Enhanced recovery after surgery in paediatrics: a review of the literature.

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This review article explores the evidence surrounding the application of the ERAS concept in paediatric surgery and is co-authored by a member of the ERAS society currently driving its application in paediatrics. Whilst it seems likely the same bundle of care measures would be transferable to the adolescent population, the authors admit it remains to be established what ERAS might look like in younger children. It is hard, however, to ignore the growing evidence base of success in the adult population. ERAS does at times seem to be a magic bullet, both lowering morbidity whilst reducing healthcare costs without increasing adverse events: benefitting both the patient and the financial sustainability of healthcare. The American Academy of Pediatrics and the American Pediatric Surgical Association have begun to implement ERAS in the US.

Summary of the authors’ findings with comments:

ERAS principle	Outcome Impact	Adult Grade of evidence level*	Paediatric Grade of evidence and comments
Preoperative education	Increased patient satisfaction and anxiety	Low	Unclear from article – Neonatal intestinal surgery ERAS guideline referenced lacks mention of preoperative education as an intervention. Greater emphasis in literature on distraction, visualization, hypnosis & CBT.
Minimise fasting	Improved muscle strength, earlier return of bowel function, decreased LOS	High	Unclear from article – complete absence of studies in children looking at similar outcomes
Avoidance of hyperosmotic bowel preparation	Reduced surgical site infection and LOS.	High	Unclear from article – referencing suggests currently limited to single small RCT and single retrospective intervention-control study: either no effect or outcomes reproduced
Judicious intravenous fluids	Reduced rates of anastomotic leak, ileus, abdominal infection, LOS and ICU admission	Moderate-High	Unclear from article – referencing suggests limited to single retrospective cohort study (in favour of LOS outcome). ‘Judicious fluids’ is reminiscent of the APAGBI’s postoperative fluid recommendation: 60-70% of ‘4-2-1’ maintenance1
Regional anaesthesia	Reduced ileus and LOS	High	Unclear from article – no references presented to support specific outcomes. The neonatal intestinal surgery ERAS guideline presents a high level of evidence in favour. High levels of evidence exist in terms of outcomes on pain scores and reduced PONV for a limited number of types of surgery2-4
Multi-modal opiate sparing analgesia	Opioid sparing	Moderate	Unclear from article – 2 small RCTs supportive. Support exists in large scale international guidelines but without emphasis on typical ERAS outcome measures e.g. LOS2,3.
Avoidance of invasive drainage tubes (including NG & percutaneous)	Decreased respiratory tract infection, ileus, LOS (NG) Lack of benefit (percutaneous drains)	High	Low. Avoidance of NGs supported by 2 small retrospective case-intervention studies. Avoidance of percutaneous drains supported by single RCT in Roux-en-Y hepatojejunostomy cases.
PONV prophylaxis	Extrapolated from effect of PONV: increased LOS, unplanned readmission, IV fluid administration, ileus	High	No references presented to impact aforementioned outcomes. International guidelines present a high level of evidence for preventing PONV5,6.
Early feeding	Decreased LOS and  infection	High	High

*GRADE system of assessing quality of evidence: Very Low, Low, Moderate, High.  LOS = Length of stay. NG = nasogastric tube. PONV = postoperative nausea and vomiting. CBT = cognitive-behavioral therapy. RCT = randomized controlled trial.

One problem the paediatric ERAS movement may face is generating the same volume of evidence for some surgical specialties. The volume of specific colorectal resections in adults for example is likely to be higher than any equivalent specific colorectal surgery in children over a given period of time. The adult evidence surrounding a given ERAS intervention varies significantly from procedure to procedure such that extrapolation from procedure to procedure is not always possible.

One notable trend is the lack of harm that emerges from ERAS interventions and this seems to be the case in children too. Regional anaesthesia for instance has been demonstrated to be very low risk in a large-scale survey of regional anaesthesia in children and in the NAP3 audit. Its role in sparing sedative-analgesics perioperatively and in the ICU is likely to make it increasingly popular in the current age of concerns around sedative-induced-neurotoxicity in children, the opioid crisis and the impact of opioids on cancer outcomes. Strong meta-analysis data now supports the prolongation of analgesia with block adjuncts dexamethasone and dexmedetomidine over the first 24-48hours. This article gives the reader a useful starting point in developing local protocols like ERAS that standardize care and a framework for research in paediatric ERAS.

1. 2007. APA consensus guideline on perioperative fluid management in children. Viewed 6 October 2020. https://www.apagbi.org.uk/sites/default/files/inline-files/Perioperative_Fluid_Management_2007.pdf
2. Good practice in postoperative and procedural pain management (2^nd edition). Pediatr Anesth. 2012; 22(s1): 1-79.
3. Vittinghoff M, Lonnqvist P-A, Mosetti V et al. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anesthesiology (ESPA Pain Management Ladder Initiative). Pediatric Anesthesia. 2018: 00: 1-14.
4. Suresh S, Schaldenbrand K, Wallis B, De Oliveira Jr GS. Regional anaesthesia to improve pain outcomes in paediatric surgical patients: a qualitative systemic review of randomized controlled trials. Br J Anaesth, 2014: 113(3); 375-90.
5. Martin S, Baines D, Holtby H et al. 2016. Guidelines on the prevention of post-operative vomiting in children. APAGBI. Viewed 6 October 2020. https://www.apagbi.org.uk/sites/default/files/inline-files/2016%20APA%20POV%20Guideline-2.pdf
6. Gan TJ, Belani KG, Bergese S et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg, 2020: 131(2); 411-448.

 

Reviewed by Dr Dave Stoeter