The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy
Abstract
:1. Introduction
2. Materials and Methods
3. Case Series
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
References
- Bouwmeester, N.J.; Hop, W.C.; van Dijk, M.; Anand, K.J.; van den Anker, J.N.; Tibboel, D. Postoperative pain in the neonate: Age-related differences in morphine requirements and metabolism. Intensive Care Med. 2003, 29, 2009–2015. [Google Scholar] [CrossRef] [PubMed]
- Saarenmaa, E.; Huttunen, P.; Leppäluoto, J.; Meretoja, O.; Fellman, V. Advantages of fentanyl over morphine in analgesia for ventilated newborn infants after birth: A randomized trial. J. Pediatr. 1999, 134, 144–150. [Google Scholar] [CrossRef]
- ERAS Society Guildelines. Available online: https://erassociety.org/ (accessed on 31 August 2022).
- Shinnick, J.K.; Short, H.L.; Heiss, K.F.; Santore, M.T.; Blakely, M.L.; Raval, M.V. Enhancing recovery in pediatric surgery: A review of the literature. J. Surg. Res. 2016, 202, 165–176. [Google Scholar] [CrossRef] [PubMed]
- Pearson, K.L.; Hall, N.J. What is the role of enhanced recovery after surgery in children? A scoping review. Pediatr. Surg. Int. 2017, 33, 43–51. [Google Scholar] [CrossRef] [PubMed]
- Loganathan, A.K.; Joselyn, A.S.; Babu, M.; Jehangir, S. Implementation and outcomes of enhanced recovery protocols in pediatric surgery: A systematic review and meta-analysis. Pediatr. Surg. Int. 2022, 38, 157–168. [Google Scholar] [CrossRef] [PubMed]
- Phelps, H.M.; Robinson, J.R.; Chen, H.; Luckett, T.R.; Conroy, P.C.; Gillis, L.A.; Hays, S.R.; Lovvorn, H.N. Enhancing Recovery After Kasai Portoenterostomy With Epidural Analgesia. J. Surg. Res. 2019, 243, 354–362. [Google Scholar] [CrossRef] [PubMed]
- Gurnaney, H.G.; Cook-Sather, S.D.; Shaked, A.; Olthoff, K.M.; Rand, E.B.; Lingappan, A.M.; Rehman, M.A. Extubation in the operating room after pediatric liver transplant: A retrospective cohort study. Paediatr. Anaesth. 2018, 28, 174–178. [Google Scholar] [CrossRef]
- Sahinturk, H.; Ozdemirkan, A.; Yilmaz, O.; Zeyneloglu, P.; Torgay, A.; Pirat, A.; Haberal, M. Immediate Tracheal Extubation After Pediatric Liver Transplantation. Exp. Clin. Transplant. 2021, 19, 1063–1068. [Google Scholar] [CrossRef]
- Yoeli, D.; Nguyen, T.; Wilder, M.; Huang, J.; Pahlavan, S.; Brigham, D.; Sundaram, S.S.; Wachs, M.E.; Adams, M.A. Immediate extubation following pediatric liver transplantation. Pediatr. Transplant. 2022, e14352. [Google Scholar] [CrossRef]
- Morehouse, D.; Williams, L.; Lloyd, C.; McCoy, D.S.; Miller Walters, E.; Guzzetta, C.E.; Baumgart, S.; Sill, A.; Mueller-Burke, D.; Short, B.L. Perioperative hypothermia in NICU infants: Its occurrence and impact on infant outcomes. Adv. Neonatal Care 2014, 14, 154–164. [Google Scholar] [CrossRef]
- Larsson, L.E.; Nilsson, K.; Niklasson, A.; Andreasson, S.; Ekström-Jodal, B. Influence of fluid regimens on perioperative blood-glucose concentrations in neonates. Br. J. Anaesth. 1990, 64, 419–424. [Google Scholar] [CrossRef] [PubMed]
- Sacha, G.L.; Foreman, M.G.; Kyllonen, K.; Rodriguez, R.J. The Use of Gabapentin for Pain and Agitation in Neonates and Infants in a Neonatal ICU. J. Pediatr. Pharmacol. Ther. 2017, 22, 207–211. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Engorn, B.M.; Kahntroff, S.L.; Frank, K.M.; Singh, S.; Harvey, H.A.; Barkulis, C.T.; Barnett, A.M.; Olambiwonnu, O.O.; Heitmiller, E.S.; Greenberg, R.S. Perioperative hypothermia in neonatal intensive care unit patients: Effectiveness of a thermoregulation intervention and associated risk factors. Paediatr. Anaesth. 2017, 27, 196–204. [Google Scholar] [CrossRef] [PubMed]
- Kim, P.; Taghon, T.; Fetzer, M.; Tobias, J.D. Perioperative hypothermia in the pediatric population: A quality improvement project. Am. J. Med. Qual. 2013, 28, 400–406. [Google Scholar] [CrossRef] [PubMed]
- Paap, C.M.; Nahata, M.C. Clinical pharmacokinetics of antibacterial drugs in neonates. Clin. Pharmacokinet. 1990, 19, 280–318. [Google Scholar] [CrossRef] [PubMed]
- Brindle, M.E.; McDiarmid, C.; Short, K.; Miller, K.; MacRobie, A.; Lam, J.Y.K.; Brockel, M.; Raval, M.V.; Howlett, A.; Lee, K.S.; et al. Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS). World J. Surg. 2020, 44, 2482–2492. [Google Scholar] [CrossRef]
