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Ahn JJ, Martin LD, Low DK, Fernandez N, Cain MP, Merguerian PA. Enhanced recovery program in ambulatory pediatric urology: A quality improvement initiative. J Pediatr Urol 2024; 20:744.e1-744.e7. [PMID: 38744612 DOI: 10.1016/j.jpurol.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center. METHODS A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used. RESULTS The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged. CONCLUSIONS This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.
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Affiliation(s)
- Jennifer J Ahn
- Department of Urology, Seattle Children's Hospital/University of Washington School of Medicine, USA.
| | - Lynn D Martin
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, USA
| | - Daniel K Low
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, USA
| | - Nicolas Fernandez
- Department of Urology, Seattle Children's Hospital/University of Washington School of Medicine, USA
| | - Mark P Cain
- Division of Pediatric Urology, Indiana University, Riley Hospital for Children, Indianapolis, IN, USA
| | - Paul A Merguerian
- Department of Urology, Seattle Children's Hospital/University of Washington School of Medicine, USA
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Glenski TA, Taylor CM, Weisberg EL, Doyle NM, Melanson A. The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative. Paediatr Anaesth 2024; 34:422-429. [PMID: 38217340 DOI: 10.1111/pan.14838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. METHODS Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. RESULTS After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. CONCLUSION Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.
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Affiliation(s)
- Todd A Glenski
- Department of Anesthesiology, Department of Evidence Based Practice, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Christian M Taylor
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Emily L Weisberg
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Nichole M Doyle
- Department of Anesthesiology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Andrea Melanson
- Department of Evidence Based Practice, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Kanneganti P, Verma A, Mandelia A, Upadhyaya VD, Kumar B, Kumar T, Agarwal N, Kannojia A. Safety and Efficacy of Enhanced Recovery after Surgery Protocol in Pediatric Patients Undergoing Hepato-Pancreatico-Biliary Surgery: A Prospective Randomized Control Study. J Indian Assoc Pediatr Surg 2024; 29:240-244. [PMID: 38912029 PMCID: PMC11192251 DOI: 10.4103/jiaps.jiaps_238_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/09/2024] [Accepted: 01/21/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) is a multidisciplinary approach to optimize patient care. The goal of this approach is to reduce the body's reaction to surgical stress by optimizing the perioperative nutritional status, promoting analgesia without opioids, and early postoperative feeding. In pediatric patients, very limited literature is available for the application of ERAS protocol. This study was done to evaluate the application of ERAS protocol in pediatric hepatobiliary and pancreatic patients. Materials and Methods This is a randomized prospective study conducted over a period of 2 years at a tertiary center in North India. A total of 40 hepatobiliary and pancreatic patients who were willing to participate in the study were included in the study. Patients were randomized by computer-generated method and data were collected regarding demography, clinical diagnosis, preoperative and postoperative workup, and peri-operative care including analgesia, pain scores, postoperative recovery, hospital stay, and complications. These patients were followed for 6 months postoperatively and the results were evaluated using SPSS software. Results The study included 20 patients each in both the conventional and ERAS group with median ages of 11.5 years and 7.1 years, respectively. The data analysis showed that the ERAS group of patients had better outcomes in terms of hospital stay and drain removal time with significant statistical differences. Pain scores and complications are almost the same in both groups. Conclusion Principles of ERAS can be safely applied in pediatric patients undergoing major surgery in the present era of emerging infections and also increasing patient burden without morbidity.
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Affiliation(s)
- Pujana Kanneganti
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Anju Verma
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Ankur Mandelia
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Vijai Datta Upadhyaya
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Basant Kumar
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Tarun Kumar
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Nishant Agarwal
- Department of Paediatric Surgery Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
| | - Ashish Kannojia
- Department of Anaesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
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Bozkul G, Karakul A, Düzkaya DS, Dilşen Ş. Effect of short film video and video-based education on fear, pain, and satisfaction of children undergoing day surgery. J Pediatr Nurs 2024; 75:49-56. [PMID: 38101311 DOI: 10.1016/j.pedn.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE This study aims to determine the effect of introducing the operating room environment with different informative multimedia methods to pediatric patients aged 7-12 in the preoperative period in day surgery on fear, pain, and patient satisfaction in three different groups comparatively. DESIGN AND METHODS This randomized controlled study was conducted with the guidelines of Consolidated Standards of Reporting Trials (CONSORT). The sample of children was allocated to the Short Film Group (n:30), Video Based Education Group (n:30) and Control Group (n:30). Fear, pain, and satisfaction were measured. RESULTS The age distribution of the children in the study was 7.57 ± 1.25 years in the short film group, 7.27 ± 0.52 years in the video-based education group, and 7.57 ± 2.27 years in the control group. There was no significant difference between the groups in terms of demographic status, fear, and vital signs before the procedure. Fear, pain, and satisfaction levels of children in short film groups were lower than video-based education groups. CONCLUSION The result of this research reveals that preoperative short film education in children is more effective than video-based education in reducing fear, pain, and satisfaction levels. This intervention could be an effective method to improve outcomes. Nurses can increase children's comfort by using educational programs that attract children's attention. PRACTICE IMPLICATIONS Healthcare team members working in pediatric surgical units can use the short film method, which is effective, easy, and applicable in the field, to reduce pain and fear in the preoperative period and increase satisfaction in children undergoing day surgery.
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Affiliation(s)
- Gamze Bozkul
- Tarsus University, Faculty of Health Sciences, Department of Nursing, Türkiye
| | - Atiye Karakul
- Tarsus University, Faculty of Health Sciences, Department of Nursing, Türkiye
| | | | - Şahika Dilşen
- Tarsus State Hospital, Pediatric Surgery Service, Türkiye
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Jeski MA, Stanger JD, Schafer MS, Osten AW, Conners GP. Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study. Healthcare (Basel) 2024; 12:474. [PMID: 38391848 PMCID: PMC10888031 DOI: 10.3390/healthcare12040474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024] Open
Abstract
An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.
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Affiliation(s)
- Michelle A Jeski
- Department of Nursing, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- School of Nursing, Quinnipiac University, Hamden, CT 06518, USA
| | - Jennifer D Stanger
- Department of Surgery, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Melissa S Schafer
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Andrew W Osten
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Emergency Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
| | - Gregory P Conners
- Department of Pediatrics, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Emergency Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
- Department of Public Health and Preventive Medicine, Norton College of Medicine, Upstate Golisano Children's Hospital, Upstate Medical University, Syracuse, NY 13210, USA
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Dai F, Zhang R, Deng R, Wang G, Guo H, Guo C. Regular use of low-dose of opioids after gastrointestinal surgery may lead to postoperative gastrointestinal tract dysfunction in children: a Chinese national regional health center experience sharing. BMC Gastroenterol 2023; 23:369. [PMID: 37907841 PMCID: PMC10617101 DOI: 10.1186/s12876-023-02999-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 10/14/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The need for pain management is increasing in pediatrics, but the side effects of overuse or abuse of analgesics can be harmful to children's health and even life-threatening in severe cases. METHODS Patients who underwent resection of Meckel's diverticulum at the Children's Hospital of Chongqing Medical University from July 1, 2019, to July 1, 2022, were included in this study. Opioids were administered through patient-controlled analgesia (PCA). Based on the preoperative choices made by the legal guardians, patients were stratified into two groups: PCA Group (PCAG) and Non-PCA Group (NPCAG). Data pertaining to the clinical characteristics and prognoses of these patients were subsequently collected and analyzed to assess the impact of opioid administration. RESULTS In the study, a total of 126 patients were enrolled, with 72 allocated to the Patient-Controlled Analgesia Group (PCAG) and 54 to the Non-Patient-Controlled Analgesia Group (NPCAG). When compared to the NPCAG, the PCAG exhibited a longer duration of postoperative fasting (median 72 vs. 62 h, p = 0.044) and increased utilization of laxatives (12[16.7%] vs. 2[3.7%], p = 0.022). However, the PCAG also experienced higher incidences of intestinal stasis and abnormal intestinal dilation (13[18.1%] vs. 3[5.6%], p = 0.037). No statistically significant differences were observed in pain assessments at the conclusion of the surgical procedure (0 vs. 1[1.9%], p = 0.429) or within the first 24 h postoperatively (16[22.2%] vs. 18[33.3%], p = 0.164). Additionally, NPCAG patients did not necessitate increased administration of rescue analgesics (2[2.8%] vs. 4[7.4%], p = 0.432). CONCLUSIONS The administration of opioids did not demonstrably ameliorate postoperative pain but was associated with a heightened incidence of postoperative gastrointestinal tract dysfunction. The retrospective nature of the current research should be considered and should be clarified further.
