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Reduction of Airway Complications With Fluid Management Protocol in Patients Undergoing Cervical Decompression and Fusion Across the Cervicothoracic Junction

Hart, Robert A. MD*; Dupaix, John P. MD; Rusa, Renata MD*; Kane, Marie S. MS*; Volpi, Joseph D. BS1*

doi: 10.1097/BRS.0b013e31829914ed
Cervical Spine

Study Design. Retrospective comparative cohort analysis.

Objective. To evaluate the effect of an intraoperative and intensive care unit protocol on incidence of airway complications for patients undergoing combined anterior-posterior cervical decompression and fusion crossing the cervicothoracic junction (CTAPF).

Summary of Background Data. Airway compromise remains an important potential complication for patients undergoing CTAPF. Volume of intravenous fluid replacement perioperatively has been correlated with risk of airway complications in this patient population.

Methods. A retrospective cohort study was performed comparing airway complications (postoperative airway edema requiring reintubation and/or prolonged need for intubation) in patients undergoing CTAPF prior to and after introduction of a standardized protocol. The protocol required limitation of crystalloid fluid resuscitation intraoperatively, with maintenance of blood pressure using vasopressors. Comparisons between the 2 cohorts included operative time, intraoperative blood loss, volume of IV fluid replacement, and incidence of airway complications and dysphagia.

Results. Among patients operated prior to establishment of the protocol, 45% (9/20) experienced airway edema requiring extended intubation or reintubation. This rate was reduced to zero among 8 patients operated after the adoption of the protocol (P = 0.029). Intraoperative IV fluid volumes were reduced from 6190 mL to 4802 mL after institution of the protocol (P = 0.016). EBL and total surgical time did not differ between the 2 cohorts (1024 mL vs. 869 mL, P = 0.443; and 6.76 hr vs. 7.18 hr, P = 0.460). Incidence of dysphagia was not significantly different between the 2 cohorts.

Conclusion. Establishment of a fluid and airway management protocol for patients undergoing CTAPF reduced the incidence of prolonged intubation or reintubation. Given the potentially life-threatening impact of loss of airway patency, intraoperative restriction of IV fluid while maintaining adequate blood pressure may be helpful in increasing the safety of surgical intervention in this complex patient population.

Level of Evidence: 4

After adoption of a protocol limiting crystalloid fluid delivery and using vasopressors to maintain intraoperative blood pressure, airway complications were decreased in patients undergoing combined anterior-posterior cervical decompression and fusion crossing the cervicothoracic junction. The proposed protocol may reduce risk of catastrophic loss of airway patency in these patients.

*Oregon Health and Science University, Sam Jackson Hall, Portland, OR; and

Department of Orthopaedic Surgery, University of Hawaii, Honolulu, Hawaii.

Address correspondence and reprint requests to Robert A. Hart, MD, Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Sam Jackson Hall, Ste 2360, 3181 SW Sam Jackson Park Road, Portland, OR 97239; E-mail:

Acknowledgment date: October 1, 2012. First revision date: March 5, 2013. Second revision date: April 13, 2013. Acceptance date: April 20, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants pending, payment for lectures, royalties and stock/stock options.

© 2013 by Lippincott Williams & Wilkins