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Enhanced recovery after surgery in paediatrics: a review of the literature

Open ArchivePublished:May 06, 2020DOI:https://doi.org/10.1016/j.bjae.2020.03.004
      By reading this article you should be able to:
      • Compare the differences between enhanced recovery after surgery (ERAS), perioperative surgical home and fast-track surgery.
      • Explain the various components of an ERAS protocol in paediatrics.
      • Describe the limited evidence for common ERAS interventions in paediatric practice.
      • Propose future directions for multidisciplinary paediatric standardised care protocols.
      • The concept of ERAS is that multiple, evidence-based best practice interventions combined into a protocol will contribute synergistically to improved outcomes.
      • The success of adult ERAS protocols has led to interest in creating paediatric ERAS pathways.
      • Key ERAS principles include preoperative education, reduced preoperative fasting, minimally invasive surgical techniques, multimodal opioid-sparing analgesia including regional anaesthesia, minimising the use of surgical drains and early postoperative feeding and mobilisation.
      • Although robust, high-quality evidence is lacking, the available literature demonstrates reduced length of stay, use of opioids and intraoperative fluids, and time to restarting a regular diet with paediatric ERAS protocols.

      Background: history of enhanced recovery after surgery

      In the era of modern surgery, it is vitally important to provide high-quality, resource-conscious, patient-centred care. Enhanced recovery after surgery (ERAS) is a concept developed to meet these goals. Enhanced recovery after surgery utilises a patient-centred, multidisciplinary approach through the perioperative period. Key ERAS concepts include preoperative education for patients and families, reduction of preoperative fasting, using minimally invasive surgical techniques, multimodal opioid-sparing analgesia and regional anaesthesia, minimising tubes and drains and early postoperative feeding and mobilisation.
      • Pearson K.L.
      • Hall N.J.
      What is the role of enhanced recovery after surgery in children? A scoping review.
      The concept of ERAS is that multiple, evidence-based best practice interventions can be combined into a protocol; when applied together, the interventions contribute synergistically to improved outcomes for patients.
      • Brindle M.E.
      • Heiss K.
      • Scott M.J.
      • Herndon C.A.
      • Ljungqvist O.
      • Koyle M.A.
      Embracing change: the era for pediatric ERAS is here.
      In adults, ERAS protocols reduce morbidity and increase patients' satisfaction while reducing overall costs. Clearly defined, standardised elements applied in a consistent manner can optimise care. The earliest uptake of ERAS Society guidelines was for adults undergoing colorectal surgery. As growing evidence demonstrated benefits such as reduced length of stay (LOS) and decreased costs, ERAS was expanded into other adult surgical specialties, including gynaecological, orthopaedic and cardiac surgery. This was accompanied by increasing evidence that protocolised care improves morbidity and mortality.
      • Ljungqvist O.
      • Scott M.
      • Fearon K.C.
      Enhanced recovery after surgery a review.
      The term ‘fast-track surgery’ is often used interchangeably with ERAS. ‘Fast track’ was the term initially applied to the approach developed by Kehlet in the 1990s that has subsequently become ERAS. The early goal of fast-track surgery was earlier discharge from hospital after surgery through a comprehensive programme to optimise perioperative care. Many of the original elements of fast-track surgery are similar to current ERAS concepts, including early postoperative feeding and mobilisation, use of minimally invasive surgery and avoiding tubes and catheters where possible. The term ‘enhanced recovery after surgery’ puts more emphasis on a holistic approach to recovery with a broader focus on outcomes that are important for the patient.
      An enhanced recovery protocol (ERP) is the implementation strategy used to institute an ERAS guideline. The goal of ERP is to ensure that an evidence-based and standardised approach is applied to all patients undergoing surgery. ERPs involve all multidisciplinary team members and engage the patient and their family in their care. An effective ERP uses an ERAS guideline to improve the quality and efficiency of surgical care while reducing costs.
