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Pei J, Wang S, Pan X, Wu M, Zhan X, Fang K, Wang D, Wang W, Zhu G, Tang H, An N, Peng J. Effect of enhanced recovery after surgery on postoperative outcomes in children undergoing robot-assisted laparoscopic pyeloplasty. J Pediatr Urol 2024:S1477-5131(24)00473-X. [PMID: 39389872 DOI: 10.1016/j.jpurol.2024.09.019] [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: 04/03/2024] [Revised: 09/18/2024] [Accepted: 09/23/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE To assess the effects of the enhanced recovery after surgery (ERAS) perioperative protocol on the outcomes of robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients. METHODS A total of 57 children who underwent RALP at our center between November 2021 and December 2023 were included in the study. They were randomly assigned to either the ERAS (intervention) group or the non-ERAS (control) group. The analysis focused on comparing the length of hospital stay, recovery of gastrointestinal function, incidence of complications within 90 days post-surgery, postoperative extubation time (urinary tube and double-J tube), postoperative auxiliary examinations, and readmission rates within 30 days. Additionally, the patients were divided into two age groups: <4 years old and ≥4 years old, to assess pain severity. RESULTS There were no significant differences in preoperative general information, preoperative auxiliary examination findings, or intraoperative conditions between the ERAS and non-ERAS groups. The ERAS group had a significantly shorter postoperative hospital stay compared to the non-ERAS group. Furthermore, the time to the first postoperative bowel movement was shorter, and the incidence of postoperative complications was significantly lower in the ERAS group. Among children <4 years old, there was no significant difference in pain severity between the two groups. However, in children ≥4 years old, the ERAS group experienced significantly lower pain levels at 6 and 24 h post-surgery compared to the non-ERAS group. DISCUSSION The findings of this prospective randomized controlled trial should determine if ERAS is superior to traditional perioperative management in children undergoing RALP, particularly regarding postoperative hospital stay, intestinal function recovery, pain response, and complication rates. We anticipate that our data will offer valuable clinical insights and guidance for the implementation of ERAS in pediatric robotic surgery for urinary diseases. CONCLUSION The ERAS protocol can reduce the length of hospital stay, aid in the recovery of gastrointestinal function, and lower postoperative complication rates. It also has the potential to lessen postoperative pain to varying degrees in certain pediatric patients. ERAS is a safe and effective protocol for pediatric patients undergoing RALP.
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Affiliation(s)
- Jun Pei
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Shili Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Xingyu Pan
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Moudong Wu
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Xiong Zhan
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Dan Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Wei Wang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Guohua Zhu
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Hongyu Tang
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Nini An
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
| | - Jinpu Peng
- Department of Pediatric Surgrey, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
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Mahesri K, Mayon L, Chiang YJ, Swartz MC, Moody K, Kapoor R, Austin M. An Enhanced Recovery Program for Pediatric, Adolescent, and Young Adult Surgical Oncology Patients Improves Outcomes After Surgery. J Pediatr Surg 2024:161912. [PMID: 39384490 DOI: 10.1016/j.jpedsurg.2024.161912] [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: 12/05/2023] [Revised: 08/17/2024] [Accepted: 09/05/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Enhanced Recovery after Surgery (ERAS®) is a standardized perioperative approach that utilizes a multidisciplinary team to reduce physiologic stress and improve postoperative recovery. The purpose of our study is to evaluate outcomes in pediatric, adolescent, and young adult (AYA) patients undergoing major oncologic operations before and after the implementation of an enhanced recovery program (ERP). METHODS All patients ≤23 years old who underwent major oncologic surgery between 1/2017-2/2022 were identified. ERP was implemented on 6/7/2021, with all patients enrolling on ERP after that date. Pre-ERP patients were selected based on similar age, diagnosis, and operations. The Mann-Whitney U-test was used to compare continuous variables, and the chi-squared test or Fisher exact test as appropriate to compare categorical variables between Pre-ERP and ERP patients. RESULTS A total of 47 patients were included (28 Pre-ERP, 19 ERP). The median age was 14 years (range, 1-23). 18 underwent thoracotomy, 26 laparotomy, and 3 chest wall resections. Results suggest that ERP patients had significantly shorter time to ambulation (25 h; p = 0.004) and postoperative length of stay (LOS; 3 days; p < 0.001). Two patients in the ERP group required zero narcotics after operation. CONCLUSION We found initial evidence that the implementation of an ERP for pediatric, AYA patients resulted in positive postoperative outcomes - a decrease in postoperative LOS and promoted early mobility without an increase in readmission rates. Enhanced recovery programs should be incorporated into the care of pediatric, AYA oncology patients undergoing oncologic surgery. LEVEL OF EVIDENCE Retrospective Comparative Study - Level III.
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Affiliation(s)
- Kumail Mahesri
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA; The University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX 77030, USA.
| | - Lauren Mayon
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Yi-Ju Chiang
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Maria C Swartz
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Karen Moody
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Ravish Kapoor
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Mary Austin
- The University of Texas Health Science Center at Houston, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Smith CJ, Schäfer WLA, Wilberding MJ, Reiter A, Sullivan GA, Hu A, Holl JL, Balbale SN, Blake SC, Close S, Davis TL, Johnson JK, Raval MV. Fidelity of Enhanced Recovery Protocol Implementation With Assessment of Hospital-Specific Materials. J Surg Res 2024; 302:469-475. [PMID: 39167901 DOI: 10.1016/j.jss.2024.07.087] [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: 02/01/2024] [Revised: 06/20/2024] [Accepted: 07/06/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Variability in implementation of enhanced recovery protocols (ERPs) often reduces the effects of an intervention on clinical outcomes. This study aimed to evaluate hospital-level implementation fidelity to a pediatric gastrointestinal surgery ERP by assessing site-specific implementation materials. METHODS This document analysis study operationalized implementation fidelity as adherence to the creation of specified materials at each study site. During the 12-mo implementation phase within the stepped-wedge cluster randomized control trial, ENhanced Recovery In CHildren Undergoing Surgery, study sites were provided with materials (e.g., order sets), access to peer-counseling, and given key ERP elements spanning multiple phases of care. Sixteen of the 18 total study sites submitted implementation materials, including 14 anesthesia protocols, 11 order sets, and 16 sets of patient/family education materials. These materials were assessed and graded for fidelity using prespecified criteria. Hospital-level fidelity scores could range from 0 to a maximum score of 18, and were categorized as either high or low, based on whether the score was above or below/equal to the median. Descriptive statistics and Wilcoxon rank sum test were used for analysis. RESULTS The overall hospital-level median fidelity score for inclusion of ERP elements in the implementation materials was 10.5. The median score was 12.8 at nine high-fidelity sites and was 5.6 at nine low-fidelity sites (P < 0.01). Higher adherence was noted for avoiding prolonged fasting (n = 16/18 hospitals; 89%) and preventing nausea and vomiting (n = 16/18 hospitals; 89%) in anesthesia protocols and/or order sets. Lower adherence was noted for incorporation of minimally invasive surgical techniques (n = 2/18 hospitals, 11%) and of preoperative optimization of medical comorbidities (n = 0/18 hospitals, 0%) in implementation materials. CONCLUSIONS Despite substantial resources to promote ERP elements, there was wide variation in fidelity for incorporating ERPs into implementation materials among hospital sites. Development of high-fidelity implementation materials for complex ERPs for gastrointestinal surgery in children may require longer than 12 months. Additional implementation strategies, resources, and modification of implementation-focused materials may be needed.
