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Fan GQ, Zhang XD, He YK, Lu XG, Zhong JY, Pang ZY, Gan XY. Safety and feasibility of enhanced recovery after surgery-based management model for ambulatory pediatric surgical procedures. World J Clin Cases 2024; 12:4965-4972. [DOI: 10.12998/wjcc.v12.i22.4965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/16/2024] [Accepted: 06/05/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND There is still some room for optimizing ambulatory pediatric surgical procedures, and the preoperative and postoperative management quality for pediatric patients needs to be improved.
AIM To discuss the safety and feasibility of the enhanced recovery after surgery (ERAS)-based management model for ambulatory pediatric surgical procedures.
METHODS We selected 320 pediatric patients undergoing ambulatory surgery from June 2023 to January 2024 at The First People’s Hospital of Liangshan Yi Autonomous Prefecture. Of these, 220 received ERAS-based management (research group) and 100 received routine management (control group). General information, postoperative ambulation activities, surgical outcomes (operation time, postoperative gastrointestinal ventilation time, and hospital stay), postoperative pain visual analogue scale, postoperative complications (incision infection, abdominal distension, fever, nausea, and vomiting), and family satisfaction were compared.
RESULTS The general information of the research group (sex, age, disease type, single parent, family history, etc.) was comparable to that of the control group (P > 0.05), but the rate of postoperative (2 h, 4 h, and 6 h after surgery) ambulation activities was statistically higher (P < 0.01), and operation time, postoperative gastrointestinal ventilation time, and hospital stay were markedly shorter (P < 0.05). The research group had lower visual analogue scale scores (P < 0.01) at 12 h and 24 h after surgery and a lower incidence of total postoperative complications than the control group (P = 0.001). The research group had higher family satisfaction than the control group (P = 0.007).
CONCLUSION The ERAS-based management model was safe and feasible in ambulatory pediatric surgical procedures and worthy of clinical promotion.
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Affiliation(s)
- Gui-Quan Fan
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Xin-Dan Zhang
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Yong-Ke He
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Xiao-Gang Lu
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Ji-Yong Zhong
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Zong-Yang Pang
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
| | - Xi-Yang Gan
- Pediatric Surgery, The First People’s Hospital of Liangshan Yi Autonomous Prefecture, Xichang 615000, Sichuan Province, China
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Stangl-Kremser J, Olivera L, Giudici S, Pradere B, Mertens LS, Albisinni S, Laukhtina E, Del Giudice F, Afferi L, Soria F, Sforza S, O'Kelly F, Lammers RJ, Silay MS, Minervini A, Masieri L, Akhavan A, 't Hoen LA, Moschini M, Mari A. Application of the ERAS guidelines in pediatric urological surgery: a systematic review. Minerva Urol Nephrol 2024; 76:271-277. [PMID: 38920008 DOI: 10.23736/s2724-6051.24.05511-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Consensus for Enhanced Recovery After Surgery (ERAS) in pediatrics has been achieved in neonatal intestinal surgery, yet it is not widely utilized in pediatric urology. We investigated the application of ERAS guidelines in pediatric urology, and determined its effects given the available level of evidence supporting the ERAS protocol in children. EVIDENCE ACQUISITION A systematic literature review including series providing adoption of fast-track recovery protocols for pediatric urology procedures was carried out. Main outcome measures were study characteristics, adherence to the 19 ERAS items, complication rates and length of hospital stay. Sub-group analysis by surgery type (hypospadias versus major surgery) was performed. EVIDENCE SYNTHESIS Nine series with data from 1272 surgical pediatric cases were included. An enhanced recovery pathway was applied in 67.3% of the reports. Two series included patients undergoing hypospadias repair and ERAS items were insufficiently reported. Studies including children undergoing major procedures mentioned a median of 15 ERAS items, yet applied a median of 11 items. Median compliance rate was 88.9% (range 50-100). More ERAS guideline items were reported (applied or mentioned) in the most recently published studies. CONCLUSIONS There is limited reporting and use of the ERAS guidelines in urologic surgery particularly in hypospadias repair; whilst in major surgery in children, adherence and compliance rates vary widely. In more recent series there was an increase in ERAS items that have been mentioned and applied. Future research is needed to identify barriers and to overcome them in order to fully adopt and benefit from the ERAS pathway.
