Protocol Driven Early Extubation in Patients with Flaccid Neuromuscular Scoliosis and Preexisting Lung Disease: A Case Series. (16th November 2020) - Hatef, Jeffrey
Abstract: INTRODUCTION: Diseases of lower motor neurons and skeletal muscle cause scoliosis and restrictive lung disease. Surgical correction often requires long fusions and pelvic instrumentation. Traditionally, patients remain intubated for gradual ventilator liberation. We developed a protocol for postoperative management: patients are transported to the ICU intubated and placed immediately on bilevel positive airway pressure (BiPAP) support. We present the 10-year results of our protocol. METHODS: With IRB approval, we conducted a retrospective review of 15 consecutive patients with flaccid scoliosis and preexisting lung disease. Charts were reviewed for demographic data, pulmonary function, intra- and postoperative course, and long-term outcomes of surgery. RESULTS: Fifteen patients underwent 18 operations on our protocol. The average age and weight were 11.7 (1.5-19) years and 41.2 (7.4-94) kg. Average forced vital capacity and forced expiratory volume were 46% and 50% of expected. Ten patients required nocturnal BiPAP. The most common operation were long-segment fusion to sacrum (10), and growing rod implant (6). Three surgeries were revisions. Estimated blood loss was 578 mL. All patients were extubated to BiPAP according to protocol. Average ICU stay was 1.7 days; average hospital stay was 6.9 days. No differences were seen in revision cases. There was one complication: pulmonary edema requiring two days of ICU treatment. There were no re-intubations. Cobb angle decreased from 71 degrees to 34 degrees at last follow up. CONCLUSION: Correction of neuromuscular scoliosis requires large operations in medically frail patients. Our series shows that despite poor preoperative respiratory function, early extubation with postoperative support with BiPAP is safe. Further studies are needed to determine the potential improvement in clinical and economic outcomes.