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Affiliation(s)
- Fangyu Dai
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Anesthesiology Class 1, Chongqing Medical University, 2020, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Rensen Zhang
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ruyu Deng
- Department of Respiratory Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guoyong Wang
- Department of Pediatrics, Chongqing health center for women and children, Chongqing, P.R. China
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Hongjie Guo
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Anesthesiology Class 1, Chongqing Medical University, 2020, Chongqing, P.R. China.
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.
- Department of Pediatric General Surgery, Women and Children's Hospital of Chongqing Medical University, 120 Longshan Road, Yubei District, 401147, Chongqing, Chongqing, P.R. China.
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Zhang JG, Li HW, Wu XM, Yu HB, Liu YH, Qi L, Bai Y, Yang L, Zhang HL, Wang XY, Jia YQ. The impact of enhanced recovery after surgery on inflammatory indicators and prognosis related to complex appendicitis in children. Front Pediatr 2023; 11:1261191. [PMID: 37928355 PMCID: PMC10623122 DOI: 10.3389/fped.2023.1261191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023] Open
Abstract
Objective To explore the application effect of enhanced recovery after surgery (ERAS) perioperative plan in the treatment of complex appendicitis in children, and further enrich the implementation plan of ERAS in the field of pediatric surgery. Method This study selected 122 children who underwent laparoscopic complex appendectomy at Inner Mongolia Maternal and Child Health Hospital and Baotou Fourth Hospital from August 2018 to July 2022, and randomly divided them into a traditional surgery group (TS) and an enhanced recovery surgery group (ERAS). The changes of white blood cell (WBC), hypersensitive C-reactive protein (CRP), pro Calcitonin (PCT) and interleukin 6 (IL-6) before and after surgery were compared. The degree of pain, recovery time of intestinal function, length of hospital stay, hospital costs, postoperative complications and parental satisfaction were compared between the two groups. Result The WBC and CRP levels in the ERAS group at 6 h after surgery, as well as the IL-6 levels on the 3rd day after surgery, were lower than those in the TS group. Meanwhile, the analgesic effect of ERAS group at 3 h and 6 h after surgery was better than that of TS group. And the ERAS group had a shorter postoperative first exhaust time, fewer overall hospital stays, and lower hospitalization costs. In addition, the ERAS group had high parental satisfaction during hospitalization. There was no statistically significant difference in postoperative complications between the two groups of children. Conclusion ERAS can promote postoperative recovery of children, reduce surgical stress, save family medical expenses, alleviate the pain of children, and improve parental satisfaction. It is a safe and effective method for treating complex appendicitis in children.
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Affiliation(s)
- Jian-Guo Zhang
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Hao-Wei Li
- Pediatric Surgery, The Fourth Hospital of Baotou, Baotou, China
| | - Xiang-Ming Wu
- Pediatric Surgery, The Fourth Hospital of Baotou, Baotou, China
| | - Hai-Bin Yu
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Yan-Hui Liu
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Lin Qi
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Yu Bai
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Lin Yang
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Hai-Long Zhang
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Xiao-Yun Wang
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
| | - Yue-Qi Jia
- Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, China
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Hoffmann C, Snow A, Chedid C, Abi Shadid C, Miyasaka EA. Quadratus Lumborum Block as a Cornerstone for Neonatal Intestinal Surgery Enhanced Recovery (ERAS): A Case Series. Local Reg Anesth 2023; 16:165-171. [PMID: 37841495 PMCID: PMC10576531 DOI: 10.2147/lra.s403567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Purpose Neonates present unique challenges for pediatric surgical teams. To optimize outcomes, it is imperative to standardize perioperative care by using early extubation and multimodal analgesic techniques. The quadratus lumborum (QL) block provides longer duration and superior pain relief than other single-injection abdominal fascial plane techniques. The purpose of this case series was to report our initial experience with QL blocks in neonatal patients treated with intestinal ERAS. Patients and Methods Ten neonates requiring intestinal surgery at a single tertiary care center who received QL blocks between December 2019 and April 2022 for enhanced recovery were studied. Bilateral QL blocks were performed with 0.5 mL/kg of 0.25% ropivacaine per side with an adjuvant of 1 mcg/kg of dexmedetomidine. Results Gestational age at birth ranged from 32.2 to 41 weeks. The median age, weight, and American Society of Anesthesiologists (ASA) score at the time of surgery was 5 days [range 7.5 hours, 60 days], 2.84 kg [range 1.5, 4.5], and 3, respectively. Bilateral QL blocks were performed without complications in all patients. Two patients were outside the neonatal range from birth to surgery, but were under 42 weeks gestational age when corrected for prematurity. All patients were extubated with well-controlled pain, and no patient required reintubation within the first 24 hours. Postoperatively, median cumulative morphine equivalents were 0.16 mg/kg [range 0, 0.79] and six patients received scheduled acetaminophen. Morphine (0.1 mg/kg) was administered to patients with a modified neonatal infant pain scale (NIPS) score greater than or equal to 4, and pain was reassessed 1 hour after administration (Appendix). Conclusion When developing intestinal ERAS protocols, Bilateral QL blocks may be considered for postoperative analgesia in the neonatal population. Further prospective studies are required to validate this approach in neonates.
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Affiliation(s)
| | - Angela Snow
- Pediatric Anesthesiology, Nemours Children’s Hospital, Wilmington, DE, USA
| | - Celine Chedid
- Pediatric Anesthesiology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Carol Abi Shadid
- Pediatric Anesthesiology, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Eiichi A Miyasaka
- Pediatric Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
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Su Y, Xu L, Hu J, Musha J, Lin S. Meta-Analysis of Enhanced Recovery After Surgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery. J Pediatr Surg 2023; 58:1686-1693. [PMID: 36610934 DOI: 10.1016/j.jpedsurg.2022.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This meta-analysis aimed to investigate the effects and safety of enhanced recovery after surgery (ERAS) for the management of pediatric colorectal surgery. METHODS We retrieved relevant studies from PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) from its inception until 20 May 2022. Meta-analysis was performed using RevMan 5.4, and power analysis was calculated using G∗Power 3.1. RESULTS Ten studies involving 1298 patients were included for meta-analysis. Meta-analysis suggested that ERAS protocol significantly lessened intraoperative fluids (mean difference [MD], -3.11; 95% confidence interval, -4.99 to -1.22) and postoperative opioid usage (MD, -0.58; 95% CI, -1.08 to -0.26), shortened time to bowel return (MD, -12.02; 95% CI, -20.03 to -4.02), first enteral nutrition (MD, -20.88; 95% CI, -28.34 to -13.42) and oral intake (MD, -1.40; 95% CI, -1.96 to -0.84), lowered readmission rate in 30 days (relative risk [RR], 0.61, 95% CI, 0.41 to 0.90), shortened length of hospital stay (MD, -1.50; 95% CI, -1.25 to -1.09), and reduced in-hospital costs (MD, -0.26; 95% CI, -0.34 to -0.18); however, there was a comparable rate of postoperative complications between the two groups. Sensitivity analysis significantly changed the result of the readmission rate in 30 days. The statistical power of all outcomes ranged from 26.84% to 99.44%. CONCLUSIONS Our findings demonstrate the beneficial role of the ERAS protocol in accelerating rehabilitation, shortening the length of hospital stay, and decreasing in-hospital costs among pediatric patients undergoing colorectal surgery. LEVELS OF EVIDENCE LEVEL V.