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Affiliation(s)
- Charesa J Smith
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Willemijn L A Schäfer
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Maxwell J Wilberding
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Audra Reiter
- Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Gwyneth A Sullivan
- Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Andrew Hu
- Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, Illinois
| | - Salva N Balbale
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, Chicago, Illinois; Department of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL & Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sharron Close
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Teaniese L Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Julie K Johnson
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, 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; Department of Surgery, Feinberg School of Medicine, Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University, 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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Su L, Wu F, Wang H. Enhanced recovery after surgery in children with congenital scoliosis. Sci Rep 2024; 14:19270. [PMID: 39164304 PMCID: PMC11335747 DOI: 10.1038/s41598-024-66476-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/01/2024] [Indexed: 08/22/2024] Open
Abstract
To assess the impact of Enhanced Recovery After Surgery (ERAS) protocol in children undergoing corrective surgery for congenital scoliosis. A retrospective analysis was conducted on children undergoing surgical correction for congenital scoliosis, with participants categorized into either the ERAS group or the control group. Comparative evaluations were made across clinical, surgical, laboratory, and quality of life parameters. Following propensity score matching, 156 patients were analyzed. Within the initial 3 days following surgery, the ERAS cohort demonstrated lower pain intensity and exhibited higher daily oral intake compared to their counterparts in the control group. A mere 14.1% of patients in the ERAS group experienced a peak body temperature exceeding 38.5°, illustrating a significantly lower incidence compared to the 33.3% recorded in the control group. The ERAS cohort displayed expedited timeframes for the onset of initial bowel function and postoperative discharge when contrasted with the control group. Levels of IL-6 assessed on the third day post-surgery were markedly reduced in the ERAS group in comparison to the control group. Noteworthy is the similarity observed in postoperative hemoglobin and albumin levels measured on the first and third postoperative days between the two groups. Assessments of quality of life using SF-36 and SRS-22r questionnaires revealed comparable scores across all domains in the ERAS group when juxtaposed with the control cohort. ERAS protocol has demonstrated a capacity to bolster early perioperative recovery, alleviate postoperative stress responses, and uphold favorable quality of life outcomes in children undergoing corrective surgery for congenital scoliosis.
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Affiliation(s)
- Li Su
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China
| | - Feiran Wu
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China
| | - Hui Wang
- Department of Spine, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Zhengzhou, China.
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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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Thompson AR, Vernamonti JP, Rollins P, Speck KE. Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments. J Surg Res 2024; 298:371-378. [PMID: 38669783 DOI: 10.1016/j.jss.2024.03.039] [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: 08/14/2023] [Revised: 02/25/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.
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Affiliation(s)
- Allison R Thompson
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Jack P Vernamonti
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Department of Surgery, Maine Medical Center, Portland, Maine
| | - Paris Rollins
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - K Elizabeth Speck
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Mansfield SA, Kotagal M, Hartman S, Murphy AJ, Davidoff AM, Anghelescu DL, Mecoli M, Cost N, Hogan B, Rove KO. Development of an enhanced recovery after surgery program for pediatric solid tumors. Front Surg 2024; 11:1393857. [PMID: 38840973 PMCID: PMC11150694 DOI: 10.3389/fsurg.2024.1393857] [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: 02/29/2024] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) is an evidence-based, multi-modal approach to decrease surgical stress, expedite recovery, and improve postoperative outcomes. ERAS is increasingly being utilized in pediatric surgery. Its applicability to pediatric patients undergoing abdominal tumor resections remains unknown. Methods and Analysis A group of key stakeholders adopted ERAS principles and developed a protocol suitable for the variable complexity of pediatric abdominal solid tumor resections. A multi-center, prospective, propensity-matched case control study was then developed to evaluate the feasibility of the protocol. A pilot-phase was utilized prior to enrollment of all patients older than one month of age undergoing any abdominal, retroperitoneal, or pelvic tumor resections. The primary outcome was 90-day complications per patient. Additional secondary outcomes included: ERAS protocol adherence, length of stay, time to administration of adjuvant chemotherapy, readmissions, reoperations, emergency room visits, pain scores, opioid usage, and differences in Quality of Recovery 9 scores. Ethics and Dissemination Institutional review board approval was obtained at all participating centers. Informed consent was obtained from each participating patient. The results of this study will be presented at pertinent society meetings and published in peer-reviewed journals. We expect the results will inform peri-operative care for pediatric surgical oncology patients and provide guidance on initiation of ERAS programs. We anticipate this study will take four years to meet accrual targets and complete follow-up. Trial Registration Number NCT04344899.
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Affiliation(s)
- Sara A. Mansfield
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Meera Kotagal
- Department of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Stephen Hartman
- Department of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Andrew J. Murphy
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Doralina L. Anghelescu
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Marc Mecoli
- Division of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Nicholas Cost
- Department of Urology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Brady Hogan
- Department of Urology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Kyle O. Rove
- Department of Urology, Children’s Hospital Colorado, Aurora, CO, United States
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Nasher O, Thornber J, Dean J, Goldthorpe J, Rajfeld L, Smith L, Hannon E. The principles of enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG): a UK tertiary center experience. Pediatr Surg Int 2024; 40:123. [PMID: 38704451 DOI: 10.1007/s00383-024-05693-1] [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: 04/08/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) pathways have been shown to improve surgical outcomes and patient satisfaction. The aim of the study was to assess whether the implementation of a perioperative enhanced recovery after percutaneous endoscopic gastrostomy (ERaPEG) pathway based on ERAS principles was safe, satisfactory to parents and improved outcomes. METHODS Following a quality improvement project, a multimodal ERaPEG pathway was introduced as standard practice within the department and children undergoing elective same-day admission percutaneous endoscopic gastrostomy (PEG) at a single UK tertiary center were prospectively enrolled. Exclusion criteria were patients undergoing other concurrent procedures and those who underwent a laparoscopic assisted/open procedure. Data included patient demographics, underlying diagnosis, indication, length of stay (LOS) and 30-day readmission. Parental experience and satisfaction were determined using a questionnaire including 5-point Likert scales. A retrospective cohort was used for comparison. Data were analyzed using Chi-Square test and Mann-Whitney U tests. RESULTS Ninety-five patients met the inclusion criteria: 50 pre and 45 post the implementation of ERaPEG. Median age was 3 and 2 years, respectively. Neurodisability was the underlying diagnosis in most patients (84%-pre-ERaPEG; 76%-post-ERaPEG). Most common PEG indication was medication/nutritional supplementation (52%-pre-ERaPEG; 51%-post-ERaPEG). The LOS significantly decreased from a median of 51.5 h (pre-ERaPEG) to 32 h (post-ERaPEG) (p < 0.001). Thirty-day readmission rates were similar (6% vs 11%). Most parents felt that the educational material was easy to access and understand. Post-operatively the majority of parents (≥ 80%) were confident in managing the gastrostomy device, setting up/giving the feeds and also felt that the LOS was appropriate. CONCLUSION This study shows that the implementation of an ERaPEG pathway significantly reduced LOS following PEG. In addition, the pathway was satisfactory to parents and offered the benefit of improved resource utilization.
