Enhanced Recovery After Surgery (ERAS) in paediatrics · Enhanced Recovery After Surgery (ERAS) in...

Enhanced Recovery After Surgery(ERAS) in paediatrics

Koen Huysentruyt

Overview

l Introduction

l Preoperative nutritional assessment

l Preoperative fasting guidelines

l Metabolic response to surgical stress in children

l Postoperative early oral nutrition

l Current experience for ERAS in children

l Conclusion

2

ERAS elements

3

PreoperativeIntraoperative

Postoperative

ü Preadmission counselingü Fluid & CHO loadingü No prolonged fastingü No/selective bowel

preparationü Antibiotic prophylaxisü Thromboprophylaxisü No premedication

ü Short-acting anesthetic agentsü Epidural anestesia/analgesiaü No drainsü Avoidance of salt & water

overloadü Maintanace of normothermiaü Surgical techniques

ü Epidural anesthesia/analgesiaü No nasogastric tubesü Prevention of nausea/vomitingü Avoidance of salt & water

overloadü Audit of compliance outcomes

Scott et al. Acta Anaesthesiologica Scandinavica 2015

ü Early removal of catheterü Early oral nutritionü Early mobilisationü Non-opioid oral

analgesia/NSAIDsü Stimulation of gut motility

IntroductionNutritional assessmentPre-op fastingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

ERAS

Preoperativecounselling

Preoperativepreparation Admission

IntraoperativeManagement

Recovery Room

Post-operativeManagement

Discharge

SUCCESS

FAILURE

Adapted from “The Slight Edge”, by Jeff Olsen

ERAS: aggregation of marginal gains to provide large benefits


ERAS in paediatrics ?

5

Majority of paediatric surgery is outpatient

Need for age-dependent protocols

Children are not small adults


Prevalence of under-nutrition:general vs surgical population

Hecht et al. Clinical nutrition 2014 ;; Huysentruyt et al. Acta paediatrica 20136

Surgical20%

Paediatric80%

7%

93%

Under-nutrition

No undernutrition

Europe (2014)

General population

Belgium (2013)Surgical

10%

Infectious62%

Other28%

13%

87%

Under-nutrition

No undernutrition

Surgical vs paediatric under-nutrition: p=0.897

Surgical vs paediatric under-nutrition: p=0.230

General population

Nutritional status

Nutritional status

(7.1% under-nutrition)




Preoperative assessment & surgical outcome

7 Wessner & Burjonrappa. Journal of Pediatric Surgery 2014

Inclusion of 6 articles in review:• 3 prospective cohort studies

• 3 retrospective chart studies

IntroductionNutritional assessmentPre-op fasting Metabolic responsePostop feedingCurrent evidence for ERASConclusion

Study specifics

8

Setting Design N Nutrition assessment Outcome

Canada, 2007 Prospective 175 SGNA, albumin, transferrin, WFA, HFA, BMI, MUAC, TSF, hand grip strength

30d mortality, surg/infcomplic., LoS, Ab use

Major (non-cardiac) thoracic or abdominal surgery

Cardiac surgery

Secker & Jeejeebhoy. Am J of Clin Nutr 2007;; Leite et al. Nutrition 2005;; Radmanet al. J Thorac Cardiovas Surg 2014;; Vivanco et al. Bol Med Hosp Infant Mex 2010;; Wakita et al. Nutr Clin Pract 2011;; Toole et al. Congenit Heart Dis 2014

Setting Design N Nutrition assessment Outcome

Japan, 2011 Retrospective 36 PNI, WFA, HFA, WFA Mortality, PICU LoS, mech vent, LoS

Brazil, 2005 Prospective 30 Albumin, WFA, HFA, WFH 30d mortality, LoS, inf

Mexico, 2010 Retrospective 289 WFA at birth, BMI LoS>6d, mortality

USA/Guetamala2014

Prospective(2 centres)

41/30

TSF, albumin, pre-albumin 30d mortality, PICU LoS, mech vent., inotropics

USA, 2014 Retrospective 121 WFH, HFA LoS, PICU LoS, mechvent.


Anthropometric assessmentHFA BMI/WFH TSF MUAC

Secker, Canada

ü LoS LoS LoS LoS

complic . complic. complic. complic .

mortality mortality mortality mortality

Wakita, Japan

LoS LoS

mechanical ventilation

mechanicalventilation

Vivanco-Munoz, Mexico

ü mortality

Radman, USA/Guatemala

ü LoS (USA) LoS (Guat.)

ü mechanical ventilation (USA) mechanical ventilation (Guat.)

