NM-288
Pulmonary function testing is an unreliable tool for risk assessment of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion
Rao K, Wieser J, Evans M, Toaz E, Burjek N
Lurie Children's Hospital, Chicago, IL, USA
Avoiding unnecessary preoperative testing is a high-priority area for reducing the waste of medical resources. (1) Adolescent idiopathic scoliosis (AIS) is the surgical condition with the greatest cumulative annual cost in pediatric inpatient care, making it a target for quality improvement. (2) Pulmonary function tests (PFTs) are often recommended for risk stratification of pediatric patients undergoing posterior spinal fusion (PSF). (3) This practice has been called into question due to frequently inconclusive results and unclear impact of PFTs on perioperative clinical management. (4) We hypothesize that a large percentage of patients undergoing PSF for AIS are unable to produce meaningful results on PFTs, and that among patients who are able to complete the test, results do not predict perioperative risk.
We performed a retrospective observational chart review of all patients undergoing PSF for AIS from June 2012 through August 2017 at a single tertiary care pediatric center where preoperative PFTs are routinely ordered. The primary outcome was incidence of satisfactory completion of PFTs. The secondary outcomes were diagnosis of severe restrictive lung disease and postoperative pulmonary complications requiring intensive care unit (ICU) admission.
The charts of 356 patients were reviewed. PFTs were attempted in 294 cases. Among these, 219 patients (74%) successfully completed the test, while 75 (26%) had incomplete or non-reproducible results. Fourteen patients in the cohort (4%) were admitted to the ICU postoperatively. Only one patient remained intubated postoperatively, and this was due to hemodynamic instability from a large iatrogenic pneumothorax. The other thirteen patients were admitted for hemodynamic instability or neurologic monitoring; none had pulmonary complications. Of the 219 patients who completed PFTs with acceptable and reproducible results, 25 (11%) had high risk results (FVC < 40% predicted or maximum inspiratory pressure < 30 cmH2O). Two of these patients required postoperative ICU care, both for hypotension. The cost of PFTs is $1471 per patient.
Patients with AIS frequently produce uninterpretable or non-reproducible PFT results. Pulmonary complications among patients with AIS undergoing PSF are rare, even among patients with high risk preoperative PFTs. Elimination of preoperative pulmonary function testing would result in a significant decrease in health care resource utilization.
PFTs do not reliably predict perioperative risk in otherwise healthy patients undergoing posterior spinal fusion, and should not be routinely performed for risk stratification of these patients.
References:
(1) Onuoha O, Arkoosh V, Fleisher L. Choosing wisely in anesthesiology: the gap between evidence and practice. JAMA Intern Med. 2014; 174(8):1391-1395.
(2) Keren R, Luan X, Localio R, et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med. 2012;166(12):1155-1164.
(3) Tsiligiannis T, Grivas T. Pulmonary function in children with idiopathic scoliosis. Scoliosis. 2012; 7:7.
(4) Sullivan D, Primhak R, Bevan C, et al. Complications in pediatric scoliosis surgery. Pediatric Anesthesia. 2014; 24: 406-411.
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