Feasibility of fast-track elements in pediatric surgery

Evolution of enhanced recovery for children undergoing elective intestinal surgery

Enhanced recovery protocols (ERP) have been widely adopted in adult populations, with over 30 years of experience demonstrating the effectiveness of these protocols in patients undergoing gastrointestinal (GI) surgery. In the last decade, ERPs have been applied to pediatric populations across multiple subspecialties. The objective of this manuscript is to explore the evolution of how ERPs have been implemented and adapted specifically for pediatric populations undergoing GI surgery, predominantly for inflammatory bowel disease. The reported findings reflect a thorough exploration of the literature, including initial surveys of practice/readiness assessments, consensus recommendations of expert panels, and data from a rapidly growing number of single center studies. These efforts have culminated in a national prospective, multicenter trial evaluating clinical and implementation outcomes for enhanced recovery in children undergoing GI surgery. In short, this historical and clinical review reflects on the evolution of ERPs in pediatric surgery and expounds upon the next steps needed to apply ERPs to future pediatric populations.

Implementation of Enhanced Recovery Protocols After Minimally Invasive Surgery in Children: A Multinational Survey Study Among International Pediatric Endosurgery Group and European Paediatric Surgeons' Association Members

Aim: The aim of this multinational survey was to provide insights into individual surgeon's experience with implementation of enhanced recovery after surgery (ERAS) programs centered on minimally invasive surgery (misERAS) and to identify perceived barriers to utilization of these protocols. Methods: An online survey was conducted between July 2021 and March 2022 on behalf of the International Pediatric Endosurgery Group (IPEG) and European Paediatric Surgeons' Association (EUPSA) Research Committees. All IPEG and EUPSA members were contacted by e-mail and asked to complete an anonymous questionnaire that included 20 items. Results: Of an estimated 890 IPEG and 800 EUPSA members, 248 completed the survey (14.7%). A minority of respondents (n = 45, 18.1%) stated that misERAS protocols were followed as "utilizing specific ERAS guidelines," whereas 67.3% (n = 167) replied that they were trying to adhere to the basic ERAS principles in their practice. Almost half (n = 117, 47.2%) of the respondents stated that there was an increase in implementation of specific misERAS guidelines over the last 5 years. A lack of education and standardized protocols, lack of support and collaboration, and the existing culture leading to moderate to extreme barriers to misERAS implementation were reported by 25%-40% of respondents. Conclusions: This survey demonstrates that pediatric surgeons from the IPEG and EUPSA communities try to adhere to basic ERAS principles when performing MIS. The major barrier to misERAS implementation is profound lack of education. The fact that only 18% of respondents utilize specific institutional misERAS protocols suggests that at present, ERAS has not found its way into MIS in the broad landscape.

Evaluating caretaker satisfaction with same-day discharge after gastrostomy tube placement

BACKGROUND

Same-day discharge (SDD) after laparoscopic gastrostomy tube (G-tube) placement, using written and video-based preoperative education, has been our standard institutional practice since 2017. We aim to evaluate caretaker satisfaction with this protocol.

METHODS

All patients planned for SDD after G-tube placement from February 2021-February 2022 were identified. Chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length of stay (LOS), and complications requiring emergency department evaluation, readmission, or reoperation. Telephone follow-up at two weeks postoperatively was conducted to evaluate satisfaction with the SDD protocol.

RESULTS

Forty-nine patients were eligible for SDD with a median age of 1.1 years [0.7, 4.4]. Forty-two (86%) patients were successfully discharged the same day with a median LOS of 7.5 h [6.7, 8.1], and 7 (14%) were admitted postoperatively for further education or emesis with a median LOS of 30.4 h [26.9, 31.2]. Median time to initiation of feeds was 2.3 h [1.7, 2.9]. 8 (16%) patients were evaluated in the emergency department within 30 days postoperatively, resulting in two re-admissions: one for peri‑stomal erythema and fever requiring oral antibiotics at 21 days and one for G-tube dislodgement requiring reoperation and replacement at 28 days. On two-week telephone follow-up, 42 caretakers (100%) felt that their education was adequate for same-day discharge and felt comfortable with the same-day discharge protocol. Six (14%) caretakers stated their child's pain was not well controlled at some point between discharge and survey follow-up, and three caretakers (7%) called a provider within the first 24 h for issues with pain. Forty-one caretakers (98%) expressed satisfaction going home the day of surgery.

