Inpatient Clinical Pathway for Adolescent Idiopathic Scoliosis (AIS) Spinal Fusion Rapid Recovery — Inpatient

Day 0: Surgical Day Post Anesthesia Care Unit (PACU)

PACU Management	Hydromorphone PCA ordered by acute pain service (APS) and set up in the PACU Anesthesia team order rescue doses of morphine/hydromorphone for administration in the PACU using Epic orderset For ongoing pain, consider Diazepam 0.05 mg/kg IV up to 2.5 mg for muscle spasm Management of continuing nausea or vomiting using the PONV orderset

Surgical Day 4E/4S

Goals

PCA Initiation
Analgesia regimen
Early mobilization: log rolling and sit at edge of bed

Pain Management	Post-Operative – to be managed by pain team Consult Pain Management for specific dosing management and all pain-related questions/concerns, initiate Hydromorphone PCA Hydromorphone rescue IV q3hr PRN for severe pain Nalbuphine IV q4hr PRN for itching Acetaminophen IV q6hr x 3 doses Diazepam PO q6hr PRN for muscle spasticity Ondansetron IV q8hr PRN for nausea/vomiting
Activity/PT	Log roll q2hrs and PRN until rolling independently Sit on edge of bed
Nutrition	Clear liquid diet IVF at maintenance overnight until tolerating clears
Tubes/Drains	Record JP drain output q8 hrs Maintain Foley catheter and monitor UOP
Respiratory	Incentive Spirometry q2hrs while awake Turn/cough/deep breathe
Medication Ordered by Orthopedic Team	Post-operative antibiotic prophylaxis as prescribed Start Famotidine IV x3 doses Begin bowel regimen at night: Senna 17.2 mg nightly Bisacodyl suppository 10 mg — Daily PRN 1st line constipation PONV prophylaxis: Dexamethasone 0.1 mg/kg up to 4mg IV over 15 mins 8 hrs after intraoperative dose Severe PONV rescue plan unresponsive to dexamethasone/ondansetron: Consider fluid bolus: 10 ml/kg lactated ringers Additional dexamethasone: 0.1 mg/kg up to 4 mg IV over 15 mins (can give up to 2 doses post-op, 8 hrs apart)
Discharge Planning	Surgical recovery teaching with family Promote early movement and oral pain control

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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.