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Affiliation(s)
- Omar Nasher
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Julia Thornber
- Nutrition & Dietetics, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Dean
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jenny Goldthorpe
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Linsay Rajfeld
- Department of Pediatric Gastroenterology, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Liz Smith
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edward Hannon
- Department of Pediatric Surgery, Leeds Children's Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Zhang H, Liu H, Zhang X, Zhao M, Guo D, Bai Y, Qi X, Shi H, Li D. Short-term outcomes of an enhanced recovery after surgery pathway for children with congenital scoliosis undergoing posterior spinal fusion: a case-control study of 70 patients. J Pediatr Orthop B 2024; 33:258-264. [PMID: 37339529 DOI: 10.1097/bpb.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Increasing evidence demonstrates the advantages of an enhanced recovery after surgery (ERAS) protocol; however, few studies have evaluated ERAS in pediatric patients. This study aimed to evaluate the effect of ERAS in pediatric patients with congenital scoliosis. Seventy pediatric patients with congenital scoliosis underwent posterior hemivertebra resection and fusion with pedicle screws and were prospectively randomly assigned to the ERAS group ( n = 35) and control group ( n = 35). ERAS management comprised 15 elements including a shortened fasting time, optimized anesthesia protocol, and multimodal analgesia. The control group received traditional perioperative management. Clinical outcome was evaluated by hospital stay, surgery-related indicators, diet, pain scores, laboratory tests, and complications. The surgical outcome showed a similar correction rate in the ERAS group (84.0%) and control group (89.0%; P = 0.471). The mean fasting time was significantly shorter in the ERAS group than in the control group. Compared with the control group, the ERAS group had significantly shorter mean times to postoperative hospital stay, first anal exhaust and defecation, significantly lower mean pain scores in the first 2 days postoperatively ( P < 0.05), and a significantly lower mean interleukin-6 concentration on postoperative day 1 ( P < 0.001). The incidence of complications was similar in the ERAS group and control group ( P > 0.05). The ERAS protocol is effective and safe for pediatric patients with congenital spinal deformity and may significantly improve the treatment efficacy compared with traditional perioperative management methods. Levels of Evidence: III.
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Affiliation(s)
- Hanwen Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haonan Liu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xuejun Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Mengqi Zhao
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Dong Guo
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Yunsong Bai
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xinyu Qi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haixia Shi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Duoyi Li
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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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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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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12
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Perez MN, Raval MV. Evolution of enhanced recovery for children undergoing elective intestinal surgery. Semin Pediatr Surg 2024; 33:151400. [PMID: 38608432 DOI: 10.1016/j.sempedsurg.2024.151400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Enhanced recovery protocols (ERP) have been widely adopted in adult populations, with over 30 years of experience demonstrating the effectiveness of these protocols in patients undergoing gastrointestinal (GI) surgery. In the last decade, ERPs have been applied to pediatric populations across multiple subspecialties. The objective of this manuscript is to explore the evolution of how ERPs have been implemented and adapted specifically for pediatric populations undergoing GI surgery, predominantly for inflammatory bowel disease. The reported findings reflect a thorough exploration of the literature, including initial surveys of practice/readiness assessments, consensus recommendations of expert panels, and data from a rapidly growing number of single center studies. These efforts have culminated in a national prospective, multicenter trial evaluating clinical and implementation outcomes for enhanced recovery in children undergoing GI surgery. In short, this historical and clinical review reflects on the evolution of ERPs in pediatric surgery and expounds upon the next steps needed to apply ERPs to future pediatric populations.
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Affiliation(s)
- Mallory N Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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13
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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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Issac A, Dhiraaj S, Halemani K, Thimmappa L, Mishra P, Kumar B, Mavinatop A. Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2023; 33:454-462. [PMID: 36724826 DOI: 10.1055/s-0043-1760837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.
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Affiliation(s)
- Alwin Issac
- College of Nursing, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Orissa, India
| | - Sanjay Dhiraaj
- Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kurvatteppa Halemani
- College of Nursing, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Latha Thimmappa
- College of Nursing, All India Institute of Medical Sciences Kalyani, Kalyani, West Bengal, India
| | - Prabhakar Mishra
- Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Basant Kumar
- Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anusha Mavinatop
- Department Nutrition/Dietetic, JSS Medical College, Mysore, Karnataka, India
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15
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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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16
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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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17
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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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Lewit R, Phillips A, Camp L, Knaus M, Bright M, Mansfield S, Craner D, Harmon K, Hayes K, Holden K, Kelly E, St John B, Paton E, Gosain A. Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation. J Surg Res 2023; 288:290-297. [PMID: 37058985 DOI: 10.1016/j.jss.2023.03.025] [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: 12/05/2022] [Revised: 02/25/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
INTRODUCTION There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation. METHODS This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation. RESULTS The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14). CONCLUSIONS For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.
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Affiliation(s)
- Ruth Lewit
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Alisa Phillips
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Lauren Camp
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Maria Knaus
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Michael Bright
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Sara Mansfield
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Domenic Craner
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Kristin Harmon
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Kathleen Hayes
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Kylie Holden
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Emma Kelly
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Bradley St John
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Elizabeth Paton
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Ankush Gosain
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.
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Sullivan GA, Schäfer WLA, Raval MV, Johnson JK. Implementation science for quality improvement in pediatric surgery. Semin Pediatr Surg 2023; 32:151282. [PMID: 37075658 DOI: 10.1016/j.sempedsurg.2023.151282] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Despite the widespread integration of quality improvement principles into pediatric surgical practice, the actual adoption of evidence-based practices continues to be a challenge. The field of pediatric surgery, in particular, has been slow to adopt clinical pathways and protocols that lead to decreased practice variation and improved clinical outcomes. This manuscript provides an introduction to how implementation science principles into quality improvement efforts may optimize uptake of evidence-based practices, ensure success of these endeavors, and help assess the effectiveness of the interventions. Examples of implementation science application to pediatric surgical quality improvement endeavors are explored.
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Affiliation(s)
- Gwyneth A Sullivan
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Willemijn L A Schäfer
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Mehul V Raval
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611
| | - Julie K Johnson
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, 633 N. Saint Clair St, 20(th) floor, Chicago, IL 60611.