CONCLUSION

Caretaker satisfaction and comfort with same-day discharge following laparoscopic G-tube placement are high, ascribed to comprehensive preoperative education and anticipatory guidance.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

Level 1.

An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay

BACKGROUND

Pediatric unilateral renal tumors in the US are treated with upfront nephrectomy and surgical staging. We applied enhanced recovery after surgery (ERAS) principles in care of children after Wilms nephrectomy.

METHODS

We reviewed records of pediatric unilateral nephrectomies for Wilms tumors, and analyzed tumor stage, surgical approach, length of operation, use of anesthesia adjuncts and catheters, diet advancement, hospital length of stay (LOS), and complications. Our ERAS protocol includes: parental education regarding discharge criteria and anticipated LOS, avoiding thoraco abdominal incisions, avoiding routine nasogastric tubes, clear liquids starting day of surgery, minimizing opiates, routine IV ketorolac use, and avoiding routine ICU stay. We examined the effects of our protocol on postoperative hospital LOS and complication rates.

RESULTS

Sixty six children (31 boys, mean age 3.8y, range 0-11.9) underwent unilateral total nephrectomy for Wilms tumor. Mean nephrectomy duration was 2.7 h. Post operatively, seven (11%) had temporary gastric tubes and 24 (36%) had epidural catheters. Ten (15%) recovered in the ICU. Patients were given regular diets mean of 1.9 days post op. Mean LOS was 3.7 days, with 56% of patients being discharged within 2-3 days. Presence of tumor thrombus, longer epidural catheter duration, delayed diet advancement, and total IV narcotic usage were associated with longer LOS. Routine use of IV ketorolac was associated with shorter LOS.

CONCLUSIONS

Use of an ERAS protocol in children undergoing nephrectomy for Wilms tumor is safe, resulting in rapid return to regular diet and compared to the published literature, shorter postoperative LOS without an increase in complications or return to ED/OR.

LEVEL OF EVIDENCE

Level III.

Systematic Review of Definitions and Outcome Measures for Postoperative Ileus and Return of Bowel Function after Abdominal Surgery in Children

This review aims to objectify which definitions and outcome measures are used for the return of bowel function and postoperative ileus in children. PubMed and Embase were systematically searched from inception to December 17, 2020. Prospective studies conducted in children (aged 0-18 years) undergoing gastrointestinal surgery which reported on definitions and/or outcome measures for post-operative ileus or return of bowel function were evaluated. Definitions and outcome measures were extracted. From 4,027 references, 71 articles were included. From the 17 articles mentioning postoperative ileus, 8 (47%) provided a definition. In total, 34 outcome measures were used and 12 were unique. "Abdominal distension" was the most reported (41%) measure. In 41%, the outcome measures only described the return of gastric motility, while 18% described the return of intestinal motility. The return of bowel function was mentioned in 67 articles, none provided a definition. In total, 133 outcome measures were used and 37 were unique. Time to oral intake was the most reported (14%) measure. In 49%, the outcome measures only described the return of gastric motility, while 10% described the return of intestinal motility. High variation in definitions and outcome measures has limited the generalizability of research into postoperative bowel function in children. Without standardization, it will be impossible to compare research results and evaluate treatments. In children, the return of gastric motility seemingly should get more focus compared to adults. Therefore, we believe that a definition of postoperative ileus with an accompanying core outcome set, developed by a multidisciplinary team, specifically for children is required.

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery

BACKGROUND

Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery.

