ERAS recommendations for neonatal perioperative care

Myron Yaster MD, Francis Veyckemans MD, and Megan Brockel MD

Today’s PAAD by Pilkington et al.¹ provide evidence based Enhanced Recovery After Surgery  (ERAS) recommendations for surgical neonates. “The guidelines and their respective components are intended to minimize the physiologic stress of surgery and the resultant catabolic state that contributes to adverse surgical outcomes.”¹ Currently, there is only one ERAS guideline for the treatment of neonates undergoing GI resection.^1,2  The authors “sought to reevaluate the recommendations for neonates undergoing intestinal resection and update and expand these guidelines to apply to a broader population of all surgical neonates.”¹  Perhaps most importantly to you, the PAAD readership, analgesia related topics are NOT included in this position/guideline statement. I’ve asked Dr. Megan Brockel, an expert in pediatric ERAS protocol development, to assist Francis and me.  Myron Yaster MD

Original article

Pilkington M, Nelson G, Pentz B, Marchand T, Lloyd E, Chiu PPL, de Beer D, de Silva N, Else S, Fecteau A, Giuliani S, Hannam S, Howlett A, Lee KS, Levin D, O'Rourke L, Stephen L, Wilson L, Brindle ME. Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care. JAMA Surg. 2024 Jul 31. doi: 10.1001/jamasurg.2024.2044. Epub ahead of print. PMID: 39083294.

Enhanced Recovery After Surgery protocols have dramatically changed the practice of adult surgery and anesthesia.  In adults, ERAS care pathways have been shown to reduce complications, reduce postoperative length of stay (without increasing readmissions), and reduce costs.³  Its spread into pediatrics has been less robust and initially centered on patients undergoing complex procedures like major urologic reconstructive surgery, colorectal surgery, and posterior spine surgery.^4,5 More recently a single center’s ERAS protocols for pediatric ambulatory surgery have also been published.⁶  In an effort to expedite uptake of ERAS elements and protocols in the neonatal population, today’s PAAD by Pilkington et al sought to develop a set of commonalities that could be used to develop broadly applicable  guidelines rather than replicating ERAS guidelines and algorithms for each type of neonatal surgery. The results of their efforts are found in the table below.

We don’t think there is anything in these recommendations that is either new or outside the scope of common sense. They are part of the 10 -N pediatric anesthesia quality checklist of the SAFETOTS initiative published in 2015.⁷ (Figure) Unfortunately, common sense doesn’t always translate into common practice, but protocols and audits can bridge the gap between what we know and what we do.

The recommendations for perioperative lung protective ventilation, which are rightly acknowledged as weak (no clear evidence so far), depend critically on the equipment available: most modern anesthesia ventilators are unable to measure accurately tidal volumes in neonates⁸ and the difference between end-tidal and arterial CO2 is often larger than in older children. But perhaps the most controversial and difficult to implement aspects of ERAS in the newborn surgical population revolve around analgesia, particularly perioperative multi-modal analgesia. Unfortunately, this was not discussed in this article. There is so much we do not know. For example: are around the clock NSAIDs and acetaminophen, features of ERAS in other surgical populations, safe and effective in the newborn? Based on the experience with PDA closure, NSAIDS can have important renal effects, and the dosage of acetaminophen needs to be adapted to the postmenstrual age.⁹  What is the role of regional anesthesia and continuous infusions of local anesthetic postoperatively?  Or nurse controlled PCA?  Who is primarily responsible for analgesia in the NICU?  The NICU staff or pediatric pain services?  What about non-pharmacologic interventions? The list goes on. Fortunately, the authors commissioned a separate working group for this undertaking and we’ll look forward to reading their analgesia-related recommendations when they are published.

Send your thoughts and comments to Myron who will post in a Friday reader response.

References 

1.            Pilkington M, Nelson G, Pentz B, et al. Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care. JAMA surgery 2024 (In eng). DOI: 10.1001/jamasurg.2024.2044.

2.            Brindle ME, McDiarmid C, Short K, et al. Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS(®)) Society Recommendations. World journal of surgery 2020;44(8):2482-2492. (In eng). DOI: 10.1007/s00268-020-05530-1.

3.            Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA surgery 2017;152(3):292-298. (In eng). DOI: 10.1001/jamasurg.2016.4952.

4.            Han DS, Brockel MA, Boxley PJ, et al. Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery. Pediatr Surg Int 2021;37(1):151-159. (In eng). DOI: 10.1007/s00383-020-04775-0.

5.            George JA, Salazar AJG, Irfan A, et al. 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(7):1349-1353. (In eng). DOI: 10.1016/j.jpedsurg.2022.01.004.

6.            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 2022;135(6):1271-1281. (In eng). DOI: 10.1213/ane.0000000000006256.

7.            Weiss M, Vutskits L, Hansen TG, Engelhardt T. Safe Anesthesia For Every Tot - The SAFETOTS initiative. Current opinion in anaesthesiology 2015;28(3):302-7. (In eng). DOI: 10.1097/aco.0000000000000186.

8.            Abouzeid T, Perkins EJ, Pereira-Fantini PM, Rajapaksa A, Suka A, Tingay DG. Tidal Volume Delivery during the Anesthetic Management of Neonates Is Variable. The Journal of pediatrics 2017;184:51-56.e3. (In eng). DOI: 10.1016/j.jpeds.2017.01.074.

9.            Veyckemans F, Anderson BJ, Wolf AR, Allegaert K. Intravenous paracetamol dosage in the neonate and small infant. British journal of anaesthesia 2014;112(2):380-1. (In eng). DOI: 10.1093/bja/aet559.