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Close S, Blake SC, Davis TT, Balbale SN, Perry JE, Weingard R, Ingram MC, Schäfer W, Strople J, Raval MV. Implementation of Enhanced Recovery Protocols for Gastrointestinal Surgery in Children: Practical Tools From Key Stakeholders. J Surg Res 2023; 284:204-212. [PMID: 36586313 PMCID: PMC9911379 DOI: 10.1016/j.jss.2022.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/10/2022] [Accepted: 11/25/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION We explored patient, caregiver, and provider recommendations for development of a tool kit to implement enhanced recovery protocols (ERPs) for pediatric patients undergoing gastrointestinal surgery. ERPs are widely used for adults to decrease hospital length of stay, hospital costs, and complications while hastening patient recovery after surgery. With limited data available for ERPs among pediatric populations informed modification of adult ERPs is needed to facilitate successful implementation for pediatric surgery. METHODS Using a qualitative research design, semistructured interviews were conducted with hospital-based teams including surgeons, anesthesiologists, gastroenterologists, nursing, and physician assistants. Four in-person focus groups were held at two pediatric hospitals with patients and caregivers. Codes were developed and applied to interview and focus groups transcripts for structural content analysis. Thematic analysis guided by the Active Implementation Framework, included recommendations that informed ERP implementation tool kit development. RESULTS Key components of the ERP tool kit included the need for a structured and systematic approach, leadership support from key champions, and buy-in from surgical partners and hospital management. Providers identified the need for multimodal educational materials on ERP elements for staff and patients; use of uniform checklists, care sets and an electronic repository to collect outcome data for quality assurance assessment. Patients and caregivers endorsed expansion of the team to include child-life specialists, nutritionists, and patient-parent supporters to help navigate the surgical experience. CONCLUSIONS This study is the first to leverage key input from patients, caregivers, and providers to identify practical components for an ERP implementation tool kit for children undergoing gastrointestinal surgery.
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Affiliation(s)
- Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Teaniese Tina Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Salva N Balbale
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph E Perry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Reed Weingard
- 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; Division of Gastroenterology and Hepatology, Department of 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
| | - Willemijn Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, 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
| | - 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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21
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Svetanoff WJ, Diefenbach K, Hall B, Craver A, Rutledge S, McManaway C, Eneli I, Tobias J, Michalsky MP. Utilization of an Enhanced Recovery After Surgery (ERAS) protocol for pediatric metabolic and bariatric surgery. J Pediatr Surg 2023; 58:695-701. [PMID: 36641311 DOI: 10.1016/j.jpedsurg.2022.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) protocols for pediatric metabolic and bariatric surgery are limited. In 2018, an ERAS protocol for patients undergoing robotically assisted vertical sleeve gastrectomy (r-VSG) was instituted. This study's aim was to compare outcomes before and after ERAS initiation. METHODS A single institution retrospective review of patients undergoing r-VSG from July 2015 to July 2021 was performed. The multimodal ERAS protocol focused on limiting post-operative nausea and narcotic utilization. Subjects were categorized into non-ERAS (July 2015-July 2018) and ERAS (August 2018-July 2021) groups. In-hospital and 30-day outcomes were compared. RESULTS 110 subjects (94 females) with a median age of 17.6 years (range 12.5-22.0 years) were included (60 non-ERAS, 50 ERAS). Demographics were similar except for a higher proportion of females in the non-ERAS group (97% vs 72%, p < 0.001). A significant decrease in narcotic use (p < 0.001) and higher utilization of acetaminophen (p < 0.001) and ketorolac (p < 0.001) was observed in the ERAS group. Additionally, median time to oral intake, a proxy for postoperative nausea and vomiting [2:00 h (1:15, 2:30) vs. 3:22 h (2:03, 6:15), p < 0.001] and hospital length of stay (LOS) [1.25 days (1.14, 1.34) vs. 2.16 days (1.48, 2.42), p < 0.001] were shorter in the ERAS group. Eleven subjects (10%; ERAS = 5, non-ERAS = 6) experienced post-discharge dehydration, prompting readmission 8 times for 7 (6%) individuals. CONCLUSION Utilization of ERAS led to a significant decrease narcotic utilization, time to first oral intake, and hospital LOS with no change in adverse events following pediatric metabolic and bariatric surgery. Larger studies, including comparative analysis of health care utilization, should be carried out. LEVEL OF EVIDENCE III. TYPE OF STUDY Treatment Study.
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Affiliation(s)
- Wendy Jo Svetanoff
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Karen Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Brian Hall
- Department of Anesthesia and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Amber Craver
- Department of Anesthesia and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Sarah Rutledge
- Department of Anesthesia and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Cindy McManaway
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Ihuoma Eneli
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Joseph Tobias
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Marc P Michalsky
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
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22
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Eakes AM, Purcell LN, Burkbauer L, McCauley CM, Mangat S, Lupa C, Akinkuotu AC, McLean SE, Phillips MR. The Effect of an Enhanced Recovery Protocol on Pediatric Colorectal Surgical Patient Outcomes at a Single Institution. Am Surg 2023:31348231161673. [PMID: 36912211 DOI: 10.1177/00031348231161673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Enhanced recovery protocols (ERP) have been associated with fewer postoperative complications in adult colorectal surgery patients, but there is a paucity of data on pediatric patients. Our aim is to describe the effect of an ERP, compared to conventional care, on pediatric colorectal surgical complications. MATERIALS AND METHODS We performed a single institution, retrospective cohort study (2014-2020) on pediatric (≤18 years old) colorectal surgery patients pre- and post-implementation of an ERP. Bivariate analysis and logistic regression were used to assess the effect of an ERP on return visits to the emergency room, reoperation, and readmission within 30-days. RESULTS There were 194 patients included in this study, with 54 in the control cohort and 140 in the ERP cohort. There was no significant difference in the age, BMI, primary diagnosis, or use of laparoscopic technique between the cohorts. The ERP cohort had a significantly shorter foley duration, postoperative stay, and had nerve blocks performed. After controlling for pertinent covariates, the ERP cohort experienced higher odds of reoperation within 30 days (OR 5.83, P = .04). There was no significant difference in the other outcomes analyzed. CONCLUSION In this study, there was no difference in the odds of overall complications, readmission or return to the ER within 30-days of surgery. However, although infrequent, there were higher odds of returns to the OR within 30 days. Future studies are needed to analyze how adherence to individual components may influence patient outcomes to ensure patient safety during ERP implementation.
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Affiliation(s)
- Ali M Eakes
- School of Medicine, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura N Purcell
- Department of Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura Burkbauer
- Department of Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christopher M McCauley
- Department of Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sabrina Mangat
- Department of Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Concetta Lupa
- Department of Anesthesiology, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adesola C Akinkuotu
- Department of Surgery, Division of Pediatric Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, Division of Pediatric Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Department of Surgery, Division of Pediatric Surgery, 214495University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Raval MV, Brockel MA, Kolaček S, Simpson KE, Spoede E, Starr KNP, Wulf KL. Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel. Nutrients 2023; 15:nu15051270. [PMID: 36904269 PMCID: PMC10005187 DOI: 10.3390/nu15051270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting.