METHODS

Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay.

RESULTS

Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I² = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I² = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I² = 93%) were significantly less in the EEN group.

CONCLUSION

EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings.

LEVEL OF EVIDENCE

V.

A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure

Background

A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control.

Methods

All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort.

Results

Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002).

Conclusions

Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization

BACKGROUND

Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care.

METHODS

Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes.

RESULTS

Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P = 0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant.

CONCLUSIONS

At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

Application effect of initiation of enteral nutrition at different time periods after surgery in neonates with complex congenital heart disease: A retrospective analysis

Early enteral nutrition (EN) promotes the recovery of critically ill patients, but the initiation time for EN in neonates after cardiac surgery remains unclear.This study aimed to investigate the effect of initiation time of EN after cardiac surgery in neonates with complex congenital heart disease (CHD).Neonates with complex CHD admitted to the CICU from January 2015 to December 2017 were retrospectively analyzed. Patients were divided into the 24-hour Group (initiated at 24 hours after surgery in 2015) (n = 32) and 6-hour Group (initiated at 6 hours after surgery in 2016 and 2017) (n = 66). Data on the postoperative feeding intolerance, nutrition-related laboratory tests (albumin, prealbumin, retinol binding protein), and clinical outcomes (including duration of mechanical ventilation, CICU stay, and postoperative hospital stay) were collected.The incidence of feeding intolerance was 56.3% in 24-hour Group and 39.4%, respectively (P = .116). As compared to 24-hour Group, prealbumin and retinol binding protein levels were higher (160.7 ± 64.3 vs 135.2 ± 28.9 mg/L, P = .043 for prealbumin; 30.7 ± 17.7 vs 23.0 ± 14.1 g/L P = .054 for retinol-binding protein). The duration of CICU stay (9.4 ± 4.5 vs 13.3 ± 10.4 day, P = .049) and hospital stay (11.6 ± 3.0 vs 15.8 ± 10.3 day, P = .028) were shorter in 6-hour Group.Early EN improves nutritional status and clinical outcomes in neonates with complex CHD undergoing cardiac surgery, without significant feeding intolerance.

Clinical application of enhanced recovery after surgery (ERAS) in pectus excavatum patients following Nuss procedure

Background

Evaluate the effect of enhanced recovery after surgery (ERAS) protocol on postoperative recovery quality of pectus excavatum patients with Nuss procedure.

Methods

A retrospective study was performed on patients undergoing Nuss procedure from the Department of Thoracic Surgery of The Cancer Hospital of China Medical University between September 2016 and September 2019. Patients were divided into 2 groups by perioperative management: the traditional procedure group (T group) and the ERAS strategy group (E group). The outcome measures were postoperative drainage time, postoperative hospital time, and postoperative complications measured by the Clavien-Dindo method.

Results

Of the 168 patients from this time period, 148 met the inclusion criteria (75 in Group T and 73 in Group E). All operations involved in this study were completed successfully. There was no statistical difference between the 2 groups with respect to baseline demographics (P>0.05). In Group E, postoperative drainage time (2.53±0.72 vs. 3.45±2.07 days) and postoperative hospitalization time (4.96±1.48 vs. 7.71±7.78 days) were statistically significantly better than those in Group T (P<0.05). There was no difference in overall postoperative complications as measured by Clavien–Dindo score.

Conclusions

The measures of no indwelling urinary catheter (IDUC), laryngeal mask anesthesia, and indwelling tubule drainage can improve postoperative recovery quality of pectus excavatum patients following Nuss procedure.

Protocol for enhanced recovery after surgery with 3D laparoscopic excision for choledochal cysts can benefit the recovery process

OBJECTIVE

To explore the clinical value of enhanced recovery after surgery (ERAS) with laparoscopic choledochal cyst (CDC) excision in children.

