Enhanced Recovery in Pediatric Surgery Diana L Diesen, M.D., FACS Assistant Professor, Department of Surgery University of Texas Southwestern Medical Center Children s Health Dallas Dallas, Tx
Disclosures None
What is Enhanced Recovery? Goal: optimize patient care/provide high-value care by improving outcomes and minimizing resource utilization Theory: maintain physiologic homeostasis and minimize stress on the body quicker return to baseline Results: Ideally decreased LOC, decreased mortality/morbidity, decreased costs
http://www.anesthesiallc.com/publications/anesthesia-industry-ealerts/778-enhanced-recovery-after-surgery-and-anesthesia
What is enhanced recovery? https://www.sages.org/smart-enhanced-recovery-program
What is special about children? Role of ERAS in Pediatric Surgery
Not little adults Not all children can be treated the same: Age dependent protocols
Metabolic Response to Surgery Adults Neonates Energy metabolism of newborns only minimally modified by operative trauma. McHoney et al Eur J Ped Surg 2009
Metabolic response to surgery Teitelbaum & Coran Nutrition 1998; McHoney et al Eur J Peid Surg 2009
Role of family Ambulatory pediatric surgery > 7yo PACU no parent vs. parent present Ramesh et al Anesth Analg 2001
... but we are the same species. Nutrition is critically important Secker & Jeejeebhoy Am J clin Nutr 2007
Not all elements shown to be as effective in children Epidural data in children mixed Improve pain control/less consistent pain control Shorter hospitalization/longer hospitalizations DVT prophylaxis often not needed in children Prior to puberty Unclear exactly which elements critical in pediatric surgery or which need to be added Parent readiness, education, engagement? Family in room > x%/day
What do we do differently in Pediatric Surgery? Preoperative Intraoperative Postoperative Preoperative counseling - Family education Allow po preop Clears 2-4 hrs (including EBM) Preoperative anxiolytic Short-acting anesthetics Avoiding tubes (kids pull them out) NG Foley Drains Normothermia important in pediatrics Local anesthesia/analgesic - Epidural controversial Early mobilization - have you tried to make a toddler lay still? Avoiding Narcotics Especially small children apnea with narcotics
What are the data? Fast track vs. ERAS Often 5-10 elements Limited and often mixed populations More in adolescent colorectal
Safe, feasible in kids Parents like it No increase complications Works for ~30% of pediatric surgeries Journal of Pediatric Surgery (2007) 42, 234 238
Implementation of fast-track pediatric surgery in a German nonacademic institution without previous fast-track experience Schukfeh, Reismann, Ludwikowski, Hofmann, Kaemmerer, Metzelder, & Ure 2014 The Fast Track modality was successfully implemented and resulted in high patient/parent satisfaction.
Fast-track Concepts In Routine Pediatric Surgery: A Prospective Study In 436 Infants And Children Reismann,Dingemann, MathiasWolters, Laupichler, Suempelmann & Ure 2009 Feasibility of fast-track surgery according to type of procedure in patients undergoing abdominal, thoracic, and urologic surgery. Data of procedures performed less than five times are not shown
Ped Surgical Procedures using Fast Track Reismann et al, Feasibility of Fast-Track Elements in Pediatric, Surgery Eur J Pediatr Surg 2012
Fast-track management is safe and effective after bowel resection in children with Crohn's disease Vrecenak & Mattei 2014 Age 8-18 45/71 FT Lap ileocecectomy No Δ disease progression No Δ in complications Accelerated mean time to full diet (p < 0.01) Decreased mean duration of ileus (p < 0.01) Decreased mean narcotic requirements (p = 0.03) Decreased mean length of stay (p < 0.01)
Shinnick et al Journal Surgical Research 2016 Pediatric Surgery ERAS
2017
Are Ped Surgeons willing to change?
What do we need to implement ERAS in children? Outcomes Best practice/consensus What are appropriate peds outcomes? What components should be applied to children? Engagement Education DATA Does it help? complications, cost, LOS, satisfaction
Which components? How many? Do we apply all of these to children? Epidurals DVT prophylaxis Insulin for hyperglycemia Do we apply these to babies/toddlers? Different disease process Different physiologic response Age dependent protocols Challenges Medications approved in children Patient and parent compliance Teenagers Toddlers Lack of data Limited numbers of pt hard for team to get in routine Lack of consensus in pediatric surgery on best practice
ERAS in Children Conclusion You/We can do it! Limit evidence Current evidence suggests that ERAS can be done safely in children In some instances decreased LOS, decreased complications, family satisfaction Metabolic response is different, especially babies Need age dependent protocols