Keeping That Hospital Time Under 24-Hours for Lumbar Spinal FusionEvents that occur before, during, and after surgery can cause problems for patients. These factors are referred to as preoperative, intraoperative, and postoperative variables. Identifying such risk factors can help reduce the number of days patients are hospitalized with complications. And that translates into less pain and suffering and lower costs.
In this study, predictive factors are investigated for patients having a single-level spinal fusion of the lumbar spine. Just over 100 patients had a minimally invasive procedure using the transforaminal lumbar interbody fusion (TLIF) approach. One surgeon performed all of the fusions.
By looking back at the patients' medical records, the surgeon and his team could see the patients naturally fell into two groups: those patients who were hospitalized for less than 24 hours (group one) and those who were in the hospital for more than a day (group two). But what made the difference between these two groups? That was the important question.
There are many, many possible reasons why someone might develop problems and need longer hospitalization. Age, sex (male or female), body size, use of narcotic medications to control pain, and general health are preoperative factors to consider. Type of anesthesia used, number of minutes under anesthesia, blood loss, blood pressure, and administration of fluids (e.g., crystalloids, colloids) are intraoperative factors. And pain, blood values (e.g., hemoglobin, hematocrit, creatinine), use of narcotics, and formation of problems such as blood clots, kidney failure, heart attacks, or breathing problems were the types of postoperative factors examined.
After analyzing all the data on each patient in both groups, there were a few helpful findings. Patients requiring more than 24 hours to recover had longer surgical times and higher use of narcotic pain killers before surgery. The longer operative time is important because the patient's body temperature drops as a result of the anesthesia. Decreased body temperature has been linked with heart attacks, death, infection, and problems stabilizing blood.
This factor (longer operative time) is important for the surgeon to keep in mind. And also for the surgeon, another significant predictive factor of a longer hospital stay was the use of crystalloids and colloids and the ratio between them. These fluids are used to help keep the patient hydrated and replace fluids lost due to bleeding.
The longer the operative time, the more fluids are "pushed" so-to-speak. This finding suggests that a more "restrictive" use of fluids may be better than a "liberal" amount. And other studies have shown better postoperative results with fewer lung problems when lower amounts of fluids are given during the surgery.
Another finding from this study was labeled as "surprising" by the surgeon. Patients who used more (not less) narcotic medications before surgery had faster postoperative recovery and thus shorter hospital stays. This led to the thought that perhaps preoperative pain control is protective -- keeping the nervous system from setting up a pain response to the surgery. If that is the case, surgeons can administer oral narcotics as more of a pre-emptive strike to lower the overall pain experience before and after surgery. The end result is a happier, healthier patient. A small financial investment before surgery (i.e., the cost of the drug) can mean a large (thousands of dollars) post-operative savings.
In summary, the surgical team can take some steps to improve results for patients undergoing a transforaminal interbody fusion of the lumbar spine. Narcotic use before surgery for better pain control, fluid balance during and after surgery, and careful attention to blood values after surgery (e.g., hemoglobin, creatinine) can help keep the hospital stay under 24 hours.
Krzysztof Siemionow, MD, et al. Predictive Factors of Hospital Stay in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion and Instrumentation. In Spine. November 15, 2012. Vol. 37. No. 24. Pp. 2046-2054.
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