METHODS

A retrospective review was performed on the clinical data from 33 in-patients whose final diagnosis was CDC. We included 18 patients who underwent the traditional treatment for CDC from April 2017 to October 2017 as the control group and 15 patients who underwent the enhanced recovery protocol (ERP) from November 2017 to May 2018 as the ERAS group. All the patients had received three-dimensional (3D) laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy by the same group of pediatric surgeons. The time of initial water intake, postoperative time to total enteral nutrition (TEN), postoperative hospital stay, total cost in hospital, postoperative complications, and readmission rate within 30 days were analysed.

RESULTS

The postoperative time of initial water intake, postoperative time to TEN, postoperative hospital stay, and total cost in hospital were (21.5 ± 2.1) h, (4.3 ± 0.5) days, (5.3 ± 0.6) days, and (35,945.49 ± 6071.46) China Yuan (CNY) in the ERAS group and (44.1 ± 3.5) h, (7.7 ± 2) days, (9.1 ± 2.5) days, and (45,609.08 ± 11,439.80) CNY in the control group, respectively. These values in the ERAS group were significantly lower than those in the control group (p < 0.05). There was no significant difference between the two groups in terms of postoperative complications. No readmission patient within 30 days was encountered in either of the two groups.

CONCLUSION

Enhanced recovery protocols can shorten postoperative hospital stay, relieve perioperative discomfort, lighten the financial burden, and result in substantial improvements.

Epidemiology of long-stay patients in the pediatric intensive care unit: prevalence, characteristics, resource consumption and complications

Background

The impact of pediatric intensive care unit (PICU) utilization and resource consumption among long-stay patients has not been characterized recently. This study aimed to describe the resource consumption and characteristics of long-stay patients in a PICU.

Methods

This was a single-center descriptive cohort study of 1309 patients admitted to a PICU in 2017. The main outcome was ICU length of stay (LOS). Patients were divided into prolonged LOS (PLS) and non-PLS groups if they had an LOS of ≥ 28 or < 28 days, respectively. Two groups were compared to characterize PLS.

Results

Thirty-two (2.4%) patients had a PLS and utilized 33% of PICU bed days. Factors associated with PLS with odds ratio [95% confidence interval (CI)] were being a neonate (7.8 [2.5-25.4], p = <0.001), being an infant (2.9 [1.0-9.0], p = 0.04), admission for a respiratory ailment (7.3 [1.6-44.2], p = 0.003), cardiovascular dysfunction (24.1 [4.8-152.1], p = <0.001), post-cardiac operation (8.0 [1.7-50.1], p = 0.003), post-cardiopulmonary arrest (22.8 [1.7-211.9], p = 0.01), and transfer from another facility (4.2 [1.8-10.7], p = 0.001). PLS patients developed more nosocomial infections and disproportionately received monitoring and therapeutic resources.

Conclusions

A PLS was associated with substantial PICU utilization and complication rates. Future studies should aim to alleviate both institutional and patient-related issues in the affected population harboring possible risk factors for PLS.

Enhanced recovery after surgery among adolescents undergoing bariatric surgery

Enhanced recovery after surgery (ERAS) has evolved over the past two decades. Originally aimed to standardize care among adults undergoing colorectal surgery, the tenets that developed have since been broadly accepted by a large number of adult surgical subspecialties, including bariatric surgery. This multidisciplinary, patient-centered approach involving optimizing pre-, intra-, and postoperative phases of care has resulted in shorter hospitalizations, fewer complications, and lower mortality rates. Recently, multiple pediatric surgery subspecialties have adopted ERAS principles and have documented similar favorable outcomes. Among adolescent bariatric patients, outcomes following the implementation of ERAS have not yet been described. We will review the history and goals of ERAS and detail pediatric surgery specific implementations. We will also review outcomes associated with ERAS within specific pediatric surgical subspecialties. Lastly, we will discuss the current ERAS protocol developed at Children's Hospital Colorado for adolescent bariatric surgery.

