I accidentally posted this PAAD last week before it underwent final review. I’m reposting it today…
Several years ago, my good friend and Society for Pediatric Anesthesia Life-Time achievement award winner, Chuck Berde, speaking at a SPA annual meeting said, “if you ever see an article by Dr. Henrik Kehlet read it and believe it!” Dr. Kehlet is the pioneer of enhanced recovery after surgery (ERAS).1,2 Based on improved understanding of the pathophysiology of postoperative recovery within an integrated multidisciplinary approach, ERAS protocols, first developed by Dr. Kehlet, have been extremely effective at reducing hospital length of stay and medical complications in adult patients, without increased re-admission rates in a wide range of surgical procedures. The effects of ERAS in pediatric surgical procedures are less well known and studied. I’ve asked my good friend and mentee, Dr. Megan Brockel who has published several studies on pediatric ERAS protocols in urologic procedures to assist in today’s PAAD.3-5 Myron Yaster MD
Original article
Jessica A George, Andres J Gonzalez Salazar, Ahmer Irfan, Laura Prichett, Isam W Nasr, Alejandro V Garcia, Emily F Boss, Eric B Jelin. 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 Jul;57(7):1349-1353.PMID: 35153077 6
The key to understanding ERAS protocols is that they are standardized, protocol driven bundles and to a large degree eliminate individual physician and nursing prerogatives and resultant variability in patient care. Thus, just like in a research study, if the protocol calls for say patients to eat green jello before surgery, individual physicians and nurses can’t give red jello to their patients, even if they think red jello is better than green (and it is!). Overcoming anesthesiologist, surgeon, nursing, and institutional preference and culture and having them ALL buy in to the protocol is the key to ERAS success and failure.
“Two elements that are particularly important in an ERAS bundle for the pediatric population are enhanced, streamlined pain management and early enteral feeding”.6 In 2015, Dr George and her colleagues “noticed a spike in the number of postoperative surgical site infections associated with colorectal surgery, concurrent with a postoperative infection rate that rose to 10–12% based on National Surgical Quality Improvement Program (NSQIP) pediatric risk-adjusted data”.6 They wondered if a standardized ERAS protocol reduce this infection rate as it did in adult patients?1,2
In today’s study, the authors “compared outcomes of pediatric patients who underwent colorectal surgery after ERAS protocol implementation to those of a historical control group. They hypothesized that adherence to a pediatric-specific colorectal pathway would improve outcomes, including patient LOS, postoperative pain scores, and postoperative complication rates as measured by NSQIP data, and reduce perioperative opioid use”.6
They did! “Enhanced recovery pathways decreased LOS, opioid use, postoperative pain scores for children undergoing colorectal surgery and NSQIP-identified postoperative complications (particularly infection and sepsis).”6 Further, the decreased pain scores occurred despite lower opioid consumption. The authors recommend that “ERAS protocols should be considered for this patient population”.6
Before we all jump in, unlike Megan, I (MY) think we should “hold the phone”…One of the problems in this type of preintervention and postintervention retrospective studies is that lots of other confounding things change in medical and nursing practice over time. Some of the benefits found in the study may have had nothing to do with the ERAS protocols. Additionally, because this is a single center study, some of the changes like LOS and opioid use may have changed because this was precisely the focus of the study and because without blinding of care and outcomes, the author’s results could have subtly and (un)consciously influenced the outcomes. This is why randomized, controlled and blinded multi-institutional studies are needed. Indeed, as you will see, we have argued about this ourselves. However, fear not. “An NIH-funded, prospective, randomized controlled trial involving the implementation of enhanced recovery protocols in children undergoing surgery is actively recruiting patients (https://enrich-us.org). That trial will help to address these limitations and provide a clear answer regarding the benefits of enhanced recovery pathway implementation.”
Finally, do we think protocolized care improves outcomes? Absolutely! And therein lies another rub. Once protocols are put into place and improve outcomes within an institution, they lose equipoise and it is virtually impossible to do prospective studies that may challenge the results or the protocols. If we tried to make a change, there would tremendous push back. “How can we not use the protocols that WORK in our practice or in the literature, after all, why subject our patients to inferior care?” Hopefully we’ll address some of these issues in future PAADs.
I (MB) disagree with Myron about the need to “hold the phone.” The impact that ERAS pathways have had on adult perioperative care is profound and, while not as robust, the evidence that similar pathways adapted for children improve perioperative outcomes in pediatric practice is mounting.7 Blinding in ERAS studies is challenging and at this point, with the evidence that we have, many would argue, and Myron and I have argued about this a lot, that true randomization is no longer possible (we lack equipoise). Indeed, in the ongoing ENRICH-US trial described above, children are not randomized to an ERAS pathway versus standard of care, 18 hospitals are randomized into one of three clusters, all of which implement an ERAS pathway.
There are several individual elements of ERAS protocols, especially those pertain to our (anesthesiology) practice that are not controversial. Minimizing fasting in accordance with ASA guidelines, aiming for euvolemia, implementing multimodal analgesia are all things that we can (I hope) agree are in the best interest of our patients. What we found with a recent SPA survey is that it's not necessarily the elements that people are resistant to, it's the concept of a protocol and the perceived loss of autonomy and independence. This is a tough nut to crack even though we know that evidence-based, protocolized care improves outcomes.
Finally, at a recent ERAS conference, Dr. Andrew Franklin of Vanderbilt University quoted Dr. Kehlet as saying that the future of ERAS isn’t more studies showing the efficacy of ERAS, it’s taking the “E” out of ERAS and no longer considering this enhanced or special care but rather considering it standard care. We know that it is better. And we remember what Dr. Berde said about Dr. Kehlet… and we agree. As with other protocolized care, ERAS pathways minimize variability and disparities in care and lead to highly reliable care with improved outcomes as described by Dr. George and her colleagues in their paper. Changes in clinical practice take effect years after evidence becomes available and pediatric evidence often lags behind adult evidence. Rather than “holding the phone,” and waiting for randomized, controlled, and blinded studies, I (MB) would suggest that we implement and study at the same time to minimize further delay.
References
1. Kehlet H: Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia 2020; 75 Suppl 1: e54-e61
2. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H: Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466-77
3. Han DS, Brockel MA, Boxley PJ, Dönmez M, Saltzman AF, Wilcox DT, Rove KO: Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery. Pediatr Surg Int 2021; 37: 151-159
4. Rove KO, Brockel MA, Brindle ME, Scott MJ, Herndon CDA, Ljungqvist O, Koyle MA: Embracing change-the time for pediatric enhanced recovery after surgery is now. J Pediatr Urol 2019; 15: 491-493
5. Rove KO, Brockel MA, Saltzman AF, Donmez MI, Brodie KE, Chalmers DJ, Caldwell BT, Vemulakonda VM, Wilcox DT: Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations. J Pediatr Urol 2018; 14: 252.e1-252.e9
6. 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
7. Loganathan AK, Joselyn AS, Babu M, et al. Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38: 157-168