Enhanced Recovery After Surgery protocols have dramatically changed the practice of adult surgery and anesthesia. Its spread into pediatrics has been less robust and initially centered on patients undergoing complex procedures like major urologic reconstructive surgery and posterior spine surgery. Today’s PAAD discusses how one institution, Seattle Children's Hospital and its Bellevue Ambulatory Surgical Center, developed ERAS protocols for ALL patients in their ambulatory care setting. After reading the article I wasn’t sure if I understood all of the results and methodology, so I asked the article’s first author, Dr. Lynn Martin, to assist me in this review. For those of you who don’t him, Lynn was a former President of the Society for Pediatric Anesthesia, the former Division Chief at Seattle Children’s Hospital, and currently the Medical Director of the Bellevue Ambulatory Surgical Center. I also asked Dr. Megan Brockel, a frequent PAAD contributor on all ERAS related articles to assist as well. Myron Yaster MD
Original article
Lynn D Martin, Jennifer L Chiem, Elizabeth E Hansen, Daniel K Low, Kayla Reece, Corrie Casey, Christina S Wingate, Leah K Bezzo, Paul A Merguerian, Sanjay R Parikh, Srinivas M Susarla, Vikas N O'Reilly-Shah. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2022 Dec 1;135(6):1271-1281. PMID: 36384014
In adults, implementation of ERAS protocols has shortened hospital length of stay and reduced complication rates, mortality, and costs.1 Although limited, similar findings are emerging in the pediatric population as well.2-4 As we’ve discussed in previous PAADs, how to implement ERAS into pediatric anesthesia and surgery practice is only in its infancy. One reason is that most pediatric surgery is ambulatory and even in adult patients, ERAS protocols have been applied to ambulatory surgery infrequently. “To address unique aspects of the pediatric population, recent efforts have been focused on defining appropriate ERAS elements for children. Nineteen pediatric-specific ERAS elements arose from this comprehensive review”.4, 5 These included preoperative elements (preop screening, family education, preoperative fasting [carbohydrate loading], preemptive analgesia, and thromboembolic prophylaxis), intraoperative elements (minimally invasive surgery, antibiotic prophylaxis, euvolemia, lung protective ventilation, normothermia, glycemic control, multimodal anti-emetics, opioid sparing analgesia), and postoperative elements (standardized antiemetic rescue, opioid sparing techniques, early feeding and mobilization). Finally, and most importantly, the ERAS elements were developed and applied for ALL of the patients undergoing ambulatory surgery and not directed at any specific surgical procedures.
How did they do it? Prior to the start of this project, the Seattle team had already introduced 11 of the pediatric ERAS elements into their ASC practice. This team has championed and used AdaptX OR Advisor (AdaptX, Seattle, WA), a software program that ingests frequently updated, row-level, information from the hospital’s EMR.6 Aggregate measures were generated to analyze and improve, including those derived from statistical process control (SPC) methods”.5 Technology was also used to embed anesthesia and nursing protocols in the EMR and visualize real-time outcome, process, and balance measures; thereby allowing rapid completion of PDSA improvement cycles”5.
Building upon their opioid-free ambulatory anesthesia practice6,7, they attempted to expand to 17 of 19 ERAS elements, two elements being deemed not applicable to this ambulatory population (lung-projective ventilation and glycemic control). The team planned for 8 enhancements of existing ERAS elements and implementation of 6 new ERAS elements. They had many obstacles to overcome and were not entirely successful; only 3 of 8 enhancements and 5 of 6 implementations of new elements were successful, thus creating an enhanced recovery program with 16 of 19 elements. Nevertheless, using “frequent communications and education at staff meetings, posting of pertinent ERAS Protocol publications (to educate the ambulatory team), and displaying dynamic data as the project progressed, they were by and large successful. They were able to shorten PACU length of stay by about 6 minutes and achieve very high patient/family satisfaction scores. They did not affect maximum pain scores in recovery or surgical complication rates. The biggest disappointment of this project for me (LDM) was the poor response rate from parents on post-operative (at home) measures. This has become the current focus for team improvement.
An interesting issue to me (MY) is how they handled preoperative fasting. As all readers of the PAAD know, this is a lightning rod issue. In this study parents were actively encouraged to give their children carbohydrate rich clear fluids along with an age-appropriate dose of oral acetaminophen 3 hours before scheduled surgery. They achieved a 60% and 70% success rate respectively for these two pre-op protocols. We’ve recently published several PAADs that point us in another direction, namely, to stop thinking about fasting and consider offering carbohydrate rich fluids to children on arrival to the preop center. I (MY) suspect this would and can be an interesting tweak to these protocols in the future. In fact, we (LDM) are actively discussing drinking up to center arrival (60 minutes prior to the surgery) as a next step for this pre-op element.
This demonstration project proves that ERAS protocols and standardization of practice can affect how we can provide and improve pediatric anesthesia care for entire populations, in this case all pediatric outpatient surgery patients, and not limit these protocols to specific, complex patient procedures. The Seattle team is leading the way in this and is now extending their methodology to other aspects of perioperative anesthetic care including inpatient surgical populations and reducing anesthesia greenhouse gas emissions and OR pollution8.
References
1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA surgery. Mar 1 2017;152(3):292-298. doi:10.1001/jamasurg.2016.4952
2. Rove KO, Brockel MA, Brindle ME, et al. Embracing change-the time for pediatric enhanced recovery after surgery is now. Journal of pediatric urology. Oct 2019;15(5):491-493. doi:10.1016/j.jpurol.2019.04.005
3. Loganathan AK, Joselyn AS, Babu M, Jehangir S. Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. Pediatr Surg Int. Jan 2022;38(1):157-168. doi:10.1007/s00383-021-05008-8
4. Short HL, Heiss KF, Burch K, et al. Implementation of an enhanced recovery protocol in pediatric colorectal surgery. J Pediatr Surg. Apr 2018;53(4):688-692. doi:10.1016/j.jpedsurg.2017.05.004
5. Martin LD, Chiem JL, Hansen EE, et al. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesthesia and analgesia. Dec 1 2022;135(6):1271-1281. doi:10.1213/ane.0000000000006256
6. Franz AM, Dahl JP, Huang H, et al. The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project. Paediatric anaesthesia. Jul 2019;29(7):682-689. doi:10.1111/pan.13662
7. Franz A, Martin LD, Liston D, et al. In pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center – A Quality Improvement Initiative. Anesth Analg 2021; 132:788-97. (PMID: 32282383)
8. Hansen EE, Righter-Foss K, Chiem JL, et al. Project SPRUCE: Saving our Planet by Reducing Carbon emissions, a pediatric anesthesia sustainability quality improvement initiative. Anesth Analg 2023 (in press).