Application of enhanced recovery after surgery during the perioperative period in infants with Hirschsprung's disease - A multi-center randomized clinical trial

BACKGROUND & AIMS

Various enhanced recovery after surgery (ERAS) guidelines have been established for several kinds of adult surgeries. While the guidelines for pediatric surgeries remained to be explored. The aim of the study was to prospectively evaluate the safety and efficacy of an ERAS protocol for Hirschsprung's disease (HSCR) infants undergoing pull-through procedures.

METHODS

An infant-specific ERAS protocol was developed and implemented at multiple centers from June 1, 2016 to December 31, 2017. The study included 145 consecutive patients who underwent pull-through surgery for HSCR in three Children's hospitals. Patients were primarily divided into three groups based on the clinical classification and surgical methods. Group I included patients with the short segment type who received transanal endorectal pull-through (TEPT) surgery. Group II comprised of patients with the classical type and long segment type who received laparoscopic-assisted pull-through (LAPT) surgery. Group III involved patients with the long segment type (who had received ileostomy or colostomy during the neonatal period) and total colonic aganglionosis who received open pull-through (OPPT) surgery. Patients in the three groups mentioned above were randomly and equally assigned into the ERAS group and traditional (TRAD) group with random number table row randomization. The primary outcome was the length of postoperative hospital stay (LOS). Secondary outcomes of interest included white blood cell (WBC) and C-reactive protein (CRP) on postoperative day 1 (POD 1), the blood glucose at the time of anesthesia and 24 h after surgery, time to first defecation, time to regular diet, plasma markers of nutrition status on POD 5, plasma natrium on POD 5, the mean intraoperative fluid volume, time to discontinuation of intravenous infusion, incidence of postoperative complications, re-admission within 30 days, hospitalization costs, parental satisfaction, and growth from admission to 6 months after surgery.

RESULTS

73 and 75 patients were assigned to the TRAD and ERAS groups, respectively. There were no significant differences in demographic data. The LOS decreased from 9.5 days in the TRAD group to 7.9 days (P < 0.001) in the ERAS group. WBC count on POD 1 showed no significant difference between the two groups. CRP on POD 1 in the ERAS group was significantly lower (P < 0.001). In the ERAS group, the blood glucose was higher at anesthesia compared to the TRAD group (P < 0.001). On the contrary, the blood glucose at 24 h after surgery was significantly lower in the ERAS group (P < 0.001). Intraoperative fluid volume was lower in the EARS group (P < 0.001). ERAS could also reduce the time to first defecation (P < 0.001), discontinuation of intravenous infusion (P < 0.001) and regular diet (P < 0.001). In the ERAS group, the concentrations of prealbumin and retinol conjugated protein on POD 5 were higher than those in the TRAD group (P < 0.001, P < 0.001, respectively). The plasma natrium had no difference in the two groups on POD 5 (P > 0.05). The rate of complications (P > 0.05) and 30-day re-admission (P > 0.05) were not significantly different between the two groups. Hospitalization costs were also reduced (P < 0.001). ERAS group has a higher parental satisfaction rate, although there was no statistical difference (96% vs 89%). There was no difference in growth between the ERAS and the TRAD groups from admission to 6 months after the surgery (weight for age z score: P > 0.05, weight for length z score: P > 0.05). We also found that the shortening of LOS by the application of ERAS protocol was more obvious in the OPPT group (-2.5 ± 1.0) than that in the TEPT (-1.9 ± 1.3) and LAPT (-1.3 ± 0.4) groups.

CONCLUSIONS

Implementation of the ERAS protocol in infants undergoing HSCR pull-through operations is safe and efficient. The ERAS protocol is worthy of recommendation.

TRIAL REGISTRATION

Clinical Trials.gov identifier: NCT02776176.

An evolving anesthetic protocol fosters fast tracking in pediatric cardiac surgery: A comparison of two anesthetic techniques

Background:

The past two decades have seen rapid development of new surgical techniques for repair as well as palliation of complex congenital heart diseases. For a better patient outcome, minimal postoperative ventilation remains one of the most important endpoints of an effectual perioperative management.

