Clinical Strategies to Accelerates Recovery

After Surgery in Pediatric Patients

Hasanul Arifin
rakajati84@yahoo.co.id

The 6th SOAC Yogyakarta

Minggu, 8 Agustus 2021
 Pendahuluan,
• Penatalaksanaan perioperatif bedah mengalami
pergeseran paradigma, dimana paradigma
tradisional seperti pemanjangan waktu puasa
preoperasi yang lama (nil by mouth from midnight),
pembersihan saluran pencernaan, dan pemberian
nutrisi kembali setelah 3-5 hari setelah operasi
sudah mulai dan harus ditinggalkan
 Q
How to accelerate recovery after surgery in
pediatric patients ?

AERAS
(Enhanced Recovery After Surgery)
in Paediatrics ?
 Enhanced Recovery After Surgery
(ERAS)
definisi,
penatalaksanaan perioperatif yang berbasis multimodal,
multidisiplin yang didesain untuk menurunkan respon
stress selama operasi, mengurangi komplikasi, lama
rawat, dan mempercepat waktu pemulihan
 Pembedahan
& trauma
Respon kompleks metabolik,
hormonal, hematologi, dan
imunologi tubuh serta
mengaktivasi sistem saraf simpatis

Efek yang berbahaya

bagi pasien
• Preparing
Currently,Enhanced
the direct evidenceRecovery for After
adapting ERAS
Surgery
pathways to pediatric surgery patients is limited.
for implementation in pediatric populations
• Challenges for implementation of ERAS programs for
Ira children
L. Leeds, MD,include
MBA1, Emilylack ofMD,
F. Boss, direct
MPH2,translatability
Jessica A. George, MD,of adult
MEd3,
Valerie Strockbine, RN4, Elizabeth C. Wick, MD1, and Eric B. Jelin, MD4
evidence as well as varying levels acceptability of ERAS
principles among pediatric providers and patients’
families.
Pediatr Surg. 2016 December ; 51(12): 2126–2129. doi:10.1016/j.jpedsurg.2016.08.029
Conclusions:
Our results indicate that implementation of ERAS protocols is safe
and feasible in pediatric gastrointestinal surgery. They can
improve patient comfort, shorten the duration of the postoperative
hospital stay, reduce hospital costs, and accelerate postoperative
rehabilitation without increasing the risk of postoperative
complications.
Therefore, ERAS protocols deserve wider implementation and
promotion.
 ERAS elements
 Preadmission counseling
 Fluid & CHO loading

No prolonged fasting
 No/selective bowel Preoperative Intraoperative
preparation
 Antibiotic
ERAS  Short-­acting anesthetic agents
prophylaxis  Epidural anestesia/analgesia
 Thromboprophylaxis  No drains
 No premedication  Avoidance of salt & water
Postoperative overload
 Maintanace of
normothermia
 Surgical techniques
 Epidural anesthesia/analgesia  Early removal of catheter

 No nasogastric tubes  Early oral nutrition
 Prevention of nausea/vomiting  Early mobilisation
 Avoidance of salt & water  Non-­opioid oral
overload analgesia/NSAIDs
 Audit of compliance  Stimulation of gut
outcomes motility
3 Scott et al. Acta Anaesthesiologica Scandinavica 2015
 ERAS: aggregation of
gains to provide large benefits
marginal

SUCCESS
Discharge
Post-­operative
Recovery Management
Preoperative Preoperative Intraoperative Room
counselling preparation Admission Management

FAILURE

Adapted from “The Slight Edge”, by Jeff Olsen

 ERAS in paediatrics ?

Children are not small adults

Need for age-­dependent protocols

Majority of paediatric surgery is

outpatient
5
 What is Enhanced Recovery?
• Goal: optimize patient care/provide high-value care by
improving outcomes and minimizing resource
utilization
• Theory: maintain physiologic homeostasis and
minimize stress on the body  quicker return to
baseline
• Results: Ideally decreased LOC, decreased
mortality/morbidity, decreased costs
What is special about
children?
Role of ERAS in Pediatric
Surgery
Not little adults

Not all children

can be
treated the same:
Age dependent protocols
 Metabolic Response to Surgery
Adults

Neonates

Energy metabolism of newborns

only minimally modified
by operative trauma.

