Neuromuscular Scoliosis Spinal Fusion Clinical Pathway — ICU, Inpatient, Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Related Pathways
- Perioperative Care, Anesthesia/Sedation, ED and Inpatient
- Spinal Fusion Rapid Recovery, Inpatient

Complications

ICU
Respiratory insufficiency
Blood loss/coagulopathy
Lactic acidosis
SIRS response
Neurogenic shock
Ileus
Inpatient
Increased respiratory requirements
Incisional drainage
Ileus
Persistent fever > 72 hours
Urinary retention
Seroma

Fever Management

Patient with Neuromuscular Scoliosis
Requiring Spinal Fusion

Orthopedic Preoperative Evaluation
Guidance for Determining Risk

Preoperative Evaluation by Anesthesia Resource Center

1 Day Before Surgery
Anesthesia Preoperative Preparation

Intraoperative Considerations

OR Team

Anesthesia Providers

Admit Postop

All Patients: Standard Postoperative Management
Pain Management
Tubes and Drains
Nutrition
Infectious Disease
Consultations

Moderate-Risk – Consider PICU Admission
High-Risk – PICU

Patient characteristics:
- Preop: Baseline trach/vent, CPAP/BiPAP, cardiac dysfunction
- Intraop: Spinal shock, blood loss > 1 blood volume, ongoing hypotension

ICU Goals
IV analgesia
CV stability
Pulmonary toilet
Advance mobility

PICU Transfer Out Criteria
Extubated
Adequate analgesia
Arterial line removed
Hemodynamically stable

ICU Management
Hemodynamic
Respiratory
Activity
Laboratory testing

Low-Risk – 4E/4S Surgical Unit or 8 South

Patient characteristics:
- Preop: Ambulatory, minimal pulmonary disease
- Intraop: Curve < 80 degrees

Inpatient Goals
Convert to PO/
enteral analgesia
Pulmonary toileting
Advance mobility

Inpatient Management
Hemodynamic
Respiratory
Activity
Laboratory testing

Transfer to Surgical/Specialty
Pulmonary/PCU/4E/4S as appropriate

Inpatient Goals
Convert to PO/
enteral analgesia
Pulmonary toileting
Advance mobility

Inpatient Management
Hemodynamic
Respiratory
Activity
Laboratory testing

Discharge Home After POD #5

Posted: May 2016
Last Revised: October 2024

Authors:
- K. Baldwin, MD;
- T. Muhly, MD;
- K. Devine, CRNP;
- D. Singh, MD;
- H. Wolfe, MD;
- P. Konen, CRNP

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

Inpatient and PICU Clinical Pathway for Management of Children with Neuromuscular Scoliosis Undergoing Spine Fusion

Evidence