Aims and Objectives:

The aim of this randomized open-label trial was to compare postoperative extubation time and intensive care unit (ICU) stay when two different anesthetic regimens, comprising of induction with ketamine and low-dose fentanyl versus high-dose fentanyl, are used, in pediatric patients undergoing corrective/palliative surgery.

Materials and Methods:

Patients with congenital cardiac defects, under 14 years of age undergoing cardiac surgery under cardiopulmonary bypass (CPB) and epidural analgesia, were enrolled into two groups – Group K (ketamine with low-dose fentanyl) and Group F (high-dose fentanyl) – over a period of 10 months, starting from January 2018. The effect of both these drugs on postoperative extubation time and ICU stay was compared using Mann–Whitney U-test.

Results:

A total of 70 patients were assessed with equal distribution in both the groups. In Group K, 32 of 35 patients were extubated in the operation room, whereas extubation time in Group F was18.1 ± 11 h. Total ICU stay in Group K and Group F was 45.2 ± 30.1 and 60.1 ± 24.5 h, respectively (P = 0.02). Systolic blood pressure was significantly higher in Group K.

Conclusion:

Ketamine along with low-dose fentanyl, when used for anesthetic induction, in comparison to high-dose fentanyl, reduces postoperative extubation time and ICU stay, in pediatric patients undergoing corrective/palliative surgery under CPB and epidural analgesia for congenital cardiac defects.

Enhanced recovery after surgery in pediatric gastrointestinal surgery

Objective

Enhanced recovery after surgery (ERAS) protocols help optimize inpatient care and minimize discomfort. This study was performed to explore the safety, feasibility, and clinical and social value of ERAS in pediatric gastrointestinal surgery.

Methods

This study included all children (n = 125) who underwent appendectomy, pyloromyotomy, transabdominal Soave’s procedure, Meckel’s diverticulum resection, or reduction of intussusception in our institution from January to September 2018. We compared surgical outcomes between children who underwent surgery under conventional perioperative regimens (control group, n = 57) and those who were treated with ERAS protocols (ERAS group, n = 68).

Results

There were no significant intergroup differences in demographic or surgical data. However, the bowel function recovery time, postoperative intravenous nutrition time, duration of postoperative hospital stay, and hospital costs were significantly lower in the ERAS group than control group. There was no significant intergroup difference in the complication rate.

Conclusions

Our results indicate that implementation of ERAS protocols is safe and feasible in pediatric gastrointestinal surgery. They can improve patient comfort, shorten the duration of the postoperative hospital stay, reduce hospital costs, and accelerate postoperative rehabilitation without increasing the risk of postoperative complications. Therefore, ERAS protocols deserve wider implementation and promotion.

Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012-2016

PURPOSE

To examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort.

METHODS

Retrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012-2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation.

RESULTS

348 patients were identified (range, 46-96 per year); 55.2-69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ± 2.9 days to 7.3 ± 9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ± 3.0 days to 5.7 ± 4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small.

CONCLUSIONS

Postoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist.

LEVEL-OF-EVIDENCE

III Retrospective comparative study.

Embracing change: the era for pediatric ERAS is here

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS^® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS^® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS^® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS^® in 2018 has set the stage for a new era in pediatric surgical safety.

Factors associated with early extubation of patients after corrective tetralogy of Fallot

OBJECTIVE

To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina.

METHODS

A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis.

RESULTS

16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26).

CONCLUSIONS

Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.

Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations

BACKGROUND

Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children.

OBJECTIVE

The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls.

STUDY DESIGN

Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery.

RESULTS

A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations.

DISCUSSION

Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding.

CONCLUSION

ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.

