Pre-op or intraop steroids during spinal surgery

Tenesma · May 27, 2003

stevierae - i will start with your last comment about not having guidelines... the whole point of a higher graduate educations is for you to use your education/available research, etc... to make clinical decisions - there won't be guidelines and protocols for everything

regarding spinal cord edema - spine surgery hopefully avoids damaging the cord and therefore there shouldn't be any edema from the surgery itself... if the spine surgery is performed because of cord edema in the first place (cord compression issues) then the surgery itself removes the compressing factor on the spinal cord, and hence you don't need steroids for the cord...

in fact most neurosurgeons don't recommend steroids anymore as it turns out the outcomes are worse with steroids than without unless the steroids are given within 4 to 6 hours of the initial event (trauma to spine)...

by the way i don't administer drugs just because the surgeon wants it - if i think their drug request is inappropriate then i usually ask them if they have research to back up their request - if not, i don't give the drug

my 2 cents

stevierae · May 28, 2003

Oh, I agree, absolutely. I trained as a corpsman during the Vietnam era and have always made my own clinical decisions based on experience and gut instinct, most of which I developed then--not in nursing school later. I have to say it drives me crazy when I work in an OR where even experienced RNs cannot make the simplest clinical decisions without running for the Policies and Procedures Manual, not recognizing that every case is different; that not all patient care can or should be delivered "by the book--"

I am more concerned about the times JCAHO comes around, asking for written drug administration protocols, or if a legal case was to come up, i.e. involving intraop quadraplegia during a risky spinal case in which there is a high chance of paralysis post-op anyway, despite sophisticated neuro monitoring--or when there are brand new RNs in the OR orienting, and they don't have the experience to make complicated clinical judgements without guidelines--

I always tell new nurses that I am orienting that guidelines are just that--GUIDELINES--not hard and fast rules written in stone. However, in a paralysis case, you can bet that attorneys are going to be asking for written standards of care, despite the fact that informed consent cites paralysis, even death, as a possible complication of spinal surgery, especially ones with pre-existing severe stenosis or cord compression issues.

I don't see anything in the extensive research I have done that recommends the use of Solu-Medrol pre-op; only for the treatment of spinal shock once a

an insult to the spine has occurred, and then within that critical time frame. This is my point--I still see it being given routinely pre-op by neurosurgeons who believe it helps, and by anesthesia providers who apparently do, as well. I am an OR nurse, not a CRNA. I am concerned about my own liability whether I not I give the Solu-Medrol to the CRNA or anesthesiologist, since there seem to be different schools of thought on pre-op steroids, depending where the neurosurgeon or anesthesia provider trained, or how long they have been working, and what has worked for them in the past.

That is why I brought up the issue of pre-op Decadron to minimize laryngeal edema. I have worked with anesthesiologists and ENT docs who swear by it, and have written papers on it. I have also worked with anesthesiologists and ENT docs who swear that it makes no difference whatsoever, and don't give it. Who ya gonna believe? What happens in court if a patient, particularly a child, DOES have a bad outcome (i.e, cerebral anoxia or even death from airway edema) and the plaintiff lawyers have the research that indicates it DOES work? And what happens when they ask us, as RNs circulating in the room "In your experience, have you worked with anesthesia providers and ENT doctors who routinely give Decadron to minimize laryngeal edema? Are you familiar with the literature that supports its use? As a matter of fact, didn't Doctor X, where you used to work, write one of the articles recommending its use in pediatric ENT cases? Then why didn't you, as the circulating nurse and patient's advocate, ensure that it was given to this pediatric patient?" As RNs, we do our own reading,research, CE classes, and have our own stories to tell about how we did it in other operating rooms and why, but we don't make the final decisions, despite our levels of knowledge, skill and clinical experience. I think we are in a really vulnerable position.

loisane · May 28, 2003

stevierae,

Tenesma has explained it well.

Additionally-during lawsuits, professionals are held to the "reasonable" standard. That means, did the professional perform in such a way that any other reasonable practitioner of the same level would have performed, given the facts available at the time.

Most things are not black or white. Instead, it is up to each of us to read, and stay current with the literature. What is the evidence that supports any particular drug/treatment/etc. Many, many issues will have supporting evidence, and other non supporting evidence. Each professional weighs the evidence, and makes a decision about their individual practice.

You bring up a significant issue. I have seen SRNAs try to study themselves blind, trying to find the 100% "right" answer. When really, you need to stack up the supporting evidence in one pile, and compare it to the non supporting evidence in another pile. As professionals we are duty bound to be able to tackle this kind of complicated decision making. It just isn't as simple and straightforward as some people would like.

For instance, in the debate about steroids in spine surgery- you have to consider the side effects of steroids. It is all about the balance of risk and benefit. The benefits have to outweigh the risks. Steroids delay healing by inhibiting the immune system. They also raise blood sugar, which can increase the chance of wound infection. Also, increased blood sugar is associated with increased risk of neuro deficit in the case of a neurologic event. I am not a neuro expert, but I would imagine this is the kind of thing that is part of this debate.

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