SPN-7704

Posterior lumbar fusion

Spine · open · prone · 3.5 h · Dr. Luis Ortega

Patient instructions Audit this case Summary sheet

ERAS pathway: ANESTHESIA REVIEW REQUIRED

Age / sex: 70 · male
BMI: 29.1
ASA: 3
Apfel: 2 · Non-smoker, Postoperative opioids expected
Surgery: Oct 22, 2026, 8:00 AM
Arrival: Oct 22, 2026, 6:00 AM
Consult: Yes
Block: Erector spinae plane block

Before surgery

Counseling and shared expectations

baseline Review the pathway, the fasting clock, pain plan, and who to call.

Rules: baseline · ERAS Society guidelines

Prehabilitation

MODIFY

path_prehab_short Less than the minimum prehab window. Use a short plan: breathing, walking, and protein — not a 4-week program.

note_prehab_strong Prehabilitation is strongly recommended because of age, frailty, or malnutrition.

Rules: path_prehab_short · ERAS Society guidelines

Carbohydrate drink

baseline One carbohydrate drink, about 400 mL, finished by the stop-drinks time. ASA 2023 supports this in healthy adults.

Rules: baseline · ASA 2023 fasting guideline

Clear liquids

baseline Clear liquids until 2 hours before anesthesia. The patient sheet uses the earlier of that time and 2 hours before arrival.

Rules: baseline · ASA 2023 fasting guideline

Solid food fasting

baseline Stop solids 6 hours before surgery. Stop fried or fatty meals 8 hours before.

Rules: baseline · ASA 2023 fasting guideline

No long-acting sedative premedication

baseline Do not give a long-acting sedative or benzodiazepine premedication.

note_delirium Delirium risk: no benzodiazepines. Use the orientation, sensory, sleep, and mobility bundle.

Rules: baseline · ERAS Society guidelines

Anticoagulant or antiplatelet plan

MODIFY

baseline Confirm the agent, the last dose, and the ASRA interval before a needle goes in.

Rules: baseline · ASRA anticoagulation guidelines

Gabapentinoid

HOLD

safe_frailty_gaba Age, frailty, or a delirium history: do not give a gabapentinoid. Age 70

Do not give gabapentin or pregabalin.

Rules: safe_frailty_gaba · ERAS Society guidelines

During surgery

Acetaminophen

baseline Scheduled acetaminophen unless the liver plan says otherwise.

Rules: baseline · ERAS Society guidelines

NSAID or COX-2

baseline Give a scheduled NSAID or COX-2 unless a safety rule holds it. Do not tell every patient to stop NSAIDs for 7 days.

Rules: baseline · ERAS Society guidelines

Dexamethasone

baseline Single-dose dexamethasone for analgesia and nausea, unless a rule modifies it.

Rules: baseline · ERAS Society guidelines

Regional or neuraxial block

HOLD

safe_ac_deep Neuraxial or deep block is held until the ASRA interval is met. Fascial options need a separate decision. Apixaban requires 72 hours. Documented gap is 48 hours.

Erector spinae plane block

Rules: safe_ac_deep · ASRA anticoagulation guidelines

PONV prophylaxis

baseline Prophylaxis follows the Apfel score and the Fourth Consensus Guidelines.

Apfel 2 (Non-smoker, Postoperative opioids expected). Give 2 agents: dexamethasone and ondansetron.

Rules: baseline · Fourth Consensus PONV Guidelines 2020

Goal-directed fluids

baseline Aim for euvolemia. Avoid both liberal fluid and under-resuscitation.

Rules: baseline · ERAS Society guidelines

Normothermia

baseline Active warming. Keep core temperature at or above 36°C.

Rules: baseline · ERAS Society guidelines

Glucose control

baseline Treat hyperglycemia. Non-diabetic patients need a check only when clinically indicated.