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Affiliation(s)
| | - Laura Olivera
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
- Department of Pediatric Urology, Meyer Children Hospital, University of Florence, Florence, Italy
| | - Sofia Giudici
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix du Sud Hôpital, Quint Fonsegrives, France
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Simone Albisinni
- Unit of Urology, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Ekaterina Laukhtina
- Comprehensive Cancer Center, Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Francesco Soria
- Urology Division, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Simone Sforza
- Department of Pediatric Urology, Meyer Children Hospital, University of Florence, Florence, Italy
| | - Fardod O'Kelly
- Division of Pediatric Urology, Beacon Hospital, University College, Dublin, Ireland
| | - Rianne J Lammers
- Department of Urology, University Medical Center, Groningen, the Netherlands
| | - Mesrur S Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Biruni University, Istanbul, Türkiye
| | - Andrea Minervini
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Lorenzo Masieri
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
- Department of Pediatric Urology, Meyer Children Hospital, University of Florence, Florence, Italy
| | - Ardavan Akhavan
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Lisette A 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marco Moschini
- Division of Experimental Oncology, Department of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Mari
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy -
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Strine AC, Chu DI, Brockel MA, Wilcox DT, Vricella GJ, Coplen DE, Traxel EJ, Chaudhry R, VanderBrink BA, Yerkes EB, Chan YY, Burjek NE, Zee RS, Herndon CDA, Ahn JJ, Merguerian PA, Meenakshi-Sundaram B, Rensing AJ, Frimberger D, Rove KO. Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study. J Pediatr Urol 2024; 20:256.e1-256.e11. [PMID: 38212167 PMCID: PMC11032233 DOI: 10.1016/j.jpurol.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/11/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION/BACKGROUND Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. OBJECTIVE We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. STUDY DESIGN Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. RESULTS A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. DISCUSSION The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. CONCLUSIONS ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.
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Affiliation(s)
- Andrew C Strine
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - David I Chu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan A Brockel
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Duncan T Wilcox
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Gino J Vricella
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Douglas E Coplen
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Erica J Traxel
- Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Rajeev Chaudhry
- Division of Pediatric Urology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian A VanderBrink
- Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Yvonne Y Chan
- Division of Pediatric Urology, Children's Health Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas E Burjek
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rebecca S Zee
- Division of Urology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - C D Anthony Herndon
- Division of Urology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Jennifer J Ahn
- Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Paul A Merguerian
- Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Bhalaajee Meenakshi-Sundaram
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Adam J Rensing
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Dominic Frimberger
- Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA
| | - Kyle O Rove
- Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Li Y, Ma Y, Guo W, Ge W, Cheng Y, Jin C, Guo H. Effect of transcutaneous electrical acupoint stimulation on postoperative pain in pediatric orthopedic surgery with the enhanced recovery after surgery protocol: a prospective, randomized controlled trial. Anaesth Crit Care Pain Med 2023; 42:101273. [PMID: 37419321 DOI: 10.1016/j.accpm.2023.101273] [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: 04/15/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
STUDY OBJECTIVE To evaluate the safety and effectiveness of transcutaneous electrical acupoint stimulation (TEAS) in postoperative analgesia following pediatric orthopedic surgery with the enhanced recovery after surgery (ERAS) protocol. DESIGN Prospective randomized controlled trial. SETTING The Seventh Medical Center of the Chinese People's Liberation Army General Hospital. PARTICIPANTS Eligible participants were children aged 3-15 years who were scheduled to undergo orthopedic surgery of the lower extremities under general anesthesia. INTERVENTIONS A total of 58 children were randomly allocated into two groups: TEAS (n = 29) and sham-TEAS (n = 29). The ERAS protocol was used in both groups. In the TEAS group, the bilateral Hegu (LI4) and Neiguan (PC6) acupoints were stimulated starting from 10 min before anesthetic induction until the completion of surgery. In the sham-TEAS group, the electric stimulator was also connected to the participants; however, electrical stimulation was not applied. MEASURES The primary outcome was the severity of pain before leaving the post-anesthesia care unit (PACU) and at postoperative 2 h, 24 h, and 48 h. Pain intensity was measured with the Faces Pain Scale-Revised (FPS-R). RESULTS None of the participants had any TEAS-related adverse reactions. In comparison with the sham-TEAS group, FPS-R scores in the TEAS group were significantly decreased before leaving the PACU and at postoperative 2 h and 24 h (p < 0.05). The incidence of emergence agitation, intraoperative consumption of remifentanil, and time to extubation were significantly reduced in the TEAS group. Furthermore, the time to first press of the patient-controlled intravenous analgesia (PCIA) pump was significantly longer, the pressing times of the PCIA pump in 48 h after surgery was significantly decreased, and parental satisfaction was significantly improved (all p < 0.05). CONCLUSION TEAS may safely and effectively relieve postoperative pain and reduce the consumption of perioperative analgesia in children following orthopedic surgery with the ERAS protocol. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200059577), registered on May 4, 2022.