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Affiliation(s)
- Yingchun Su
- Urology, Surgical Oncology, and Neurosurgery Department, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China.
| | - Lu Xu
- Operating Room, Urumqi First People's Hospital (Children's Hospital), Urumq, 830000, China
| | - Jinhui Hu
- Intensive Care Unit, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
| | - Jiayinaxi Musha
- Urology and Surgical Oncology, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
| | - Song Lin
- Urology and Surgical Oncology, Urumqi First People's Hospital (Children's Hospital), Urumqi, 830000, China
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Balbale SN, Schäfer WLA, Davis TL, Blake SC, Close S, Sullivan GA, Reiter AJ, Hu AJ, Smith CJ, Wilberding MJ, Johnson JK, Holl JL, Raval MV. A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery. Implement Sci Commun 2023; 4:82. [PMID: 37464448 DOI: 10.1186/s43058-023-00463-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Rapid-cycle feedback loops provide timely information and actionable feedback to healthcare organizations to accelerate implementation of interventions. We aimed to (1) describe a mixed-method approach for generating and delivering rapid-cycle feedback and (2) explore key lessons learned while implementing an enhanced recovery protocol (ERP) across 18 pediatric surgery centers. METHODS All centers are members of the Pediatric Surgery Research Collaborative (PedSRC, www.pedsrc.org ), participating in the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) trial. To assess implementation efforts, we conducted a mixed-method sequential explanatory study, administering surveys and follow-up interviews with each center's implementation team 6 and 12 months following implementation. Along with detailed notetaking and iterative discussion within our team, we used these data to generate and deliver a center-specific implementation report card to each center. Report cards used a traffic light approach to quickly visualize implementation status (green = excellent; yellow = needs improvement; red = needs significant improvement) and summarized strengths and opportunities at each timepoint. RESULTS We identified several benefits, challenges, and practical considerations for assessing implementation and using rapid-cycle feedback among pediatric surgery centers. Regarding potential benefits, this approach enabled us to quickly understand variation in implementation and corresponding needs across centers. It allowed us to efficiently provide actionable feedback to centers about implementation. Engaging consistently with center-specific implementation teams also helped facilitate partnerships between centers and the research team. Regarding potential challenges, research teams must still allocate substantial resources to provide feedback rapidly. Additionally, discussions and consensus are needed across team members about the content of center-specific feedback. Practical considerations include carefully balancing timeliness and comprehensiveness when delivering rapid-cycle feedback. In pediatric surgery, moreover, it is essential to actively engage all key stakeholders (including physicians, nurses, patients, caregivers, etc.) and adopt an iterative, reflexive approach in providing feedback. CONCLUSION From a methodological perspective, we identified three key lessons: (1) using a rapid, mixed method evaluation approach is feasible in pediatric surgery and (2) can be beneficial, particularly in quickly understanding variation in implementation across centers; however, (3) there is a need to address several methodological challenges and considerations, particularly in balancing the timeliness and comprehensiveness of feedback. TRIAL REGISTRATION NIH National Library of Medicine Clinical Trials. CLINICALTRIALS gov Identifier: NCT04060303. Registered August 7, 2019, https://clinicaltrials.gov/ct2/show/NCT04060303.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Jr. VA Hospital, Edward Hines, Hines, IL, 60141, USA.
| | - Willemijn L A Schäfer
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Teaniese L Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Audra J Reiter
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew J Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charesa J Smith
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Maxwell J Wilberding
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Alassiri A, AlTayeb A, Alqahtani H, Alyahya L, AlKhashan R, Almutairi W, Alshawa M, Al-Nassar S, Habib Z, AlShanafey S. Implementation of Enhanced Recovery After Surgery protocols for gastrostomy tube insertion in patients younger than 14 years of age: a retrospective cohort study. Ann Saudi Med 2023; 43:227-235. [PMID: 37554026 DOI: 10.5144/0256-4947.2023.227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have improved treatment outcomes and have standardized patient care. OBJECTIVES Identify the benefit of introducing the ERAS protocol for feeding after gastrostomy insertion with or without Nissen fundoplication, the effects on the time of reaching the full feeds the length of stay single-center experience, and complications associated with early feeding protocols. DESIGN Retrospective cohort study SETTING: Tertiary hospital METHODS: The study review included cases performed between 2015 and 2021 by four surgeons, and cases performed in 2022 by all surgeons using ERAS feeding protocol (P) in a tertiary hospital. MAIN OUTCOME MEASURES Comparison the mean and mode of the length of stay (LOS) and the time until the patient reached full feed (TFF). SAMPLE SIZE 224 patients; 181 by the four surgeons and 43 cases by the ERAS protocol group. RESULTS The difference in the ERAS protocol from the four surgeons in TFF and LOS was statistically significant (P<.001). There was no noticeable difference in postoperative complications after introducing the ERAS protocol. CONCLUSION ERAS improved the TFF and decreased the LOS without any increase in procedure complications. Increasing bed utilization and reducing costs were two benefits of reducing LOS at our hospital. LIMITATIONS Single-center study, which may not be generalizable. Multiple comorbidities. Travel time from different parts of the country could impact LOS. Retrospective and thus dependent on the accuracy of the information in file notes. CONFLICT OF INTEREST None.
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Affiliation(s)
- Ali Alassiri
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Afaf AlTayeb
- From the College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hawazin Alqahtani
- From the Department of General Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Lama Alyahya
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Raghad AlKhashan
- From the College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Waad Almutairi
- From the Department of Pediatric Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alshawa
- From the Department of Pediatric Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saleh Al-Nassar
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Zakaria Habib
- From the Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saud AlShanafey
- From the Department of Pediatric Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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12
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Lam JY, Howlett A, Stephen LM, Brindle ME. Parental perceptions and experiences of care in the surgical neonatal intensive care unit. Pediatr Surg Int 2023; 39:210. [PMID: 37261599 PMCID: PMC10234908 DOI: 10.1007/s00383-023-05484-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Parents endure significant stress when their newborns require surgery while in the neonatal intensive care unit (NICU). Our study aims to explore the surgical NICU experience from the parents' perspective and identify areas that may improve this experience. A secondary objective was to integrate their feedback to refine the implementation strategy of the neonatal enhanced recovery after surgery (ERAS®) guideline. METHODS In December 2019, five surgical NICU parents participated in a focus group. Conversation surrounded parents' perspectives and experiences of the surgical NICU. Inductive analysis was performed to identify data, themes, and concepts that emerged from the discussion. RESULTS Participants identified four major interrelated themes that impacted the surgical parents' NICU experience. These themes include (1) parental state, both physical and emotional, (2) the altered parental caregiver role which necessitates identifying alternative meaningful parental experiences, (3) the care team dynamic, incorporating consistency and effective communication, and (4) the discharge process which may be significantly eased through graduated, hands-on training. CONCLUSION Key elements of the neonatal ERAS® guideline address major themes and stressors identified by parents. The parental perspective may help clinicians appreciate the parent surgical NICU experience and assist in improving family-centered care to surgical infants and their families.