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Affiliation(s)
- Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 63, Chicago, IL 60611, USA
- Correspondence:
| | - Megan A. Brockel
- Department of Anesthesiology, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Sanja Kolaček
- Referral Centre for Pediatric Gastroenterology and Nutrition, University Children’s Hospital Zagreb, 10000 Zagreb, Croatia
| | | | - Elizabeth Spoede
- Pediatric Clinical Dietitian, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Kathryn N. Porter Starr
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC 27708, USA
- Durham VA Health Care System, Durham, NC 27705, USA
| | - Karyn L. Wulf
- Abbott Nutrition, Abbott Laboratories, Columbus, OH 43219, USA
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24
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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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McMullin JL, Hu QL, Merkow RP, Bilimoria KY, Hu YY, Ko CY, Abdullah F, Raval MV. Are Kids More Than Just Little Adults? A Comparison of Surgical Outcomes. J Surg Res 2022; 279:586-591. [DOI: 10.1016/j.jss.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 10/31/2022]
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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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The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy. CHILDREN 2022; 9:children9111675. [DOI: 10.3390/children9111675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children’s Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.
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Yang Y, Cao J, Chen X, Liu D, Lv Q, Ma J, Zhang Y, Song X. Perioperative pain management based on enhanced recovery after surgery in children undergoing adenotonsillectomy: A prospective, randomized controlled trial. Laryngoscope Investig Otolaryngol 2022; 7:1634-1642. [PMID: 36258845 PMCID: PMC9575122 DOI: 10.1002/lio2.910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/21/2022] [Accepted: 08/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Pain management, as a key component of enhanced recovery after surgery (ERAS), can effectively relieve perioperative pain and anxiety. However, there are few studies on the application of pain management based on ERAS in pediatric surgery patients. We aimed to examine the effect of ERAS-based perioperative pain management in children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy. Methods From March 2021 to July 2021, a randomized controlled single-blind study was conducted on children with OSA and scheduled to undergo adenotonsillectomy. The children were randomly assigned to either control group (n = 60) or ERAS group (n = 60). Traditional analgesia measures were provided to children in the control group, whereas ERAS-based optimized analgesia measures were provided to children in the ERAS group. The pain scores, anxiety scores and diet quality scores were compared between the two groups. Results The pain scores after surgery in the ERAS group were significantly lower than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. Furthermore, the diet quality scores in the ERAS group were significantly higher than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. The anxiety scores after surgery in the ERAS group were significantly lower than those in the control group. Conclusions Perioperative pain management based on ERAS can significantly alleviate postoperative pain, improve quality of life, and promote the accelerated rehabilitation of children with OSA undergoing adenotonsillectomy. Level of evidence 1.
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Affiliation(s)
- Yujuan Yang
- Department of Otolaryngology, Head and Neck Surgery, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
| | - Jiayu Cao
- Department of Otolaryngology, Head and Neck Surgery, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
| | - Xiumei Chen
- Shandong Provincial Clinical Research Center for Otorhinolaryngologic DiseasesYantaiChina
| | - Dawei Liu
- Department of Otolaryngology, Head and Neck Surgery, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
- Shandong Provincial Clinical Research Center for Otorhinolaryngologic DiseasesYantaiChina
| | - Qiaoying Lv
- Department of Otolaryngology, Head and Neck Surgery, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
- Shandong Provincial Clinical Research Center for Otorhinolaryngologic DiseasesYantaiChina
| | - Jiahai Ma
- Department of Anesthesiology, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
| | - Yu Zhang
- Shandong Provincial Clinical Research Center for Otorhinolaryngologic DiseasesYantaiChina
| | - Xicheng Song
- Department of Otolaryngology, Head and Neck Surgery, Yantai Yuhuangding HospitalQingdao UniversityYantaiChina
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Portuondo JI, Mehl SC, Shah SR, Raval MV, Zhu H, Fallon SC, Wesson DE, Massarweh NN. Association between index complication and outcomes after inpatient pediatric surgery. J Pediatr Surg 2022; 57:1-8. [PMID: 35422334 DOI: 10.1016/j.jpedsurg.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE A cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. METHODS National cohort study of patients within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. RESULTS Among 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8-59.7%) and FTR (0.3-31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36-11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0-39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5-23.4]) and readmission (OR 18.7 [17.6-19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95-9.83]). CONCLUSIONS Different types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. TYPE OF STUDY Cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Jorge I Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States.
| | - Steven C Mehl
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sohail R Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Huirong Zhu
- Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sara C Fallon
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - David E Wesson
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Chen SY, Ourshalimian S, Kim E, Russell CJ, Kelley-Quon LI. Tramadol Use in Pediatric Surgery: Trends After the Food and Drug Administration Black-Box Warning. J Surg Res 2022; 280:10-18. [PMID: 35944445 DOI: 10.1016/j.jss.2022.07.008] [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: 01/24/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The U.S. Food and Drug Administration (FDA) issued a black-box warning in 2017 contraindicating tramadol in children <12 y. Longitudinal trends and factors associated with perioperative tramadol use in children remain unclear. METHODS A retrospective, multi-institutional cohort study utilizing the Pediatric Health Information System database was performed for children 2-18 y who underwent one of ten common surgeries from 1/2009-2/2020. Temporal trends correlated with the FDA tramadol contraindication were evaluated. Hierarchical multivariable logistic regression analysis identified factors associated with tramadol use. RESULTS Of 477,153 children undergoing surgery, 5857(1.2%) received tramadol during hospitalization. Tramadol use occurred in 942 (16.1%) children after the black-box warning, 390 of whom were <12 y. For children <12 y, annual tramadol use peaked at 1.87% (2016) and decreased to 0.66% (2019). Female sex (odds ratio OR 1.32; 95% confidence interval CI:1.24,1.40), age ≥12 y (OR 2.79; 95%CI: 2.62,2.97), and Midwest location (OR 4.07; 95% CI:1.64,10.11) increased likelihood of receiving tramadol. Tramadol use was more likely after cholecystectomy (OR 1.17; 95% CI:1.04,1.32) and in children with gastrointestinal (OR 2.39; 95% CI: 2.19,2.60), metabolic (OR 1.39; 95% CI:1.26,1.53) or transplant-related (OR 1.82; 95% CI: 1.57,2.10) comorbidities. Children of Hispanic/Latino ethnicity and those with public insurance had decreased likelihood of receiving tramadol. Adjusting for patient and hospital characteristics, children <12 y were less likely to receive tramadol following the black-box warning (OR 0.65; 95% CI: 0.59,0.70). CONCLUSIONS Despite the FDA contraindication, tramadol prescribing continues among children <12 y undergoing surgery, with use varying by patient and institutional factors. Interventions are required to reduce perioperative tramadol use in children.