Toole, USA

ü LoSinverse ?

LoS



9 Wessner & Burjonrappa. Journal of Pediatric Surgery 2014


Biochemical assessment

l Albumin• Leite (Brazil):

• post-‐op infections• mortality

• Secker (Canada):• post-‐op infections• minor complications• LoS• Albumine in normal

range for all children!

• Radman (USA/Guat):• mech ventilation (USA)

l Pre-albumin• Radman (USA/Guat):

• mech ventilation (USA)

Wessner & Burjonrappa. Journal of Pediatric Surgery 201410


Subjective assessment

11 Wessner & Burjonrappa. Journal of Pediatric Surgery 2014;; Secker & Jeejeebhoy. Am J Clin Nutr 2007


l “Children encouraged to drink clear fluids up to 2h before elective surgery”• Applies for neonates, infants and children• Comfort ↑, thirst ↓, risk of dehydration ↓• Permitted volume does not impact intragastric

volume of pH

l “Breast milk safe up to 4h beforeelective surgery”

l “Other milk safe up to 6h before elective surgery”

12

Preoperative fasting guidelinesIntroductionNutritional assessmentPre-op fastingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

Smith et al. Eur J Anaesthesiol 2011;; American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011

Metabolic responses to surgery

l Operative trauma = “controlled injury”

Triggers range of inflammatory pathways

l Can be the setting for deleterious effects• Systemtic inflammatory response syndrome• Prolonged catabolism of body stores

l Different in children from adults

McHoney et al. Eur J Pediatr Surg 200913


McHoney et al. Eur J Pediatr Surg 2009;; Basics in Clinical Nutrition, fourth edition14

Cytokine response

• Targets: thymocytes, neutrophils, T and B cells, skeletal muscle, hepatocytes, osteoblasts

• Actions: immunoregulation, inflammation, fever, anorexia, °acute phase protein, muscle proteolysis

IL-1αIL-1β

•Targets: fibroblasts, endothelium, skeletal muscle, hepatocytes, osteoblasts

•Actions: immunoregulation, inflammation, fever, anorexia, °acute phase protein, muscle proteolysis

TNF-α

•Targets: thymocytes, T and B cells, hepatocytes•Actions: immune cell differentiation, °acute phase proteinIL-6

•Targets: monocytes, SMC’s, ....•Actions: supresses the production of pro-inflammatory cytokines

IL-10


Factors affecting response

l Age

l Nutrition and fasting

l Anaesthesia

l Operative stress & surgical approach

l Temperature

McHoney et al. Eur J Pediatr Surg 2009;; Bölke et al. Pediatric Research 2002.15

IntroductionNutritional assessmentPre-op fasting & CHO loadingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

Teitelbaum & Coran. Nutrition 199816

Metabolic responses to surgeryIntroductionNutritional assessmentPre-op fastingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

Postoperative energy metabolism

McHoney et al. Eur J Pediatr Surg 200917

In contrast tot adults, the energy metabolism of newborns undergoing major operations seems to be only minimally modified by the operative trauma per se


Postoperative feeding

l Oral intake when possible, avoid unnessecary NG tube placement

l Avoid opioids if possiblel Pyloromyotomy:• Oral feeding possible as early as 2h

postoperatively• Full enteral intake within 24-48h after

operation• Gradual increase vs liberal intake ?• Post-op vomiting related to degree of pre-op

elektrolyte disturbances and dehydration

18


Holland-Gunz & Günther Der Chirurg 2009;; St Peter et al. J Pediatr Surg 2008;; Adibe et al. J Pediatr Surg 2014

l Limited experience of “fast-track surgery” in paediatrics• Mixed procedures (pyeloplasty, appendectomy, bowel

anastomosis, fundoplication, hypospadia repair, nephrectomy)

• Ambulatory surgery

• Colonic surgery • Cardiac surgery

19

ERAS in paediatrics ?IntroductionNutritional assessmentPre-op fastingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

Mixed procedures:The Hannover criteria

20


Reismann et al. J Ped Surg 2007;; Reismann et al. Langenbecks Arch Surg 2009;; Reismann et al, Eur J Pediatr Surg 2012

Element Definition of successful application

Analgesia Pain intensity <1/3 of the maximum scale points at the evening of the day of operation

Postoperative nutrition Full oral nutrition by the evening of the 2nd

postoperative day (without nausea/vomiting)

Postoperative mobilisation 2-score points at the evening of the 2nd

postoperative day

Applicability of minimallyinvasive surgery

No conversion and no postoperative complication with any adverse effect in procedures suitable for MIT