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Affiliation(s)
- Jennifer Y Lam
- Division of Pediatric Surgery, Western University, Children's Hospital-London Health Sciences Centre, B1-188, 800 Commissioners Rd. E, London, ON, N6A 5W9, Canada.
| | - Alexandra Howlett
- Section of Neonatology, University of Calgary, Alberta Children's Hospital, 28 Oki Dr. NW, Calgary, AB, T3B 6A8, Canada
| | - Lori M Stephen
- Section of Neonatology, University of Calgary, Alberta Children's Hospital, 28 Oki Dr. NW, Calgary, AB, T3B 6A8, Canada
| | - Mary E Brindle
- Section of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, 28 Oki Dr. NW, Calgary, AB, T3B 6A8, Canada
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He J, Lai H, Zhang T, Ye L, Yao B, Qu H, Ma B, Guo Q, Zhang Y, Qiu J, Wang D. Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement. World J Urol 2023; 41:1667-1673. [PMID: 37219585 DOI: 10.1007/s00345-023-04422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP. METHODS From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss. RESULTS A total of 75 pediatric patients (0-14 years) were included. The mean POS was 2.4 ± 1.4 days, shorter than that in recent studies in China (3.3 ± 1.4 days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4 min, and blood loss was 11.8 ± 10.0 ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05). CONCLUSION The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.
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Affiliation(s)
- Jiannan He
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Huajian Lai
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Tianyou Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Lei Ye
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bing Yao
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Hu Qu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bo Ma
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Qiang Guo
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Yifei Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Jianguang Qiu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
| | - Dejuan Wang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
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Liu L, Yang F, Gao W, Li S, Tian Y, Yang L, Tu S. Median effective volume of 0.2% ropivacaine for ultrasound-guided supraclavicular brachial plexus block in children aged 1-6 years: a prospective dose-finding study. Front Pediatr 2023; 11:1157447. [PMID: 37252041 PMCID: PMC10213320 DOI: 10.3389/fped.2023.1157447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Objective To determine the median effective volume (EV50) of 0.2% ropivacaine for ultrasound-guided supraclavicular brachial plexus block (SC-BPB) in children aged 1-6 years. Methods Children aged from 1 to 6 years with an American Society of Anaesthesiologists (ASA) physical status I-II who were scheduled for unilateral upper extremity surgery at the Children's Hospital of Chongqing Medical University were recruited. All patients underwent surgery under general anaesthesia combined with brachial plexus block. SC-BPB was guided by ultrasound after anaesthesia induction, and 0.2% ropivacaine was given after localization. In the study, we used Dixon's up-and-down approach with an initial dose of 0.50 ml/kg. Considering the effect of the previous block, a successful or failed block could produce a 0.05 ml/kg decrement or increment in volume, correspondingly. The experiment was stopped when there were 7 inflection points. Using isotonic regression and bootstrapping algorithms, the EV50, the 95% effective volume (EV95) and the 95% confidence interval (CI) were calculated. The patients' general information, postoperative pain scores, and adverse events were also recorded. Results Twenty-seven patients were involved in this study. The EV50 of 0.2% ropivacaine was 0.150 ml/kg (95% CI, 0.131-0.169 ml/kg) and the EV95 (secondary metric) was 0.195 ml/kg (95% CI, 0.188-0.197 ml/kg). No adverse events occurred during the research study. Conclusions For ultrasound-guided SC-BPB in children aged 1-6 years undergoing unilateral upper extremity surgery, the EV50 of 0.2% ropivacaine was 0.150 ml/kg (95% CI, 0.131-0.169 ml/kg).
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Affiliation(s)
- Ling Liu
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fei Yang
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Wen Gao
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shangyingying Li
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yaqiong Tian
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Li Yang
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Shengfen Tu
- Department of Anesthesiology Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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15
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Martynov I, Scholz S, Perger L, Lacher M. 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. J Laparoendosc Adv Surg Tech A 2023; 33:503-511. [PMID: 37062759 DOI: 10.1089/lap.2022.0537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
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.
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Affiliation(s)
- Illya Martynov
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Stefan Scholz
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lena Perger
- Division of Pediatric Surgery, Department of General Surgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
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16
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Thompson AR, Glick H, Rubalcava NS, Vernamonti JP, Speck KE. Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair. J Surg Res 2023; 283:313-323. [PMID: 36423481 DOI: 10.1016/j.jss.2022.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.
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Affiliation(s)
- Allison R Thompson
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan.
| | - Hannah Glick
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nathan S Rubalcava
- Department of Surgery, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona; Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Jack P Vernamonti
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Maine Medical Center, Portland, Maine
| | - K Elizabeth Speck
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Lai K, Hargis-Villanueva A, Velazco CS, Weidler EM, Garvey EM, van Leeuwen K, Lee J. Early postoperative feeding in single-stage repair of anorectal malformation with vestibular or perineal fistula is not associated with increased wound complications. J Pediatr Surg 2023; 58:467-470. [PMID: 35934522 DOI: 10.1016/j.jpedsurg.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The objective of this study is to assess the postoperative outcomes of single-stage repair of anorectal malformations with vestibular (VF) or perineal fistula (PF) and early initiation of postoperative feeding. METHODS A retrospective review of patients undergoing single-stage repair of isolated low anorectal malformations (VF and PF) from 2017 to 2020 was conducted. All patients underwent an anterior anoplasty with complete mobilization of the rectal fistula, or posterior sagittal anorectoplasty (PSARP), without protective colostomy. The variables examined include age, timing of postoperative feeding initiation, length of stay (LOS), and complications. RESULTS Nineteen patients with VF or PF underwent a single-stage repair. 12/19 (63%) patients were female. All 7 males and 9/12 females had a PF. The range of age at surgery was 2 days to 3 years with median age of 92 days [IQR 1,3: 9,193]. The median postoperative day for initiation of feeds was day 0 [IQR 1,3: 0,1] and median LOS was 1 day [IQR 1,3: 1,4.5]. 18/19 (95%) patients were evaluated in follow-up and there were no wound infections, wound dehiscences, or recurrent fistulas. Within 90 days postoperatively, no patients were seen in the emergency department for postoperative issues. Within 6 months, 2/19 (11%) patients required an unplanned return to the operating room for anal dilation. CONCLUSION In single-stage repair of isolated low anorectal malformations, VF and PF, early initiation of postoperative feeding is safe, results in a short length of stay, and does not lead to increased wound complications. Early enteral feeding eliminates the need for parenteral nutrition and central venous access, and their associated complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Angela Hargis-Villanueva
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Cristine S Velazco
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Erin M Garvey
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Justin Lee
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA.
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Fung ACH, Chu FYT, Chan IHY, Wong KKY. Enhanced recovery after surgery in pediatric urology: Current evidence and future practice. J Pediatr Urol 2023; 19:98-106. [PMID: 35995660 DOI: 10.1016/j.jpurol.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/04/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To offer an up-to-date appraisal of the current status of enhanced recovery after surgery (ERAS) protocols in pediatric urology and to provide a guide for the clinical urologist. MATERIALS AND METHODS We performed a comprehensive literature search and scoping review on ERAS protocols in pediatric urology using Pubmed (from 1946), Cochrane library, and MEDLINE to December 2021 with the terms ''enhanced recovery'', ''protocolised care'', ''post-operative protocol", ''fast-track surgery'' and ''pediatric urology". Studies were excluded if they did not include perioperative intervention related to urological procedures, no full-text available and in non-English language. RESULTS To date, eight clinical studies (involving 1153 patients) have been published on ERAS protocols in pediatric urology. The patients involved ranged from neonates to adolescents, and the urological procedures included bladder augmentation, the Mitrofanoff procedure, laparoscopic pyeloplasty, laparoscopic nephrectomy, hypospadias repair, etc. Multidisciplinary components such as surgical and anesthetic considerations have been employed in ERAS protocols. The length of hospital stay was significantly lower in the ERAS groups with earlier enteral feeding resumption and return of bowel function in pediatric urology patients. The implementation of ERAS protocols does not result in higher complication and readmission rates; instead, some studies have even demonstrated a significant reduction in complication occurrence. CONCLUSION ERAS is novel to pediatric urology with a limited scale of published data in the literature. Initial clinical studies revealed that ERAS appears to be efficacious in the field of pediatric urology. Further prospective studies formulating a standardized multimodal protocol are encouraged to better understand key components of ERAS and incorporate ERAS into clinical practice to optimize surgical outcomes for pediatric urology procedures.