Rules: baseline · ERAS Society guidelines

VTE prophylaxis

MODIFY

safe_ac_vte The patient is on an anticoagulant or a P2Y12 inhibitor. Do not stack a prophylactic dose on top. Restart when hemostasis is secure and the agent-specific gap has passed. Apixaban

Rules: safe_ac_vte · ASRA anticoagulation guidelines

Tranexamic acid

baseline Give tranexamic acid unless a thrombotic contraindication is documented.

Rules: baseline · ERAS Society guidelines

After surgery

Early oral intake

baseline Start oral intake as soon as the patient is awake, unless a surgical rule restricts it.

Rules: baseline · ERAS Society guidelines

Early mobilization

baseline Mobilize the day of surgery or on postoperative day 1.

Rules: baseline · ERAS Society guidelines

Urinary catheter removal

baseline Remove the urinary catheter on postoperative day 1 unless the operation requires it to stay.

Rules: baseline · ERAS Society guidelines

Avoid routine drains

baseline Do not place a drain by routine.

Rules: baseline · ERAS Society guidelines

Avoid routine nasogastric tube

baseline Do not leave a nasogastric tube in by routine.

Rules: baseline · ERAS Society guidelines

Delirium prevention bundle

baseline Orientation, glasses, hearing aids, sleep, early mobility, and no benzodiazepines.

note_delirium Delirium risk: no benzodiazepines. Use the orientation, sensory, sleep, and mobility bundle.

Rules: baseline · ERAS Society guidelines

ASRA interval

This case: Apixaban, hold 72 hours. Interval not met.

Agent	Department interval
Aspirin	No mandatory hold before neuraxial or deep block. Continue unless the surgeon stops it for hemostasis.
Clopidogrel	Hold 5–7 days. This protocol uses 7 days.
Prasugrel	Hold 7–10 days. This protocol uses 10 days.
Ticagrelor	Hold 5 days.
Warfarin	Hold 5 days and confirm INR ≤ 1.4 before needle placement.
Apixaban	Hold 72 hours before neuraxial or deep block.
Rivaroxaban	Hold 72 hours before neuraxial or deep block.
Edoxaban	Hold 72 hours before neuraxial or deep block.
Dabigatran	72 h if CrCl ≥ 80, 96 h if 50–79, 120 h if 30–49. Avoid neuraxial block if CrCl < 30.
Enoxaparin, prophylactic	Hold 12 hours.
Enoxaparin, therapeutic	Hold 24 hours.
Heparin, subcutaneous prophylaxis	Hold 6 hours for doses used for prophylaxis (≤ 10,000 units/day).
Heparin infusion	Hold 6 hours and confirm a normal aPTT.
Fondaparinux	Hold 48 hours. Many departments avoid neuraxial block entirely.

Source: ASRA 2018, Regional Anesthesia & Pain Medicine. Confirm every interval locally before a needle is placed.

After discharge

This is the chart review. Mark whether each planned element happened. A deliberate skip stays out of the score. Compliance is done divided by done plus missed.

Meeting view

17 of 19 counted (89.5%). 5 skipped on purpose. Stay 2.6 nights. No complication. No 30-day readmission.

Nights in hospital

Complication

Return to OR

30-day readmit

PONV

Before surgery

GOCounseling and shared expectations

MODIFYPrehabilitation

GOCarbohydrate drink

GOClear liquids

GOSolid food fasting

GONo long-acting sedative premedication

MODIFYAnticoagulant or antiplatelet plan

HOLDGabapentinoid

During surgery

GOAcetaminophen

GONSAID or COX-2

GODexamethasone

HOLDRegional or neuraxial block

GOPONV prophylaxis

GOGoal-directed fluids

GONormothermia

GOGlucose control

MODIFYVTE prophylaxis

GOTranexamic acid

After surgery

GOEarly oral intake

GOEarly mobilization

GOUrinary catheter removal

GOAvoid routine drains

GOAvoid routine nasogastric tube

GODelirium prevention bundle

Teaching record for this demo case. Not a hospital chart, and not the ERAS Society audit system.