McHoney et al Eur J Ped Surg 2009

 Metabolic response to surgery

Teitelbaum & Coran Nutrition 1998; McHoney et al Eur J Peid Surg

 Role of family
Ambulatory pediatric surgery > 7yo
PACU no parent vs. parent present

Ramesh et al Anesth Analg

 ... but we are the same species.
Nutrition is critically important

Secker & Jeejeebhoy Am J clin Nutr

Not all elements shown
to be as effective/match
in children
 Not all elements shown to be as
effective/match in children
• Epidural data in children mixed
– Improve pain control/less consistent pain control

Caudal epidural ?
– Shorter hospitalization/longer hospitalizations
• DVT prophylaxis often not needed in children
– Prior to puberty
• Unclear exactly which elements critical in pediatric surgery
or which need to be added
– Parent readiness, education, engagement?
– Family in room > x%/day
✗

✗
✗
✗
What do we do differently in
Pediatric Surgery?
Preoperative Intraoperative Postoperative

Preoperative counseling Short-acting anesthetics Local anesthesia/analgesic

- Family education - Epidural controversial
Allow po preop Avoiding tubes (kids Early mobilization
Clears 2-4 hrs pull them out) - have you tried to make
(including NG a toddler lay still?
EBM) Foley
Drain
s
Preoperative anxiolytic Normothermia Avoiding Narcotics
– important in pediatrics Especially small children
– apnea with narcotics
What are the data?

Fast track vs. ERAS

Often 5-10 elements
Limited and often mixed populations
More in adolescent colorectal
 • Safe, feasible in kids
• Parents like it
• No increase complications
• Works for ~30% of
• pediatric surgeries

Journal of Pediatric Surgery (2007) 42, 234–

 Implementation of fast-track pediatric surgery in a German
nonacademic institution without previous fast-track
experience
Schukfeh, Reismann , Ludwikowski, Hofmann, Kaemmerer, Metzelder, & Ure 2014

The Fast Track modality was successfully implemented and resulted in

G-DRG : German Diagnosis Related Group
high patient/parent satisfaction.
Fast-track Concepts In Routine Pediatric Surgery: A Prospective Study
In 436 Infants And Children
Reismann ,Dingemann, MathiasWolters, Laupichler, Suempelmann & Ure 2009

Feasibility of fast-track surgery according to type of procedure in patients undergoing abdominal,

thoracic, and urologic surgery. Data of procedures performed less than five times are not shown
 Ped Surgical Procedures using Fast
Track

Reismann et al, Feasibility of Fast-Track Elements in Pediatric, Surgery Eur J Pediatr Surg
 Fast-track management is safe and effective after bowel
resection in children with Crohn's disease
Vrecenak & Mattei 2014
Age 8-18
45/71
FT
Lap
ileocecec
tomy
Accelerated
No mean time to full diet
Δ disease
(p < 0.01)
progression
Decreased mean Δ in of ileus
Noduration
complications
(p < 0.01)
Decreased mean narcotic
requirements (p = 0.03)
Decreased mean length of stay
(p < 0.01)
 Pediatric Surgery ERAS

Shinnick et al Journal Surgical Research

2017
Are Ped Surgeons
willing to change ?
 What do we need to implement
ERAS in children?
• Outcomes
– Best practice/consensus
– What are appropriate peds outcomes?
– What components should be applied to
children?
• Engagemen
t
– Education
• DATA
 Which components? How
• many?
Do we apply all of these to • Challenges
children?
– Epidurals – Medications approved in children
– Patient and parent compliance
– DVT prophylaxis • Teenagers
– Insulin for hyperglycemia • Toddlers
– Lack of data
• Limited numbers of pt
• Do we apply these to • hard for team to get in
– Lackroutine
of consensus in
babies/toddlers? pediatric on best
surgery
– Different disease practice
process
– Different physiologic
 ERAS in Children , Conclusion
You/We can do it !!!!!
 Limit Evidence.
 Current evidence suggests that ERAS can be done safely in
children.
 In some instances  decreased LOS, decreased
complications, family satisfaction.
 Metabolic response is different, especially babies
 Need age dependent protocols
Thank you for listening