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Affiliation(s)
- Yajun Li
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China.
| | - Yaqun Ma
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Wenzhi Guo
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Wenchao Ge
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Yafei Cheng
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Chenyan Jin
- Department of Anesthesiology, Shanxi Medical University, Taiyuan 030001, China; Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China
| | - Hang Guo
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing 100700, China.
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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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Enhanced Recovery After Surgery. Otolaryngol Clin North Am 2022; 55:1271-1285. [DOI: 10.1016/j.otc.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tesoro S, Gamba P, Bertozzi M, Borgogni R, Caramelli F, Cobellis G, Cortese G, Esposito C, Gargano T, Garra R, Mantovani G, Marchesini L, Mencherini S, Messina M, Neba GR, Pelizzo G, Pizzi S, Riccipetitoni G, Simonini A, Tognon C, Lima M. Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP). Surg Endosc 2022; 36:7877-7897. [PMID: 36121503 PMCID: PMC9613560 DOI: 10.1007/s00464-022-09577-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.
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Affiliation(s)
- Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, 35128, Padua, Italy.
| | - Mirko Bertozzi
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Fabio Caramelli
- Anesthesia and Intensive Care Unit, IRCCS Sant'Orsola Polyclinic, Bologna, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children's Hospital, Polytechnical University of Marche, Ancona, Italy
| | - Giuseppe Cortese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University of Naples, Naples, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
| | - Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giulia Mantovani
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Laura Marchesini
- Division of Anesthesia, Analgesia, and Intensive Care, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS San Matteo Polyclinic, Pavia, Italy
| | - Mario Messina
- Division of Pediatric Surgery, Santa Maria Alle Scotte Polyclinic, University of Siena, Siena, Italy
| | - Gerald Rogan Neba
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, Vittore Buzzi' Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milan, Milan, Italy
| | - Simone Pizzi
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, IRCCS San Matteo Polyclinic, University of Pavia, Pavia, Italy
| | - Alessandro Simonini
- Department of Pediatric Anesthesia and Intensive Care, Salesi Children's Hospital, Ancona, Italy
| | - Costanza Tognon
- Pediatric Anesthesia, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Mario Lima
- Pediatric Surgery Unit, IRCCS Policlinico Sant'Orsola, University of Bologna, Bologna, Italy
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Invited commentary on Moon, et al: An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay. J Pediatr Surg 2022; 57:266-267. [PMID: 35811166 DOI: 10.1016/j.jpedsurg.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022]
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Mittal S, Eftekharzadeh S, Aghababian A, Shah J, Fischer K, Weaver J, Tan C, Plachter N, Long C, Weiss D, Zaontz M, Kolon T, Zderic S, Canning D, Van Batavia J, Shukla A, Srinivasan A. Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis. J Pediatr Urol 2022; 18:501.e1-501.e7. [PMID: 35803865 DOI: 10.1016/j.jpurol.2022.05.025] [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: 01/11/2022] [Revised: 04/20/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVE Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events. STUDY DESIGN All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated. RESULTS 438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04). DISCUSSION The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries. CONCLUSIONS Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Sahar Eftekharzadeh
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Aznive Aghababian
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Jay Shah
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Katherine Fischer
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - John Weaver
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Connie Tan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Natalie Plachter
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher Long
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Dana Weiss
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Mark Zaontz
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Thomas Kolon
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Stephen Zderic
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Douglas Canning
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Jason Van Batavia
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Aseem Shukla
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
| | - Arun Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA.
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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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