- Goobie, S.M.; Faraoni, D.; Zurakowski, D.; DiNardo, J.A. Association of Preoperative Anemia With Postoperative Mortality in Neonates. JAMA Pediatr. 2016, 170, 855–862. [Google Scholar] [CrossRef]
- Whyte, R.K.; Jefferies, A.L.; Canadian Paediatric Society, Fetus and Newborn Committee. Red blood cell transfusion in newborn infants. Paediatr. Child Health 2014, 19, 213–222. [Google Scholar] [CrossRef] [Green Version]
- Sümpelmann, R.; Becke, K.; Brenner, S.; Breschan, C.; Eich, C.; Höhne, C.; Jöhr, M.; Kretz, F.J.; Marx, G.; Pape, L.; et al. Perioperative intravenous fluid therapy in children: Guidelines from the Association of the Scientific Medical Societies in Germany. Paediatr. Anaesth. 2017, 27, 10–18. [Google Scholar] [CrossRef]
- Somri, M.; Tome, R.; Yanovski, B.; Asfandiarov, E.; Carmi, N.; Mogilner, J.; David, B.; Gaitini, L.A. Combined spinal-epidural anesthesia in major abdominal surgery in high-risk neonates and infants. Paediatr. Anaesth. 2007, 17, 1059–1065. [Google Scholar] [CrossRef]
- Moon, J.K.; Hwang, R.; Balis, F.M.; Mattei, P. An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay. J. Pediatr. Surg. 2022, 57, 259–265. [Google Scholar] [CrossRef] [PubMed]
- Baxter, K.J.; Short, H.L.; Wetzel, M.; Steinberg, R.S.; Heiss, K.F.; Raval, M.V. Decreased opioid prescribing in children using an enhanced recovery protocol. J. Pediatr. Surg. 2019, 54, 1104–1107. [Google Scholar] [CrossRef] [PubMed]
- Kaye, A.D.; Chernobylsky, D.J.; Thakur, P.; Siddaiah, H.; Kaye, R.J.; Eng, L.K.; Harbell, M.W.; Lajaunie, J.; Cornett, E.M. Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain. Curr. Pain Headache Rep. 2020, 24, 21. [Google Scholar] [CrossRef] [PubMed]
- Stone, S.B. Ketorolac in Postoperative Neonates and Infants: A Systematic Review. J. Pediatr. Pharmacol. Ther. 2021, 26, 240–247. [Google Scholar] [CrossRef]
- Stevens, B.; Yamada, J.; Lee, G.Y.; Ohlsson, A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst. Rev. 2013, 7, CD001069. [Google Scholar] [CrossRef]
- Varma, S.; Bartlett, E.L.; Nam, L.; Shores, D.R. Use of Breast Milk and Other Feeding Practices Following Gastrointestinal Surgery in Infants. J. Pediatr. Gastroenterol. Nutr. 2019, 68, 264–271. [Google Scholar] [CrossRef]
- Quigley, M.; Embleton, N.D.; McGuire, W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst. Rev. 2018, 6, CD002971. [Google Scholar] [CrossRef]
- Ekingen, G.; Ceran, C.; Guvenc, B.H.; Tuzlaci, A.; Kahraman, H. Early enteral feeding in newborn surgical patients. Nutrition 2005, 21, 142–146. [Google Scholar] [CrossRef]
- 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. [Google Scholar] [CrossRef]
- Gao, R.; Yang, H.; Li, Y.; Meng, L.; Sun, B.; Zhang, G.; Yue, M.; Guo, F. Enhanced recovery after surgery in pediatric gastrointestinal surgery. J. Int. Med. Res. 2019, 47, 4815–4826. [Google Scholar] [CrossRef]
- Habre, W.; Disma, N.; Virag, K.; Becke, K.; Hansen, T.G.; Jöhr, M.; Leva, B.; Morton, N.S.; Vermeulen, P.M.; Zielinska, M.; et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): A prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir. Med. 2017, 5, 412–425. [Google Scholar] [CrossRef]
- Datta, P.K.; Aravindan, A. Glucose for Children during Surgery: Pros, Cons, and Protocols: A Postgraduate Educational Review. Anesth. Essays Res. 2017, 11, 539–543. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Melloul, E.; Hübner, M.; Scott, M.; Snowden, C.; Prentis, J.; Dejong, C.H.; Garden, O.J.; Farges, O.; Kokudo, N.; Vauthey, J.N.; et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J. Surg. 2016, 40, 2425–2440. [Google Scholar] [CrossRef] [Green Version]
- Schleelein, L.E.; Vincent, A.M.; Jawad, A.F.; Pruitt, E.Y.; Kreher, G.D.; Rehman, M.A.; Goebel, T.K.; Cohen, D.E.; Cook-Sather, S.D. Pediatric perioperative adverse events requiring rapid response: A retrospective case-control study. Paediatr. Anaesth. 2016, 26, 734–741. [Google Scholar] [CrossRef] [PubMed]
- Tay, C.L.; Tan, G.M.; Ng, S.B. Critical incidents in paediatric anaesthesia: An audit of 10 000 anaesthetics in Singapore. Paediatr. Anaesth. 2001, 11, 711–718. [Google Scholar] [CrossRef]