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Fraser JA, Stewart S, Pierce AL, Orrick BA, St Peter SD, Oyetunji TA. Evaluating caretaker satisfaction with same-day discharge after gastrostomy tube placement. J Pediatr Surg 2023; 58:70-75. [PMID: 36272815 DOI: 10.1016/j.jpedsurg.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Amy L Pierce
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Beth A Orrick
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States.
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20
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Xie N, Xie H, Tang W. Baseline assessment of enhanced recovery after pediatric surgery in mainland China. Pediatr Surg Int 2022; 39:32. [PMID: 36459300 DOI: 10.1007/s00383-022-05315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China. METHODS We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD). RESULTS A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%). CONCLUSIONS The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.
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Affiliation(s)
- Nan Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Hua Xie
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210000, Jiangsu Province, China.
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21
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Martin LD, Chiem JL, Hansen EE, Low DK, Reece K, Casey C, Wingate CS, Bezzo LK, Merguerian PA, Parikh SR, Susarla SM, O'Reilly-Shah VN. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg 2022; 135:1271-1281. [PMID: 36384014 DOI: 10.1213/ane.0000000000006256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.
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Affiliation(s)
- Lynn D Martin
- From the Departments of Anesthesiology & Pain Medicine and Pediatrics
| | - Jennifer L Chiem
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth E Hansen
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Daniel K Low
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Corrie Casey
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Christina S Wingate
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Leah K Bezzo
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | | | - Sanjay R Parikh
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Srinivas M Susarla
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Vikas N O'Reilly-Shah
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
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22
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Esfahanian M, Marcott SC, Hopkins E, Burkart B, Khosla RK, Lorenz HP, Wang E, De Souza E, Algaze-Yojay C, Caruso TJ. Enhanced recovery after cleft palate repair: A quality improvement project. Paediatr Anaesth 2022; 32:1104-1112. [PMID: 35929340 DOI: 10.1111/pan.14541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. AIMS The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. METHODS A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts. RESULTS Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. CONCLUSION Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.
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Affiliation(s)
- Mohammad Esfahanian
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stephen Craig Marcott
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elena Hopkins
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA
| | - Brendan Burkart
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA
| | - Rohit Kumar Khosla
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - H Peter Lorenz
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellen Wang
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth De Souza
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Claudia Algaze-Yojay
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Thomas J Caruso
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
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23
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Beckman EJ, Hovey S, Bondi DS, Patel G, Parrish RH. Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy. J Pediatr Pharmacol Ther 2022; 27:490-505. [DOI: 10.5863/1551-6776-27.6.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022]
Abstract
Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.
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Affiliation(s)
- Elizabeth J. Beckman
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY (EJB)
| | - Sara Hovey
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, University of Illinois Hospital, Chicago, IL (SH)
| | - Deborah S. Bondi
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Gourang Patel
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, Columbus, GA (RHP)
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24
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Hanna DN, McKay KG, Ghani MO, Correa H, Zamora IJ, Lovvorn HN. Elective choledochal cyst excision is associated with improved postoperative outcomes in children. Pediatr Surg Int 2022; 38:817-824. [PMID: 35338382 DOI: 10.1007/s00383-022-05108-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The majority of pediatric patients with choledochal cysts (CDC) are symptomatic prior to undergoing CDC excision. This study investigated the impact of surgical timing of CDC excision on postoperative outcomes among children. METHODS We performed a retrospective review of 59 patients undergoing open CDC excision with Roux-Y hepaticojejunostomy between 2000 and 2020. Patients were grouped based on whether they underwent an electively scheduled or urgent CDC excision, as defined as CDC excision within the same admission due to CDC-related symptoms. Patient characteristics and perioperative data were compared between the two groups. RESULTS Patients who underwent an elective surgery were older, had more Todani-type 1 CDC, and had decreased postoperative hospital length of stay and opioid use compared to patients who underwent CDC excision within the same admission due to CDC-related symptoms. No significant differences emerged regarding postoperative complications. Multivariable analysis showed that elective cyst excision (HR = 0.55, p = 0.04; HR = 0.59, p = 0.008) and type 1 CDC (HR = 0.32, p = 0.03; HR = 0.12, p < 0.001) were independently associated with decreased opioid use and postoperative hospital length of stay. CONCLUSIONS Elective CDC excision is associated with shortened hospital stay and decreased opioid use among children compared to patients who undergo a CDC excision during the same admission for CDC-related symptoms.
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Affiliation(s)
- David N Hanna
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katlyn G McKay
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Muhammad O Ghani
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irving J Zamora
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville, Doctor's Office Tower 2220 Children's Way, Nashville, TN, 37232, USA.
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25
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Kirupaharan S, Briatico D, Robinson T, Fitzgerald P, Walton JM. Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now? J Pediatr Surg 2022; 57:927-931. [PMID: 35058061 DOI: 10.1016/j.jpedsurg.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia. METHODS Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant. RESULTS Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample. CONCLUSION Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.
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Affiliation(s)
- Sawmmiya Kirupaharan
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada
| | - Daniel Briatico
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Tessa Robinson
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Peter Fitzgerald
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; McMaster Children's Hospital, Hamilton, ON, Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, ON, Canada; Division of Pediatric General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; McMaster Children's Hospital, Hamilton, ON, Canada.
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26
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Bianchini S, Nicoletti L, Monaco S, Rigotti E, Corbelli A, Colombari A, Auriti C, Caminiti C, Conti G, De Luca M, Donà D, Galli L, Garazzino S, Inserra A, La Grutta S, Lancella L, Lima M, Lo Vecchio A, Pelizzo G, Petrosillo N, Piacentini G, Pietrasanta C, Principi N, Puntoni M, Simonini A, Tesoro S, Venturini E, Staiano A, Caramelli F, Gargiulo GD, Esposito S. Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.