Patient engagement to enhance recovery for children undergoing surgery

For over 20 years enhanced recovery protocols (ERPs) have been used to decrease the physiologic stress and inflammation of surgery using evidence-based principles. ERPs include optimizing patient preparation, creating less trauma using minimally invasive anesthetic and surgical techniques, and regular audit of outcomes. A critical aspect of ERPs is patient engagement in all phases of care, which facilitates effective team function and focused oversight of patient flow through the system. Counseling extends beyond traditional review of surgical risks and benefits, by creating clear daily patient goals, establishing pain management plans, optimizing nutrition, and defining criteria for discharge. The patient and family are provided written and visual media resources to review. This counseling and education clearly outlines the bidirectional expectations, ensures preparedness, and empowers the patient and family by explaining the logic surrounding many of the ERP interventions. The patient and family are, in turn, activated as key stakeholders in the process and have a shared vision with the healthcare team. Most patients enjoy being considered partners and agents in their own healthcare. ERPs facilitate an optimal surgical experience that can improve patient satisfaction, outcomes, and value.

Fast track pediatric thoracic surgery: Toward day-case surgery?

PURPOSE

Thoracoscopic lung resection for congenital pulmonary airway malformation (CPAM) is a safe technique for children. Our purpose was to evaluate the feasibility of a fast-track protocol in such cases.

METHODS

From September 2007 to May 2016, 101 patients underwent a thoracoscopic pulmonary resection of which 83 for CPAM (lobectomy, wedge resection or sequestrectomy). We retrospectively reviewed the characteristics of surgical procedure, postoperative management and complications through three time periods (September 2007-December 2009: n=14, January 2010-March 2013: n=30, April 2013-May 2016: n=39) corresponding to management protocols modifications introducing fast-track pathways.

RESULTS

Through the 3 time periods, median postoperative hospital stay decreases (4, 3, 2days successively, P=0.02). In the third time period, 4 patients underwent surgery in day-case surgery. The overall and surgical complication rates, mainly related to air leakage, remain stable through the 3 time periods (14%, P=0.41 and 10%, P=0.52 respectively). Among the 13 patients without postoperative pleural drainage, one required secondary drainage after a partial resection of an emphysema.

CONCLUSION

Fast-track protocol for children undergoing uncomplicated thoracic surgery for CPAM seems feasible without extra morbidity. Selected patient undergoing thoracoscopic resection of the lung may benefit from the absence of pleural drainage and can be operated on in day-case surgery.

LEVEL OF EVIDENCE

Level III.

What is the role of enhanced recovery after surgery in children? A scoping review

PURPOSE

Enhanced recovery after surgery (ERAS) pathways are standard practice in adult specialties resulting in improved outcomes. It is unclear whether ERAS principles are applicable to Paediatric Surgery. We performed a scoping review to identify the extent to which ERAS has been used in Paediatric Surgery, the nature of interventions, and outcomes.

METHODS

Pubmed, Cochrane library, Google Scholar, and Embase were searched using the terms enhanced recovery, post-operative protocol/pathway, fast track surgery, and paediatric surgery. Studies were excluded if they did not include abdominal/thoracic/urological procedures in children.

RESULTS

Nine studies were identified (2003-2014; total 1269 patients): three case control studies, one retrospective review and five prospective implementations, no RCTs. Interventional elements identified were post-operative feeding, mobilisation protocols, morphine-sparing analgesia, reduced use of nasogastric tubes and urinary catheters. Outcomes reported included post-operative length of stay (LOS), time to oral feeding and stooling, complications, and parent satisfaction. Fast-track programmes significantly reduced LOS in 6/7 studies, time to oral feeding in 3/3 studies, and time to stooling in 2/3 studies.

CONCLUSION

The use of ERAS pathways in Paediatric surgery appears very limited but such pathways may have benefits in children. Prospective studies should evaluate interventions used in adult ERAS on appropriate outcomes in the paediatric setting.

A Nursing Survey on Nutritional Care Practices in French-Speaking Pediatric Intensive Care Units: NutriRéa-Ped 2014

OBJECTIVES

Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research.

METHODS

The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team.

RESULTS

Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly.

CONCLUSIONS

We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and research.