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Affiliation(s)
- Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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Behera BK, Misra S, Tripathy BB. Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery. J Pediatr Surg 2022; 57:1473-1479. [PMID: 34417055 DOI: 10.1016/j.jpedsurg.2021.07.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/09/2021] [Accepted: 07/22/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery. METHODS Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay. RESULTS Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I2 = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I2 = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I2 = 93%) were significantly less in the EEN group. CONCLUSION EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Bikram Kishore Behera
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar 751019, Odisha, India
| | - Satyajeet Misra
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar 751019, Odisha, India.
| | - Bikasha Bihary Tripathy
- Department of Pediatric Surgery, All India Institute of Medical Sciences (AIIMS), Bhubaneswar 751019, Odisha, India
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Vavolizza RD, Grabski DF, Roecker Z, Levin D, Swanson JR, McGahren ED, Gander JW. Standing Intravenous Acetaminophen is Associated With a Reduction of Post-Operative Opioid Use in Infants Aged Less Than 1 Year Treated on the Acute Care Floor. J Surg Res 2022; 276:291-297. [DOI: 10.1016/j.jss.2022.02.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022]
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Lu J, Xue M, Fu P, Qian D, Chen X, Yao D, Zhang Y. Evaluation of open reduction of distal humerus fractures in children after implementation of an enhanced recovery after surgery program. BMC Musculoskelet Disord 2022; 23:705. [PMID: 35879748 PMCID: PMC9310416 DOI: 10.1186/s12891-022-05675-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/20/2022] [Indexed: 12/04/2022] Open
Abstract
Objective This study assessed whether an enhanced recovery after surgery (ERAS) protocol could be beneficial for children with distal humerus fractures. Methods Children with distal humerus fractures (n = 85) were randomly assigned to the ERAS and control groups and subjected to different perioperative managements. This was followed by the evaluation of their intraoperative characteristics (operation time and bleeding), postoperative characteristics (food intake conditions, pain scores, and discharge time), and postoperative functions. Results The operation time, intraoperative bleeding, and postoperative hematological indices did not differ significantly between the two groups. Preoperative thirst and hunger were considerably less and the initial food intake duration following surgery was markedly shorter in the ERAS group than in the control group, whereas no difference between the groups was observed in the incidences of postoperative nausea and vomiting. A markedly reduced highest postoperative pain score and reduced mean pain score and demand for additional analgesic interventions were observed in the ERAS group compared with those in the control group, although the differences were not statistically significant. No noticeable between-group differences were observed in the incidences of postoperative incision problems, aspirational pneumonia, and gastroesophageal reflux. The total length of hospital stay was not significantly different between the two groups. However, the length of postoperative hospital stay was remarkably shorter and the elbow joint function at 2 months after surgery was significantly improved in the ERAS group compared with those in the control group. Conclusion The ERAS protocol can ameliorate preoperative discomfort and postoperative pain, shorten the postoperative hospital stay, and accelerate postoperative functional recovery without increasing the risks of postoperative nausea, vomiting, and poor incision healing and is, therefore, worthy of clinical application.
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Affiliation(s)
- Jialing Lu
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Mingfeng Xue
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Peng Fu
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Damei Qian
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Xingguang Chen
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Danhua Yao
- Department of Pediatric Orthopedics, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China
| | - Yanli Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing University (The Second Hospital of Jiaxing), Zhejiang, Jiaxing, 314000, People's Republic of China.
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George JA, Salazar AJG, Irfan A, Prichett L, Nasr IW, Garcia AV, Boss EF, Jelin EB. Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children. J Pediatr Surg 2022; 57:1349-1353. [PMID: 35153077 DOI: 10.1016/j.jpedsurg.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
Introduction In the past two decades, Enhanced Recovery After Surgery (ERAS) pathways for adults have improved efficiency of care and decreased length of stay (LOS) without increasing postoperative complications. The effects of enhanced recovery pathways for children are less well known. In this retrospective cohort study, we evaluated the effects of an enhanced recovery protocol (ERP) implementation in children undergoing colorectal surgery. Methods We introduced a colorectal ERP in 2017. Children and young adults (ages 2-22 years) were divided into pre-intervention (2014-2016) and post-intervention groups (2017-2019) for analysis. We abstracted data, including demographics, primary surgery, LOS, postoperative pain scores, and postoperative complications. Results A total of 432 patients were included. Of those,148 (34%) were pre-ERP implementation and 284 (66%) were post-ERP implementation. Post-ERP patients experienced significantly shorter LOS (5.7 vs. 8.3 days, p<0.01); required less intraoperative local anesthetic (9.5% vs. 38.5%, p<0.01) because 55% of patients received an epidural and 18% received an abdominal plane block; and used less postoperative opioid (62.5% vs. 98.7%, p<0.01) than did pre-ERAS patients. After protocol implementation, average pain scores were lower on postoperative day 1 (3.6 vs. 4.5, p<0.05) and across the hospitalization (3.0 vs. 4.0, p<0.01). Conclusion Enhanced recovery pathways decrease LOS, opioid use, and postoperative pain scores for children undergoing colorectal surgery and should be considered for this patient population.
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Affiliation(s)
- Jessica A George
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 6321, Baltimore, MD 21287, United States.
| | - Andres J Gonzalez Salazar
- Department of General Surgery, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Ahmer Irfan
- Department of Surgery, University of Alabama at Birmingham, 202 Boshell Diabetes Building, 1808 7th Avenue South, Birmingham, AL 35233, United States
| | - Laura Prichett
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Mason F. Lord Bldg, Center Tower, Suite 4200, 5200 Eastern Ave., Baltimore, MD 21224, United States
| | - Isam W Nasr
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
| | - Alejandro V Garcia
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Eric B Jelin
- Department of General Pediatric Surgery, Johns Hopkins University, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 7323, Baltimore, MD 21287, United States
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Keane OA, Dantes G, Emani S, Garza JM, Heiss KF, Clifton MS. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery. J Pediatr Surg 2022; 57:1132-1136. [PMID: 35292166 DOI: 10.1016/j.jpedsurg.2022.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. METHODS A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. RESULTS There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. CONCLUSIONS The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Srinivas Emani
- Department of Behavioral Social and Health Education Sciences, Emory University, Atlanta, GA, United States
| | - Jose M Garza
- Department of Pediatrics, Children's Healthcare of Atlanta, GI Care for Kids, Atlanta, GA, United States
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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Chorath K, Hobday S, Suresh NV, Go B, Moreira A, Rajasekaran K. Enhanced recovery after surgery protocols for outpatient operations in otolaryngology: Review of literature. World J Otorhinolaryngol Head Neck Surg 2022; 8:96-106. [PMID: 35782396 PMCID: PMC9242417 DOI: 10.1002/wjo2.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 11/07/2021] [Indexed: 11/12/2022] Open
Abstract
Objective Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based pathways designed to reduce complications, promote recovery, and improve outcomes following surgery. These protocols have been successfully applied for the management of head and neck cancer, but relatively few studies have investigated the applicability of these pathways for other outpatient procedures in otolaryngology. Our goal was to perform a systematic review of available evidence reporting the utility of ERAS protocols for the management of patients undergoing outpatient otolaryngology operations. Methods A systematic literature review was conducted using MEDLINE, EMBASE, SCOPUS, and gray literature. We identified studies that evaluated ERAS protocols among patients undergoing otologic, laryngeal, nasal/sinus, pediatric, and general otolaryngology operations. We assessed the outcomes and ERAS components across protocols as well as the study design and limitations. Results A total of eight studies fulfilled the inclusion criteria and were included in the analysis. Types of procedures evaluated with ERAS protocols included tonsillectomy and adenoidectomy, functional endoscopic sinus surgery, tympanoplasty and mastoidectomy, and septoplasty. A reduction in postoperative length of stay and hospital costs was reported in two and three studies, respectively. Comparative studies between ERAS and control groups showed persistent improvement in pre- and postoperative anxiety and pain levels, without an increase in postoperative complications and readmission rates. Conclusions A limited number of studies discuss implementation of ERAS protocols for outpatient operations in otolaryngology. These clinical pathways appear promising for these procedures as they may reduce length of stay, decrease costs, and improve pain and anxiety postoperatively.