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Affiliation(s)
- Sonia Bianchini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Laura Nicoletti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Sara Monaco
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Erika Rigotti
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Agnese Corbelli
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Annamaria Colombari
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00165 Rome, Italy;
| | - Maia De Luca
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Luisa Galli
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Silvia Garazzino
- Pediatric Infectious Diseases Unit, Regina Margherita Children’s Hospital, University of Turin, 10122 Turin, Italy;
| | - Alessandro Inserra
- General Surgery Department, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Stefania La Grutta
- Institute of Translational Pharmacology IFT, National Research Council, 90146 Palermo, Italy;
| | - Laura Lancella
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Mario Lima
- Pediatric Surgery, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Nicola Petrosillo
- Infectious Disease and Infection Control Unit, Campus Bio-Medico, Medicine University Hospital, 00128 Rome, Italy;
| | - Giorgio Piacentini
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Carlo Pietrasanta
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Mother, Child and Infant, 20122 Milan, Italy;
| | | | - Matteo Puntoni
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy;
| | - Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, 06129 Perugia, Italy;
| | - Elisabetta Venturini
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Annamaria Staiano
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Fabio Caramelli
- General and Pediatric Anesthesia and Intensive Care Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, Adult Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
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Doyle NM, Keeler K, Glenski TA, Goodrich E, Madhira M. Enhanced recovery after surgery in pediatric cerebral palsy patients undergoing bilateral lower extremity orthopedic surgery: A pilot study. Paediatr Anaesth 2022; 32:582-583. [PMID: 35212080 DOI: 10.1111/pan.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/21/2021] [Accepted: 11/28/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Nichole M Doyle
- Department of Anesthesiology, Children's Mercy Hospital, University of Missouri, Kansas City, Missouri, USA
| | - Kathryn Keeler
- Department of Orthopedic Surgery, Children's Mercy Hospital, University of Missouri, Kansas City, Missouri, USA
| | - Todd A Glenski
- Department of Anesthesiology, Children's Mercy Hospital, University of Missouri, Kansas City, Missouri, USA
| | - Ezra Goodrich
- University of Kansas School of Medicine, Kansas City, Missouri, USA
| | - Marisha Madhira
- University of Kansas School of Medicine, Kansas City, Missouri, USA
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Short SS, Zobell S, Gaddis K, Mammen L, Wynne E, Rollins MD. Use of expedited post-operative protocol for children undergoing appendicostomy reduces length of hospitalization. J Pediatr Surg 2022; 57:406-409. [PMID: 33962760 DOI: 10.1016/j.jpedsurg.2021.03.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/09/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management. In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. METHODS A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017-2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. RESULTS 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). CONCLUSIONS Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. LEVEL OF EVIDENCE Retrospective Comparative Study, Level III.
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Affiliation(s)
- Scott S Short
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States.
| | - Sarah Zobell
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
| | - Katherine Gaddis
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
| | - Lija Mammen
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
| | - Elisabeth Wynne
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
| | - Michael D Rollins
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
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Enhanced Recovery After Surgery for Pediatric Cleft Repair. J Craniofac Surg 2022; 33:1709-1713. [DOI: 10.1097/scs.0000000000008544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/21/2022] [Indexed: 02/07/2023] Open
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Balbale SN, Schäfer WLA, Davis T, Blake SC, Close S, Perry JE, Zarate RP, Ingram MC, Strople J, Johnson JK, Holl JL, Raval MV. Age- and Sex-Specific Needs for Children Undergoing Inflammatory Bowel Disease Surgery: A Qualitative Study. J Surg Res 2022; 274:46-58. [PMID: 35121549 DOI: 10.1016/j.jss.2021.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/10/2021] [Accepted: 12/27/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The use of enhanced recovery protocols (ERP) is extending to pediatric surgical populations, such as patients with inflammatory bowel diseases (IBDs). Given the variation in age- and sex-specific characteristics of pediatric IBD patients, it is important to understand the unique needs of subgroups, such as male versus female or preadolescent versus older patients, when implementing ERPs. We gathered clinician, patient, and caregiver perspectives on age- and sex-specific needs for children undergoing IBD surgery. METHODS We used semistructured interviews and focus groups to assess ERP needs and perceived differences in needs between preadolescent (10-13 y), older (14-19 y), male, and female IBD patients. Participants included clinicians, patients who had recent IBD surgery, and patients' caregivers. RESULTS Forty-eight clinicians, six patients, and eight caregivers participated. Three broad categories of themes emerged: concerns, needs, and experiences related to the (1) surgical care process; (2) continuum of IBD care; and (3) suggestions to make surgical care more patient centered. With regard to surgical care processes, stakeholders reported different communication needs for preadolescent and older children. Key themes about the continuum of IBD care were the need (1) for support from child life specialists and (b) to address young women's health issues. Suggestions to make surgical care more patient centered included providing older children with patient experiences that reflect their perspective as young adults. CONCLUSIONS The findings highlight the need to adopt a patient-centered approach for ERP use that actively addresses age- and sex-specific factors while engaging patients and caregivers as partners with clinicians to improve surgical care for children with IBD.
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Affiliation(s)
- Salva N Balbale
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Willemijn L A Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Teaniese Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Joseph E Perry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raul Perez Zarate
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Martha-Conley Ingram
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jennifer Strople
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:157-168. [PMID: 34524519 DOI: 10.1007/s00383-021-05008-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This systematic review examines the feasibility and safety of implementing Enhanced recovery after Surgery (ERAS) protocols in children. STUDY DESIGN A systematic search of Medline, PubMed, and the Cochrane library for papers describing ERAS implementation in children between January 2000 and January 2021. The systematic review was performed according to the PRISMA statement. The meta-analysis was done using R Software (Ver 4.0.2). p value of < 0.05 was considered statistically significant. RESULTS Sixteen studies, describing a total of 1723 patients, were included in the meta-analysis. An average of 15 (range 11-16) relevant components were implemented with an overall compliance close to 84%. The time to initiate feeds and reach full enteral nutrition was reduced in ERAS group with mean difference (MD) of - 21.20 h (95% CI - 22.80, - 19.59, p < 0.01), and - 2.20 days (95% CI - 2.72, - 1.71, p < 0.01), respectively. The use of opioids for postoperative analgesia was reduced with MD of -0.86 morphine equivalents mg/kg (95% CI - 1.40, - 0.32, p < 0.01). The length of hospital stay showed a significant reduction with MD of -2.54 days (95% CI - 2.94, - 2.13, p < 0.01). There was no difference in the complication and readmission rates between the groups. CONCLUSION ERP implementation in pediatric perioperative care is a viable option in a variety of surgical settings. There is clear evidence of a decrease in hospital stay duration with no increase in complication or readmission rates. The length of hospital stay reduced in inverse proportion to the number of ERAS elements implemented. Parental satisfaction is increased by initiating enteral feeding early, minimizing catheter and drain use, and reducing opioid use.
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Introduction of an enhanced recovery pathway results in decreased length of stay in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion: A description of implementation strategies and retrospective before-and-after study of outcomes. J Clin Anesth 2021; 75:110493. [PMID: 34482261 DOI: 10.1016/j.jclinane.2021.110493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE This study assessed whether implementation of an enhanced recovery-based pathway decreased length of stay without increasing readmissions among patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. DESIGN Retrospective observational before-and-after study. SETTING A tertiary children's hospital. PATIENTS A total of 117 patients were studied, 78 in the pre-intervention group and 39 in the post-intervention group. All patients underwent posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) in the same institution with one of two spine surgeons. Age, sex, American Society of Anesthesiologists physical status, and Cobb angle were comparable between the two groups. INTERVENTIONS Between the pre- and post-intervention groups an enhanced recovery protocol was developed. The pathway included standardized use of nonopioid analgesics, proactive transition to oral analgesics, scheduled antiemetics, plans for diet advancement, and specific physical therapy goals. MEASUREMENTS Outcome measurements included hospital length of stay, cumulative opioid doses in the first two postoperative days, and time to discontinuation of urinary catheter and patient-controlled analgesia. Postoperative emergency department visits, hospital readmissions and chronic pain management referrals were also measured. Pain scores on postoperative days one through four were recorded. MAIN RESULTS Hospital length of stay decreased from 4.6 days to 3.8 days. Patient-controlled analgesia (PCA) was discontinued one day earlier on average following pathway implementation. Average cumulative postoperative opioid use, in morphine equivalents, decreased in the first two postoperative days from 2.5 to 2.2 mg/kg. There was no change in hospital readmission rate or postoperative chronic pain referral. CONCLUSIONS Patients undergoing PSF for AIS experienced shorter hospital stays without increased readmissions following the implementation of an enhanced recovery pathway. Development of this pathway required buy-in from multiple stakeholders and significant coordination among services. The principles used to develop this pathway may be applied in other institutions and to other patient populations using the model outlined here.
