  

1. Goal is Hg>10 with ischemic concerns 

3. Administer FiO2 of 1.0  

1. To ensure highest oxygen content delivery 

4. Once Hemodynamically and Anesthetically optimized discuss next course of action with surgeon 

1. Hardware alteration/removal 

2. Wakeup Test 

3. Aborting Procedure 

4. Steroids  

1. Methylprednisolone 30mg/kg IV  

2. Limited data to support 

5. Arrange for Postop Imaging if necessary  

6. Alert PICU if MAP Management expected. Discuss central line if pressors required for prolonged period.  

5. Document exam when procedure concluded and patient wakes 

11. Handoff 

1. Patients traveling to ICU Call ICU attending prior to leaving room 

1. Patients are to go directly to PICU if they have full PICU status. 

2. Patients receiving Step Down Status  

1. Inform Surgeon of any expected needs 

2. Call Pediatric Pain Service to Sign Patient Out 

3. Call PICU attending to inform them of patient. Patient may to go PACU 

Post Procedure In-Patient Protocol (PAIN SERVICE) 

1. Hydromorphone PCA Demand Only (4mcg/kg demand up to 200mcg for initial setting) 

1. Reasoning of opioid type is mainly for consistency 

2. Will compare settings when database is up and running 

3. Should no Methadone or Duramorph be utilized initial basal of 4mcg/kg/hr to max 0.2mg/hr 

4. PCA should remain at minimum through POD 1 

2. Ketamine gtt  

1. On CADD Pump 

2. 2mcg/kg/min starting dose 

3. To be initiated in PACU  

3. NSAID ATC  

1. Starting Day 1 unless otherwise specified by surgeon 

2. Ketorolac 0.5mg/kg q6hrs up to max 30mg 

3. Acts as basal analgesic (When started eliminate any potential basal from PCA) 

4. Convert to Motrin ATC after tolerating PO or Naproxyn 500mg BID  

4. Clonidine TTS  Patch continues (25% efficacy 12hrs,  50% efficacy 24, 100% 48hrs) (Wolf, 2000) 

1. Placed in PACU 

2. Drug elimination half-life 20hrs 

3. Weight based dosing 

1. Patients >50 kg (Barash, 2009) 

1. TTS2 Clonidine Patch applied to shoulder 

2. Patients 40-50kg 

1. TTS1 Clonidine Patch applied to shoulder 

4. Side effect Profile: 

1. Dizziness, Orthostatic hypotension, somnolence, fatigue 

5. Exclusionary Group 

1. Chronic Renal Insufficiency 

2. Concomitant Psychotropic Medication 

3. Depressed Baseline Mental Status 

6. Continues until patch wears off on Day 7 unless CI 

1. Hypotension Remove for undesirable maps 

2. Remove as a part of over-sedation algorithm 

5. Neurontin 300mg TID times 7 days (Gurjeet Khurana, 2014) 

1. <50kg Neurontin 100mg TID 

2. ≥50kg  Neurontin 200mg TID 

3. ≥75kg  Neurontin 300mg TID 

6. Zofran  

1. Nausea 0.15mg/kg q4hrs PRN  

7. Naloxone (Itching Protocol) 

1. Naloxone 1mcg/kg/hr titratable up to 2mcg/kg/hr   (Maxwell, 2005) (Yaster, 2011 Oct) 

2. To be started in PACU prior to reaching floor 

3. Current practice of nubain not supported by pediatric literature. 

1. Doses of Nubain 50mcg/kg ineffective in children 

4. Current practice of diphenhydramine not supported in literature 

8. Naloxone (Respiratory Depression Protocol) 

1. PRN for Respiratory Depression 

2. 0.1mg/kg  (max 2mg) IV q15 minutes PRN Respiratory Depression 

3. Alert House Officer immediately if utilizing 

9. Ofirmev (IV Acetaminophen) 

1. 15mg/kg up to 50kg. q6hr ATC  

2. Beyond 50kg patient receives 1g q6hr 

3. Duration 24-48hrs while NPO 

4. Restrictions: Mild/Severe Hepatic Insufficiency (baseline INR>1.5) 

10. Antispasmodic 

1. Diazepam (Valium) 

1. Dose of  0.1mg/kg Max of 5mg q8hr PRN spasm to start 

2. Currently no oral formulation. May use Ativan 0.02mg/kg IV PRN q4hr   

2. Methocarbamol (Robaxin) 

1. 250-1000mg IV q8hr PRN 

2. 250-1000mg PO q6hr PRN (Roughly 10mg/kg in 250mg increments) 

3. Cyclobenzaprine (Flexiril)  

1. 5mg PO q8hr PRN Spasm 

11. Bowel Regiment  

1. Colace or Senna to combat opioid related constipation 

12. 24hrs of Duramorph Awareness (if Utilized)  

1. Sign over the bed indicating Duramorph on board 

2. Blue sticker on chart indicating Duramorph on board 

3. Blue arm board indicating Duramorph on board 

13. Head of Bed to 100 degrees on Pod #0 

1. Consensus based on frequent orthostasis with first ambulation  

Bibliography 

Barash. (2009). Clinical Anesthesia. Philadelphia: LWW. 

Gurjeet Khurana, M. ,. (2014). Postoperative Pain and Long-Term Functional. Spine, Volume 39 , Number 6 , pp E363 - E368. 

J. P. Rathmell, T. R. (2005). “The role of intrathecal drugs in the treatment of acute pain,” . Anesthesia and Analgesia, , vol. 101, no. 5, supplement, pp. S30–S43. 

Maxwell. (2005). The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study. Anesth Analg, Apr;100(4):953-8. 

Mayell A1, S. I. (2014 Dec). Analgesic effects of gabapentin after scoliosis surgery in children: a randomized controlled trial. Paediatric Anesthesia, 24(12):1239-44. doi:. 

Rathmell. (2005). The Role of Intrathecal Drugs in the Treatment of. Anesth Analg , 101:S30–S43). 

Rusy, L. (2010 May 1). Gabapentin Use in Pediatric Spinal Fusion Patients: A Randomized, Double-Blind, Controlled Trial. Anesthesia and Analgesia, 110(5):1393-8. 

Stricker P, e. a. (July 2012). Effects of Intrathecal Morphine on Transcranial. Anesth Analg, 160-9. 

Tripi PA, P.-K. C.-H. (2008 Sep ). Intrathecal morphine for postoperative analgesia in patients with idiopathic scoliosis undergoing posterior spinal fusion. Spine, 15;33(20):2248-51. 

Wolf, A. C. (2000). Intravenous clonidine infusion in critically ill children: dose-dependent sedative. British Journal of Anesthesia, 84(6):794-6. 

Yaster. (2011 Oct). The optimal dose of prophylactic intravenous naloxone in ameliorating opioid-induced side effects in children receiving intravenous patient-controlled analgesia morphine for moderate to severe pain: a dose finding study. Anesth Analg. , 113(4):834-42.