      The success of adult enhanced recovery strategies has led to interest in creating ERAS pathways in children. Previous literature reviews on paediatric ERAS have identified a lack of prospective and randomised control trials in this area, and have acknowledged that the creation and implementation of paediatric ERAS pathways (Table 1) has been slower than in adults.
      • Rove K.O.
      • Edney J.C.
      • Brockel M.A.
      Enhanced recovery after surgery in children: promising, evidence-based multidisciplinary care.
      Table 1Key components of paediatric ERAS pathways
      • Short H.L.
      • Taylor N.
      • Piper K.
      • Raval M.V.
      Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel.
      InterventionAPSA colorectal care pathway
      Preoperative
      Provide preoperative information and educationYes
      Optimise underlying medical conditionsYes
      Minimise the use of mechanical bowel preparationNo
      Avoid prolonged fastingYes
      Administer non-opioid preoperative analgesic medicationsYes
      Intraoperative
      Use thromboembolism prophylaxisYes
      Use preoperative antibiotic prophylaxis and skin preparationYes
      Use a standard anaesthetic protocol, including regional anaesthesia when possibleYes
      Apply a multimodal approach to preventing PONV if >2 risk factorsYes
      Utilise laparoscopic surgeryYes
      Avoid routine nasogastric tubesYes
      Use standardised protocol for hypothermia preventionYes
      Postoperative
      Avoid routine peritoneal cavity drainage after colonic anastomosisYes
      Use goal directed fluid therapy or zero fluid balance model to guide postoperative fluid managementYes
      Avoid urinary catheter placement or early removal on postoperative day 1 or 2Yes
      Use interventions to minimise postoperative ileusYes
      Minimise use of opioidsYes
      Use insulin to control severe hyperglycaemia in the ICUNo
      Provide nutritional care, including screening for nutritional statusYes
      Begin early scheduled mobilisation on postoperative days 0–1Yes
      Collect information on protocol compliance and outcomesYes
      A recent review identified one retrospective and four prospective cohort studies evaluating children undergoing gastrointestinal (GI), urological and thoracic surgery.
      • Pearson K.L.
      • Hall N.J.
      What is the role of enhanced recovery after surgery in children? A scoping review.
      The intervention bundles in the studies included six or fewer interventions, substantially less than the more than 20 recommended interventions in most adult guidelines. Despite this, the studies did suggest that ERPs may be associated with benefits such as decreased LOS and decreased use of opioids, without an increase in complications in appropriate groups of children undergoing surgery.
      In September 2016, a scoping review identified the extent to which ERAS has been used in paediatric surgery.
      • Pearson K.L.
      • Hall N.J.
      What is the role of enhanced recovery after surgery in children? A scoping review.
      The authors identified nine studies from 2003 to 2014 including 1269 patients. Interventions within these protocols were restricted in number and included early postoperative feeding and mobilisation protocols, morphine-sparing analgesia and reduced use of nasogastric (NG) tubes and urinary catheters. These relatively limited ‘fast-track’ programmes significantly reduced LOS, time to oral feeding and time to first stool.
      More extensive strategies to introduce ERAS in paediatrics have been undertaken. In 2017, at an American Academy of Paediatrics symposium, paediatric surgeons assessed an existing ERAS Society guideline in adults for use in adolescents undergoing colorectal surgery. The initial consensus agreement was to adopt 14 of the 21 key elements. After reviewing the evidence for the elements excluded, group consensus resulted in the final inclusion of 19 of the 21 elements. Experience with this paediatric-specific ERP was recently published: outcomes from 43 patients undergoing surgery before the ERP were compared with those from 36 patients after introduction of ERP. In the period before ERP, the median number of ERAS interventions per patient was five; in the period after ERP, the median number of interventions was 11. Key results included a statistically significant difference in the median LOS from 5 to 3 days with the ERP. The times to restarting a regular diet, use of opioids and volumes of fluids given during surgery were all reduced.
      • Short H.L.
      • Heiss K.F.
      • Burch K.
      • et al.
      Implementation of an enhanced recovery protocol in pediatric colorectal surgery.