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Rickard M, Chua M, Kim JK, Keefe DT, Milford K, Hannick JH, Dos Santos J, Koyle MA, Lorenzo AJ. Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty. World J Urol 2021; 39:3677-3684. [PMID: 33660089 DOI: 10.1007/s00345-021-03621-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/30/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits. METHODS We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits. RESULTS A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD. CONCLUSION Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.
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Affiliation(s)
- Mandy Rickard
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Michael Chua
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jin Kyu Kim
- Department of Urology, University of Toronto, Toronto, ON, Canada
| | - Daniel T Keefe
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Karen Milford
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jessica H Hannick
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Joana Dos Santos
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Martin A Koyle
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Schefft M, Noda A, Godbout E. Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2021; 7:138-151. [PMID: 38624879 PMCID: PMC8273156 DOI: 10.1007/s40746-021-00227-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children. Recent findings Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship. Summary The principles of stewardship and parsimonious care can improve patient safety for children.
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Affiliation(s)
- Matthew Schefft
- Department of Pediatrics, Division of Hospital Medicine, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Children’s Hospital of Richmond at VCU, 1001 E Marshall St, Richmond, VA 23298 USA
| | - Andrew Noda
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Emily Godbout
- Department of Pediatrics, Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Chan YY, Rosoklija I, Meade P, Burjek NE, Raval MV, Yerkes EB, Rove KO, Chu DI. Utilization of and barriers to enhanced recovery pathway implementation in pediatric urology. J Pediatr Urol 2021; 17:294.e1-294.e9. [PMID: 33663997 PMCID: PMC8217105 DOI: 10.1016/j.jpurol.2021.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/15/2021] [Accepted: 01/31/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Enhanced Recovery Pathways (ERPs), also known as ERAS® pathways, are standardized pathways composed of 21-24 perioperative elements designed to improve post-surgical recovery. ERP has been shown to be safe and effective in children undergoing bladder reconstruction but has not been widely utilized. OBJECTIVE The aim of this study was to assess utilization of ERPs in pediatric urology and identify barriers to establishing these standardized pathways. STUDY DESIGN Pediatric urologists who were members of the Societies for Pediatric Urology (SPU) were surveyed regarding their familiarity with standardized ERPs, current use of ERP elements, and encountered or perceived barriers to standardized ERP implementation. Willingness to implement ERP elements in a child undergoing bladder reconstruction was assessed with a 5-point Likert scale. Descriptive analysis was performed; Fisher's exact test was performed to assess associations between respondent demographics and ERP familiarity. RESULTS Of 714 distributed surveys, 113 (16%) valid responses were collected. 69% of respondents were male, 58% practiced at academic institutions, and 57% performed 1-5 bladder reconstructions a year. 61% were somewhat familiar or not familiar with standardized ERP. While 54% currently utilize individual ERP elements, only 20% have standardized pathways. Out of 24 possible ERP elements, a median of 15 elements (range 0-24) were implemented by the respondents whether they reported they were implementing ERP elements or had standardized pathways in place. 15 of 24 ERP elements were found to be nearly universally acceptable, with greater than 90% of respondents being somewhat or very willing to implement them in the presented case scenario (Summary Figure). 62% and 56% of those who currently implement ERP elements and experienced barriers noted lack of administrative/leadership support and inability to achieve consensus among pediatric colleagues, respectively, as common barriers in standardization. For those who have not attempted standardization, the most common perceived barrier was pathway unfamiliarity (48%). DISCUSSION Over half of respondents were not familiar with enhanced recovery pathways but were willing to implement a majority of the pathway elements, suggesting potential for ERP standardization in pediatric urology. Buy-in from colleagues and leadership would be necessary to overcome perceived barriers of standardized pathway development. CONCLUSION Administrative support and more widespread knowledge of ERP amongst pediatric urologists are necessary to facilitate further implementation in children undergoing bladder reconstruction.
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Affiliation(s)
- Yvonne Y Chan
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine
| | - Ilina Rosoklija
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Patrick Meade
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nicholas E Burjek
- Department of Pediatric Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine
| | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
| | - David I Chu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine.
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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Salaün JP, Ecoffey C, Orliaguet G. Enhanced recovery in children: how could we go further? WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000288. [DOI: 10.1136/wjps-2021-000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 11/04/2022] Open
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Lam JY, Howlett A, McLuckie D, Stephen LM, Else SDN, Jones A, Beaudry P, Brindle ME. Developing implementation strategies to adopt Enhanced Recovery After Surgery (ERAS®) guidelines. BJS Open 2020; 5:6056686. [PMID: 33688958 PMCID: PMC7944851 DOI: 10.1093/bjsopen/zraa011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/18/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Strong implementation strategies are critical to the success of Enhanced Recovery after Surgery (ERAS®) guidelines, though little documentation exists on effective strategies, especially in complex clinical situations and unfamiliar contexts. This study outlines the process taken to adopt a novel neonatal ERAS® guideline. METHODS The implementation strategy was approached in a multi-pronged, concurrent but asynchronous fashion. Between September 2019 and January 2020, healthcare providers from various disciplines and different specialties as well as parents participated in the strategy. Multidisciplinary teams were created to consider existing literature and local contexts including potential facilitators and/or barriers. Task forces worked collaboratively to develop new care pathways. An audit system was developed to record outcomes and elicit feedback for revision. RESULTS 32 healthcare providers representing 9 disciplines and 5 specialties as well as 8 parents participated. Care pathways and resources were created. Elements recommended for a successful implementation strategy included identification of champions, multidisciplinary stakeholder involvement, consideration of local contexts and insights, patient/family engagement, education, and creation of an audit system. CONCLUSION A multidisciplinary and structured process following principles of implementation science was used to develop an effective implementation strategy for initiating ERAS® guidelines.
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Affiliation(s)
- Jennifer Y Lam
- Department of Surgery, Section of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada.,Division of Pediatric Surgery, Western University, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Alexandra Howlett
- Department of Pediatrics, Section of Neonatology, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Duncan McLuckie
- Department of Anesthesia, Section of Pediatric Anesthesia, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Lori M Stephen
- Department of Pediatrics, Section of Neonatology, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Scott D N Else
- Department of Anesthesia, Section of Pediatric Anesthesia, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ashley Jones
- Patient and Family Advisor, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Paul Beaudry
- Department of Surgery, Section of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Mary E Brindle
- Department of Surgery, Section of Pediatric Surgery, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
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Pineda-Solis K, Burchard PR, Ruffolo LI, Schoeniger LO, Linehan DC, Moalem J, Galka E. Early Prediction of Length of Stay After Pancreaticoduodenectomy. J Surg Res 2020; 260:499-505. [PMID: 33358193 DOI: 10.1016/j.jss.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD). METHODS We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors". RESULTS A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008). CONCLUSIONS ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.