Hospital stay Significantly shorter compared to national data for similar patients in hospitals with a similar case mix index and similar structure

Postoperative symptoms No nausea or vomiting

Complications No complications

Patient/parental evaluation Satisfaction (>90%) of patients/parents, (<10%) readmission

21

Mixed proceduresIntroductionNutritional assessmentPre-op fastingMetabolic responsePostop feedingCurrent evidence for ERASConclusion

Holland-Gunz & Günther Der Chirurg 2009.;; Reismann et al. J Ped Surg 2007;; Reismann et al. Langenbecks Arch Surg 2009;; Reismann et al, Eur J Pediatr Surg 2012;; Schukfeh et al, Eur J Pediatr Surg 2014;; Dingemann et al, World J Urol 2010

Hannover 2007 (university hospital)• Pyeloplasty, appendectomy, bowel anastomosis, fundoplication,

hypospadia repair, nephrectomy• Excluded: additional diseases, reoperation, perforated appendicitis

113/159

Hannover 2009 (university hospital) adapted pain protocol• Elective abdominal, thoracic or urological surgery• Excluded: age ≤4 weeks, prematurity, reoperation, pectus excavatum

repair, consulted decision based on general condition and co-morbidities

155/436

Hannover 2012 (university hospital) feasibility study• Elective abdominal, thoracic or urological surgery• Excluded: age ≤4 weeks, prematurity, need for post-op PICU admission

182/203

Hannover 2014 (non-university hospital)• Pyeloplasty, appendectomy, pyloromyotomy, fundoplication, hypospadia

repair, nephrectomy • Excluded: age ≤4 weeks and >16 years

143/143

Mixed procedures:Hannover 2007 study

l Pain control• Mean pain scores >1/3 on the evening of operation• Due to restricted opioid use on the day of operation ?

l Mobilisation• Completed after mean of 29.5±17 h

l Oral nutrition• Completed after mean of 15±14 h

l Postoperative complications• n=2 (pain and revision of bleeding after hypospadia

repair)

l Patient/parent satisfaction• Not satisfied: n=2

22


Reismann et al. J Ped Surg 2007


l Pain control:

l Mobilization:

23


2007 study 2009 study

Reismann et al. Langenbecks Arch Surg 2009

Mixed procedures:Feasibility study

24


Successful implementation of fast-track elements

Reismann et al, Eur J Pediatr Surg 2012


l Pain control• Mean pain scores <1/3

on the evening of operation

l Mobilisation• 71% fully mobilized at

2nd post-op day

l Oral nutrition• Completed after mean

of 1.8 ±1.4 days

l Length of stay• No difference compared

to national data

Schukfeh et al, Eur J Pediatr Surg 201425


Mean hospital stay

l Difference in inclusion?• perforated appendicitis• comorbidities

l Financial reimburcement ?

Ambulatory surgery

l Children >7 years post-op randomly sent to PACU (standard, no parents present) or second-stage recovery unit (parents present):

Ramesh et al. Anesth Analg 200126


Colonic surgery

l Prospective Italian study (2009)• 46 children (38 Hirschprung, 8 IBD)

• 100% oral feeding on post-op day 1• 100% discharge before post-op day 5

• 2 re-admissions

Mattioli et al. J Laparoendoscop Adv Surg Techn 200927


Fast-track protocol• Pre-op: standardized bowel preparation, Ab, standardized fasting, full pre-op evaluation

• Intra-op:muscle-sparing approach• Post-op: avoiding drain, early removal of NG tube, pain control, minimize opioids

Colonic surgery

l Retrospective US study (2014)• 71 children (all Crohn’s disease)

• 45 fast-track vs 26 conventional

Vrecenak & Mattei. J Pediatr Surg 201428


Protocol• Pre-op: “counseled”• Intra-op: laparoscopic approach• Post-op: oral intake within 24h, no routine NG tube, rectal suppository if no stool on day 2, minimize opiods, avoiding drain

Conclusion

l Mind the nutritional status also in childrenl No overnight fastingl Metabolic response is different, especially

in small childrenl Paucity of evidence for ERAS in pediatric

surgeryl Current evidence suggests that ERAS can be

implemented safelyl At least in selected patients, ERAS can lead

to shorter hospital stay

29


Date post:	14-Mar-2019
Category:	Documents
Upload:	nguyendien
View:	222 times
Download:	0 times

Enhanced Recovery After Surgery (ERAS) in paediatrics · Enhanced Recovery After Surgery (ERAS) in...

Documents