      Paediatric evidence for common ERAS interventions

      Children pose unique physical and psychosocial challenges to the anaesthetist. The surgical stress response is complicated by physiological considerations based on a child's developmental stage. Given the unique biopsychosocial factors in paediatrics, individual ERAS principles may not be universally translatable to children, despite demonstrated evidence in adults. Adolescent ERAS guidelines may resemble adult ERAS guidelines; however, neonates will require considerably different guidelines. The paediatric evidence supporting the recommendations commonly used in adult ERAS protocols are described below.
      • Rove K.O.
      • Edney J.C.
      • Brockel M.A.
      Enhanced recovery after surgery in children: promising, evidence-based multidisciplinary care.

       Preoperative patient/family education

      Engagement and education of patients is a major component of adult ERAS protocols. In paediatrics, information should be provided to families to reduce the child's and parents' anxiety surrounding surgery. Education must be provided at an age-appropriate level before surgery. Educating families has a substantial impact on overall satisfaction with the surgical process and reduces anxiety. Involving older children and adolescents in the preoperative planning process can promote engagement and understanding and establish expectations, which has been shown to improve the quality of their care and aid their postoperative recovery.
      • Gibb A.C.N.
      • Crosby M.A.
      • McDiarmid C.
      • et al.
      Creation of an Enhanced Recovery after Surgery (ERAS) guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study.

       Minimisation of fasting and administration of a preoperative carbohydrate load

      A recent joint consensus statement by the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology and L'Association Des Anesthesistes-Renamateurs Paediatriques d’Expression Francaise agreed that based on the current literature and in the absence of a contraindication, children should be encouraged and allowed to consume clear liquids up to 1 h before elective general anaesthesia, up to a recommended maximum volume of 3 ml kg1.
      • Thomas M.
      • Morrison C.
      • Newton R.
      • Schindler E.
      Consensus statement on clear fluids fasting for elective pediatric general anesthesia.
      This is in contrast to other society guidelines, such as the ASA, which continue to recommend 2 h fasting from clear liquids before surgery.
      ASA Task Force Team
      Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on.
      With a 2 h clear liquids fasting policy, the literature suggests that patients actually fast for 6–7 h, with several studies demonstrating fasts of up to 15 h. The liberalised policy on clear fluid fasting is based on evidence that water empties from the stomach within 30 min, and other clear fluids are almost gone within an hour. There is evidence from randomised control studies demonstrating no significant difference in gastric volume or pH if children are fasted for clear fluids for 1 compared with 2 h.
      • Schmidt A.R.
      • Buehler P.
      • Seglias L.
      • et al.
      Gastric pH and residual volume after 1 and 2 h fasting time for clear fluids in children.
      Prolonged fasting primes metabolic and immune responses which induce a catabolic state, increase insulin resistance and potentially reduce intravascular volume. Giving an oral carbohydrate liquid drink 2–3 h before surgery in adults has been shown to modify this response by reducing insulin resistance, maintaining glycogen reserves, minimising protein breakdown, improving overall muscle strength and possibly contributing to earlier return of bowel function and decreased LOS, without increasing complication rates.
      • Rove K.O.
      • Edney J.C.
      • Brockel M.A.
      Enhanced recovery after surgery in children: promising, evidence-based multidisciplinary care.