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Affiliation(s)
- Kevin Chorath
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sara Hobday
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Neeraj V. Suresh
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Beatrice Go
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Alvaro Moreira
- Department of PediatricsUniversity of Texas Health‐San AntonioSan AntonioTexasUSA
| | - Karthik Rajasekaran
- Department of OtorhinolaryngologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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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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Enhanced recovery after surgery (ERAS) for adolescent idiopathic scoliosis: Standardisation of Care Improves Patient Outcomes. Anaesth Crit Care Pain Med 2022; 41:101116. [DOI: 10.1016/j.accpm.2022.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 11/24/2022]
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Kou L, Wan W, Chen C, Zhao D, Sun X, Gao Z, Wu H, Di M, Ma X, Xu B, Miao J, Wang Z, Yang Q. Can the Full-Percutaneous Endoscopic Lumbar Discectomy in Day Surgery Mode Achieve Better Outcomes Following Enhanced Recovery after Surgery Protocol? A Retrospective Comparative Study. Front Surg 2022; 9:914986. [PMID: 36034364 PMCID: PMC9407013 DOI: 10.3389/fsurg.2022.914986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundFull-percutaneous endoscopic lumbar discectomy (F-PELD) is a popular operation for the treatment of lumbar disc herniation (LDH). Some studies have reported that F-PELD in day surgery mode produced favorable outcomes for LDH. At the same time, minimally invasive spinal surgery following enhanced recovery after surgery (ERAS) presents a rising trend in recent years, but few studies reported whether F-PELD will produce better outcomes in the day surgery (DS) mode combined with ERAS.ObjectiveTo analyze whether F-PELD in day surgery mode following ERAS can produce better clinical outcomes than in traditional surgery mode.MethodsThe patients who underwent F-PELD between January 2019 and October 2020 were retrospectively analyzed, and the patients who met the inclusive criteria were followed up. The patients were divided into day surgery (DS) group (n = 152) that combined with ERAS and traditional surgery (TS) group (n = 123) without ERAS. The length of hospital stays (LOS), visual analogue scale (VAS), and Oswestry Disability Index (ODI) of two groups were compared before surgery, immediately after surgery, one month after surgery, and one year after surgery.ResultsA total of 298 patients who underwent F-PELD were reviewed. 290 patients were included in the study and followed up, and 275 patients who had completed the follow-up were available for analysis. There were no statistically significant differences between the two groups in terms of age, gender, preoperative VAS, and ODI. There were significant statistical differences in the VAS and ODI immediately after surgery (VAS for back pain: DS group 1.4 ± 1.1, TS group 2.0 ± 1.2, p < 0.001; VAS for leg pain: DS group 0.8 ± 0.8, TS group 1.1 ± 1.1, p = 0.010; ODI: DS group 5.8 ± 4.3, TS group 7.6 ± 7.4, p = 0.010) and one month after surgery (VAS for back pain: DS group 0.8 ± 0.9, TS group 1.1 ± 1.0, p = 0.035; ODI: DS group 3.2 ± 3.5, TS group 4.5 ± 6.5, p = 0.036). At one year after surgery, the VAS (back pain: DS group 0.3 ± 0.6, TS group 0.3 ± 0.7, p = 0.798; leg pain: DS group 0.2 ± 0.4, TS group 0.1 ± 0.4, p = 0.485) and ODI (DS group 0.8 ± 1.2, TS group 0.7 ± 1.7, p = 0.729) were further improved, but no statistically significant difference was observed between two groups. LOS of DS group (1.38 ± 0.49 days) was significantly shorter than the TS group (5.83 ± 2.24 days, p < 0.001), and some postoperative complications occurred in the TS group, including throat discomfort (n = 5, 4.1%), discomfort after catheterization (n = 7, 5.7%), abdominal distention (n = 3, 2.4%), and nausea (n = 5, 4.1%). None of the above complications resulted in serious consequences.ConclusionThe F-PELD in day surgery mode following ERAS produced a better short-term clinical effect and reduced the LOS, which is worthy of promotion.
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Affiliation(s)
- Le Kou
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
- Department of Orthopedics, Tianjin Baodi Hospital, Baodi Clinical College of Tianjin Medical University, Tianjin, China
| | - Wentao Wan
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Chao Chen
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Dong Zhao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Xun Sun
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Ziwei Gao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Hongjin Wu
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Mingyuan Di
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Xinlong Ma
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Baoshan Xu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Jun Miao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Zheng Wang
- Department of Orthopedics, No.1 Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
- Correspondence: Qiang Yang
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Ali S, Latif T, Sheikh MA, Shafiq MB, Zahra DEZ, Abu Bakar M. Review of Perioperative Care Pathway for Children With Renal Tumors. Cureus 2022; 14:e24928. [PMID: 35706749 PMCID: PMC9187842 DOI: 10.7759/cureus.24928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
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Opioid reduction and elimination in pediatric surgical patients. J Pediatr Surg 2022; 57:670-677. [PMID: 34799089 DOI: 10.1016/j.jpedsurg.2021.10.012] [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: 03/31/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Opioid overuse is a national concern. Mitigation strategies include judicious prescribing and encouragement of non-opioid therapies. This quality improvement project aimed to identify physician opioid prescribing and patient usage patterns at a pediatric academic center. METHODS Patients who underwent same-day general, orthopedic, or plastic surgery procedures were contacted 7 - 28 days post-operatively. Inquiries were made about opioid usage, non-opioid strategies, and overall pain management satisfaction. A subset of general surgery patients not prescribed opioids was compared to those prescribed opioids. RESULTS Between August 2017 - May 2020, 558 surveys were obtained. There was a significant increase in the use of non-opioid therapies between 2017 and 2020 (83.5% vs 97%, p=0.04). Almost all patients' opioid prescriptions were filled; however, 78-98% had leftover opioids. Only 20-25% disposed the excess opioids. In subset analysis of general surgery patients, no inguinal hernia or orchiopexy patient who was discharged without opioids required opioids later. More non-opioid patients used other therapies (acetaminophen, heat (p=0.03)); however, pain management satisfaction was higher in the opioid group (99% vs 94%, p=0.01). CONCLUSION While our opioid prescribing has decreased, physicians are still prescribing more opioids than patients require. Further education on non-opioid pain therapies and proper disposal of opioids are needed. LEVEL OF EVIDENCE III TYPE OF STUDY: prospective quality improvement study.