- Zhu, A.; Benzon, H.A.; Anderson, T.A. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review. Anesth. Analg. 2017, 125, 1569–1587. [Google Scholar] [CrossRef]
- Pehora, C.; Pearson, A.M.; Kaushal, A.; Crawford, M.W.; Johnston, B. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst. Rev. 2017, 11, CD011770. [Google Scholar] [CrossRef]
- Chan, Y.Y.; Rosoklija, I.; Meade, P.; Burjek, N.E.; Raval, M.V.; Yerkes, E.B.; Rove, K.O.; Chu, D.I. Utilization of and barriers to enhanced recovery pathway implementation in pediatric urology. J. Pediatr. Urol. 2021, 17, 294.e291–294.e299. [Google Scholar] [CrossRef]
ERP Protocol Components | Number of Patients |
---|---|
Pre-Operative Management [11,12,13,14,15] | |
Utilize dextrose-containing fluids the night previous to avoid hypoglycemia and hypovolemia | 12/12 |
Pre-op dose of Tylenol not recommended given due to liver function and coagulation abnormalities | 12/12 |
Pre-op gabapentin not recommended given the risk of sedation and lack of FDA approval in this age group | 12/12 |
Pre-warm the room, ensure forced air warmer and warming lights are in the operating room | 12/12 |
Initial intra-operative period [16,17] | |
Administer stress dose steroids when indicated | 12/12 |
Place nasopharyngeal or esophageal temperature probe and turn on forced air warmer, maintain normothermia (36.5 degrees) | 12/12 |
Give dexamethasone 0.5 mg/kg to minimize airway edema and maximize likelihood of extubation | 4/12 |
Muscle relaxants for surgical assistance | 12/12 |
Administer antibiotics within 60 min prior to incision | 12/12 |
Fluid Management [12,18,19,20] | |
All maintenance fluids on pump during case | N/A |
If present, replacement of pre-op fluid deficit at the discretion of the anesthesiologist caring for the patient. | 12/12 |
If the need for transfusion of any blood products arises, it will be decided by the attending anesthesiologist and surgeon. Consider a Hb < 9 for a healthy full-term infant or Hb < 10–11 for infant with oxygen requirements | 7/12 |
Recommend dextrose-containing fluids with intermittent glucose checks to avoid hypo- and hyperglycemia. Titrate fluids accordingly. | 12/12 |
If hypotension with concern for hypovolemia and not meeting transfusion requirements, then consdier 10 mL/kg albumin bolus to avoid hyperchloremic acidosis and/or hyponatremia. | 12/12 |
Perioperative Pain Management [21,22,23,24,25] | |
Regional anesthesia: Consider epidural, caudal, or abdominal wall regional block (check coagulopathy if considering neuraxial) | 3/12 |
IV Ketorolac at closure, communicate with surgical team for appropriate timing | 1/12 |
Dexmedetomidine bolus at discretion of anesthesiology team. Consider dexmedetomidine AFTER extubation to avoid sedation | 5/12 |
Attempt to use narcotics judiciously to maximize likelihood of extubation | 12/12 |
If continued pain concerns, low dose ketamine bolus (0.5 mg/kg−1 mg/kg) but consider post-operative sedation | 0/12 |
Postoperative Care [21,26,27,28,29] | |
Pain team consult if patient received regional anesthesia | 3/12 |
Scheduled ketorolac, q12hr | 1/12 |
Consider lingual sucrose/dextrose for minor non-painful procedures such as NG tube placement | N/A |
Continue perioperative antibiotics until tolerating enteral feeds. Switch to long-term trimethoprim/sulbactam when appropriate | 12/12 |
Consider early enteral feeds within 24–48 h if appropriate; Breast milk preferred if available and parents approve | 9/12 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Vogt, P.; Tolly, R.; Clifton, M.; Austin, T.; Karlik, J. The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy. Children 2022, 9, 1675. https://doi.org/10.3390/children9111675
Vogt P, Tolly R, Clifton M, Austin T, Karlik J. The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy. Children. 2022; 9(11):1675. https://doi.org/10.3390/children9111675
Chicago/Turabian StyleVogt, Peggy, Renee Tolly, Matt Clifton, Tom Austin, and Joelle Karlik. 2022. "The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy" Children 9, no. 11: 1675. https://doi.org/10.3390/children9111675