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Affiliation(s)
- Karen Pineda-Solis
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Paul R Burchard
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luis I Ruffolo
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luke O Schoeniger
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - David C Linehan
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacob Moalem
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Galka
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Townsley MM. Regional Anesthesia in Pediatric Cardiac Surgery: A Road to Enhanced Recovery. J Cardiothorac Vasc Anesth 2020; 34:3373-3375. [DOI: 10.1053/j.jvca.2020.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
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Xing M, Liang X, Li L, Liao L, Liang S, Jiang S, Li J, Zhang C, Zou W. Efficacy of caudal vs intravenous administration of α 2 adrenoceptor agonists to prolong analgesia in pediatric caudal block: A systematic review and meta-analysis. Paediatr Anaesth 2020; 30:1322-1330. [PMID: 32978991 DOI: 10.1111/pan.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND α2 adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α2 adrenoceptor agonists during pediatric caudal block. METHODS A systematic search, data extraction, bias risk assessment, and pooled data analysis were performed following the PRISMA guidelines. All randomized controlled trials comparing caudal with intravenous α2 adrenoceptor agonists in pediatric caudal block were included. Relative risk and weighted mean differences (the corresponding 95% confidence intervals) were calculated for dichotomous and continuous data, respectively. Trial sequential analyses were performed to evaluate the credibility of the meta-analysis. RESULTS A total of 244 patients in five trials were identified. Compared with the intravenous group (9.56 ± 4.23 hours), the time to the first rescue analgesia was prolonged in the caudal α2 adrenoceptor agonists group (12.72 ± 5.99 hours) by a weighted mean difference of 2.98 hours [95% confidence interval: 0.59-5.36 hours; P = .01]. The number of children requiring rescue analgesia in the caudal group (64, 66.67%) was lower than that in the intravenous group (80, 81.63%) [relative risk = 0.82; 95% confidence interval: 0.69-0.97; P = .02]. These findings were also verified by trial sequential analysis. There were no significant differences in the side effects. CONCLUSION Caudal α2 adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.
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Affiliation(s)
- Manyu Xing
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xia Liang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Li
- Department of Anesthesiology, The First Hospital of Changsha, Changsha, China
| | - Liping Liao
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Shuang Liang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Shasha Jiang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jingyi Li
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
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Xu L, Gong S, Yuan LK, Chen JY, Yang WY, Zhu XC, Yu SY, Huang R, Tian S, Ding HY, He MD, Xiao SJ. Enhanced recovery after surgery for the treatment of congenital duodenal obstruction. J Pediatr Surg 2020; 55:2403-2407. [PMID: 32571537 DOI: 10.1016/j.jpedsurg.2020.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been widely used in adult surgery. However, ERAS has not been reported in neonatal surgery. The present prospective study explored the application value of ERAS in treating congenital duodenal obstruction (CDO). METHODS A total of 68 cases of CDO were collected from October 1, 2017 to July 31, 2019. We divided patients with a prenatal diagnosis of congenital duodenal obstruction into the ERAS group and those who were diagnosed the disease after birth into the control group. The ERAS group adopted ERAS-related measures, and the control group followed the usual measures. The study compared the differences in the gestational age, birth weight, length of hospital stay (LOS), complications, feeding intolerance, and weight one month after surgery between the two groups. RESULTS A total of 49 patients were included in the analysis, including 23 who were allocated to the ERAS group and 26 to the control group. The LOS was 9.696±1.222 days in the ERAS group and 12.654±1.686 days in the control group, resulting in a significantly shorter LOS in the ERAS group than in the control group (p<0.001). One month after surgery, the neonates in the ERAS group weighted significantly more than those in the control group. No differences were observed in birth weight, gestational age, and the incidence of complications or feeding intolerance between the two groups. CONCLUSION In this single-center study, the implementation of neonate-specific ERAS for CDO surgery was feasible and safe and led to a shorter LOS without increasing the incidence of complications or feeding intolerance. TYPE OF STUDY Treatment Study LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Lu Xu
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Shu Gong
- Department of Radiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Li-Ke Yuan
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jia-Ying Chen
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wen-Yi Yang
- Reproductive Health and Infertility Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xiao-Chun Zhu
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Su-Yan Yu
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Rong Huang
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Song Tian
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hui-Yang Ding
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Mu-Dan He
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Shang-Jie Xiao
- Guangdong Women and Children's Hospital, Guangzhou Medical University.
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The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair. Pediatr Surg Int 2020; 36:1035-1045. [PMID: 32696123 DOI: 10.1007/s00383-020-04695-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures. METHODS Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization. RESULTS There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications. CONCLUSION Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.
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Roberts K, Brindle M, McLuckie D. Enhanced recovery after surgery in paediatrics: a review of the literature. BJA Educ 2020; 20:235-241. [PMID: 33456956 PMCID: PMC7807916 DOI: 10.1016/j.bjae.2020.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- K. Roberts
- Foothills Medical Centre, Calgary, Alberta, Canada
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - M. Brindle
- Alberta Children's Hospital, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | - D. McLuckie
- Alberta Children's Hospital, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
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Chen Y, Yuan JQ, Guo SG, Yang ZJ. Single-port laparoscopic appendectomy using a needle-type grasping forceps for acute uncomplicated appendicitis in children: Case series. Int J Surg Case Rep 2020; 70:216-220. [PMID: 32422581 PMCID: PMC7229346 DOI: 10.1016/j.ijscr.2020.03.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/17/2022] Open
Abstract
Acute appendicitis is the most common between the ages of 10 and 20 years. Our centre performed a new technology of single-port laparoscopic appendectomy using a needle-type grasping forceps (SLAN). SLAN has advantages of favourable cosmetic results, minimal trauma, and enhanced postoperative recovery.
Introduction Single-port laparoscopy has been used in any areas of surgery, including appendectomy, to reduce the operative stress and enhance postoperative recovery procedure. This paper introduces our attempt to perform single-port laparoscopic appendectomy using conventional laparoscoopic instruments and a needle-type grasping forceps (SLAN), which has dominant advantage in cosmetic appearance. Methods We report six pediatric patients who underwent SLAN for uncomplicated appendicitis from April to November 2019. SLAN was performed transumbilically, while conventional laparoscopic instruments and needle-type grasping forceps were both used. After routine intracorporeal appendectomy was completed, the pathological appendix was extracted through the single-port site, while a 10 mm trocar was used to avoid incision infectious. Clinical data and postoperative follow-up data were collected and analyzed to evaluate the feasibility, safety, and clinical outcomes of this novel technique. Results SLAN was successfully performed in all six pediatric patients. The median operative time, first exhaust time after surgery, pain score of postoperative day 1, and postoperative hospital stay were 69 (range, 50−85) min, 1.33 (range, 1–2) d, 0.83 (range, 0–3) score, 1.5 (range, 1–2) d, respectively. Neither intraoperative nor postoperative complications were noted, while no incision infectious, adhesive intestinal obstruction, and abdominal abscess were observed with 2–9 months follow up. Discussion Though there are many methods to perform single-port laparoscopic appendectomy, the use of needle grasping forceps in laparoscopic appendectomy has been confirmed a new choice for uncomplicated appendicitis in children. Conclusion SLAN is a feasible and safe technique to treat acute uncomplicated appendicitis in children. To be emphasized, surgeons must strictly grasp the indications for this surgery.
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Affiliation(s)
- Yang Chen
- Department of General Surgery, Chaoyang Central Hospital, Chaoyang, China.
| | - Jie-Qing Yuan
- Department of General Surgery, Chaoyang Central Hospital, Chaoyang, China.
| | - Shi-Gang Guo
- Department of General Surgery, Chaoyang Central Hospital, Chaoyang, China.
| | - Zhen-Jiang Yang
- Department of General Surgery, Chaoyang Central Hospital, Chaoyang, China.
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Brindle ME. The challenge of achieving continuous quality improvement in Canadian pediatric care. CMAJ 2020; 192:E79-E80. [PMID: 31995517 PMCID: PMC6989017 DOI: 10.1503/cmaj.200008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Mary E Brindle
- Departments of Surgery and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alta.
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Abstract
Enhanced recovery after surgery (ERAS) protocols are widely established in adult urology, especially for cystectomies and procedures involving the (small) bowel. However, data concerning pediatric surgery and pediatric urologic surgery are scarce. Individual items of ERAS protocols have been well-studied and significant benefits have also been shown for children without increased risk of complications. In a number of small series the safety and efficacy of implementing ERAS protocols have been reported recently. A broad consensus and a guideline for a common pediatric ERAS protocol is not yet available.
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