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Dela Merced P, Vazquez Colon C, Mirzada A, Oke A, Gal Z, Cheng J, Oetgen MM, Martin B, Pestieau SR, Cronin JA. Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities. Paediatr Anaesth 2022; 32:556-562. [PMID: 34758176 DOI: 10.1111/pan.14330] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. AIMS We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. METHODS This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. RESULTS Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity. CONCLUSIONS Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.
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Affiliation(s)
- Philip Dela Merced
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Caroll Vazquez Colon
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Ariana Mirzada
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Ayodele Oke
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Zsombor Gal
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Jenhao Cheng
- Division of Quality and Safety, Children's National Hospital, Washington, District of Columbia, USA
| | - Matthew M Oetgen
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Martin
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Sophie R Pestieau
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Jessica A Cronin
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, District of Columbia, USA
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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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Gettis M, Brown AM, Fujimoto A, Wetzel M, Thomsen J. Gabapentin Premedication to Reduce Postoperative Pain for Pediatric Tonsillectomy/Adenoidectomy: A Pilot Study. J Perianesth Nurs 2022; 37:626-631. [DOI: 10.1016/j.jopan.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
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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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Lee A, Seyednejad N, Lawati YA, Mattice A, Anstee C, Legacy M, Gilbert S, Maziak DE, Sundaresan RS, Villeneuve PJ, Thompson C, Seely AJE. Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program. J Chest Surg 2022; 55:118-125. [PMID: 35135904 PMCID: PMC9005934 DOI: 10.5090/jcs.21.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program. Methods Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1–3, 4–6, and 7–9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters. Results In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1–3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4–6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7–9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7–9 months post-ERATS (p=0.06). Conclusion The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.
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Affiliation(s)
- Alex Lee
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Nazgol Seyednejad
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Yaseen Al Lawati
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Amanda Mattice
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Caitlin Anstee
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Mark Legacy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Ramanadhan S Sundaresan
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Patrick J Villeneuve
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Calvin Thompson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew J E Seely
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
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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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Grabski DF, Vavolizza RD, Roecker Z, Levin D, Swanson JR, McGahren ED, Gander JW. Reduction of post-operative opioid use in neonates following open congenital diaphragmatic hernia repairs: A quality improvement initiative. J Pediatr Surg 2022; 57:45-51. [PMID: 34686379 DOI: 10.1016/j.jpedsurg.2021.09.027] [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: 08/26/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND A limited number of post-operative opioid reduction strategies have been implemented in the neonatal population. Given the potential neurodevelopment effects of prolonged opioid use, we created a quality improvement initiative to reduce opioids in our NICU and evaluated the intervention in our CDH population. METHODS Our opioid reduction intervention was based on standing post-operative IV acetaminophen, standardizing post-surgical sign-out between the surgical, anesthesia and NICU teams and a series of education seminars with NICU providers on post-operative pain control management. A historical control was used to perform a retrospective cohort analysis of opioid prescribing patterns in addition to a utilizing process control charts to investigate time trends in prescribing patterns. RESULTS Forty-five children with CDH underwent an operation were included in our investigation- 18 in our pre-intervention cohort, 6 in a roll-out cohort and 21 in our post-intervention cohort. Each cohort was clinically similar. The intervention reduced total post-operative opioid use (morphine equivalents) from 82.2 (mg/kg) to 2.9 (mg/kg) in our post-intervention group (p < 0.0001). Our maximum Neonatal Pain and Agitation Sedation Score over the first 48 post-operative hours were equivalent (p = 0.827). Safety profiles were statistically equivalent. The opioid reduction intervention reduced post-operative intubation length from 156 to 44 h (p = 0.021). CONCLUSION A multi-tiered intervention can decrease opioid use in post-surgical neonates with complex surgical pathology including CDH. The intervention proposed in this investigation is safe and does not increase pain or sedation scores in neonates, while lessening post-operative intubation length. EVIDENCE LEVEL Level II.
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Affiliation(s)
- David F Grabski
- Department of Surgery, University of Virginia School of Medicine, 1215 Lee St, Charlottesville, VA 22904, USA.
| | - Rick D Vavolizza
- Department of Surgery, University of Virginia School of Medicine, 1215 Lee St, Charlottesville, VA 22904, USA
| | - Zoe Roecker
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Daniel Levin
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jonathan R Swanson
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Eugene D McGahren
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jeffrey W Gander
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, 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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Arena S, Di Fabrizio D, Impellizzeri P, Gandullia P, Mattioli G, Romeo C. Enhanced Recovery After Gastrointestinal Surgery (ERAS) in Pediatric Patients: a Systematic Review and Meta-analysis. J Gastrointest Surg 2021; 25:2976-2988. [PMID: 34244952 DOI: 10.1007/s11605-021-05053-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/22/2021] [Indexed: 01/31/2023]
Abstract
AIM To systematically review literature and to assess the status of the ERAS protocol in pediatric populations undergoing gastrointestinal surgery. METHODS Literature research was carried out for papers comparing ERAS and traditional protocol in children undergoing gastrointestinal surgery. Data on complications, hospital readmission, length of hospital stay, intraoperative fluid volume, post-operative opioid usage, time to defecation, regular diet, intravenous fluid stop, and costs were collected and analyzed. Analyses were performed using OR and CI 95%. A p value <0.05 was considered significant. RESULTS A total of 8 papers met the inclusion criteria, with 943 included patients. There was no significant difference in complication occurrence and 30-day readmission. Differently, length of stay, intraoperative fluid volume, post-operative opioid use, time to first defecation, time to regular diet, time to intravenous fluid stop, and costs were significantly lower in the ERAS groups. CONCLUSIONS ERAS protocol is safe and feasible for children undergoing gastrointestinal surgery. Without any significant complications and hospital readmission, it decreases length of stay, ameliorates the recovery of gastrointestinal function, and reduces the needs of perioperative infusion, post-operative opioid administration, and costs.
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Affiliation(s)
- Salvatore Arena
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy.
| | - Donatella Di Fabrizio
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
| | - Pietro Impellizzeri
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
| | - Paolo Gandullia
- Gastroenterology and Endoscopy Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Girolamo Mattioli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Unit of Pediatric Surgery, University of Genoa, Genoa, Italy
| | - Carmelo Romeo
- Department of Human Pathology of Adult and Childhood "Gaetano Barresi", Unit of Pediatric Surgery, University of Messina, Messina, Italy
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