       Avoidance of preoperative hyperosmotic mechanical bowel preparation

      Mechanical bowel preparation (MBP) was once a mainstay in adult colorectal practice, but its utility and potential harms have recently been questioned. The goal of MBP is to reduce complications associated with stool bacterial contamination including anastomotic dehiscence, wound infection and sepsis. In adults, evidence suggests that hyperosmotic MBP may increase risk of surgical site infection (SSI), increase bowel wall oedema and increase risks of bowel leak and anastomotic dehiscence; however, the data are conflicting. In the largest study to date, 32,359 adult patients who underwent elective colorectal resections in the American College of Surgeons national surgery quality improvement programme database were analysed retrospectively.
      • Koller S.E.
      • Bauer K.W.
      • Egleston B.L.
      • et al.
      Comparative effectiveness and risks of bowel preparation before elective colorectal surgery.
      MBP alone was ineffective at reducing the risk of SSI when compared with no bowel preparation. However, oral antibiotics (OA) alone and OA plus MBP were associated with decreased risk of SSI, anastomotic leak, postoperative ileus, readmission and shorter LOS. In a similar retrospective analysis of 27,804 adult surgical patients undergoing elective colorectal resections, combined MBP/antibiotic bowel preparation (ABP) resulted in significantly lower rates of SSI, organ space infection, wound dehiscence and anastomotic leak than no preparation; and a lower rate of SSI than ABP alone.
      • Klinger A.L.
      • Green H.
      • Monlezun D.J.
      • et al.
      The role of bowel preparation in colorectal surgery: results of the 2012–2015 ACS-NSQIP data.
      Thus, future adult ERAS recommendations may recommend that patients undergoing elective colorectal resection should have both mechanical agents and OA when feasible.
      In children, MBP carries increased morbidity, often requiring an additional hospital day, NG tube placement for administration of the preparation and additional laboratory tests and i.v. fluids to ensure adequate fluid and electrolyte balance during the preparation. A small randomised control pilot study identified no significant difference in rates of anastomotic leak, intra-abdominal infection or wound infection between children who received MBP and those who did not.
      • Aldrink J.H.
      • McManaway C.
      • Wang W.
      • Nwomeh B.C.
      Mechanical bowel preparation for children undergoing elective colorectal surgery.
      A retrospective, multicentre review of 272 children who underwent reversal of colostomy found that using MBP was associated with an increased risk of wound infection, increased LOS and no reduction in any other complications. LOS in the MBP group was longer, primarily because these patients were admitted before their surgery for bowel preparation. These results suggest that omitting MBP in children is safe, and may reduce cost and discomfort.
      • Serrurier K.
      • Liu J.
      • Breckler F.
      • et al.
      A multicenter evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown.
      Whether or not MBP is a beneficial element of paediatric ERAS protocols remains to be determined. Avoidance of MBP was one of only two elements that the American Paediatric Surgical Association (APSA) ultimately excluded from their recommendations for an adolescent colorectal ERAS protocol (the other excluded element being glucose monitoring).
      • Short H.L.
      • Taylor N.
      • Piper K.
      • Raval M.V.
      Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel.
      Conflicting literature and lack of definitive evidence were among the reasons for excluding avoiding MBP in the recommendation.

       Judicious use of fluids

      A major component of adult ERAS protocols is rational and judicious fluid therapy. However, there is less evidence that children are as vulnerable to volume shifts as adults. Aggressive use of i.v. fluids has been associated with worse outcome in paediatric patients undergoing cardiac surgery, but this trend has only recently been demonstrated in other specialties such as colorectal surgery. A recent retrospective cohort study of paediatric patients undergoing colonic resection identified an association between high volume intraoperative fluid administration and worsened postoperative outcomes. Specifically, giving fluids greater than 90th percentile overall was associated with LOS >6 days (odds ratio [OR], 8.14; 95% confidence interval [CI], 1.75–37.8; p=0.007), time to first meal >4 days (OR, 5.91; 95% CI, 1.30–27.17; p=0.02) and supplemental oxygen requirement >24 h (adjusted OR [AOR], 3.60; 95% CI, 1.25–10.39; p=0.02), after adjusting for ASA status, blood loss, transfusion and open surgery.
      • Sanford E.L.
      • Zurakowski D.
      • Litvinova A.
      • Zalieckas J.M.
      • Cravero J.P.
      The association between high-volume intraoperative fluid administration and outcomes among pediatric patients undergoing large bowel resection.
      The American Society for Enhanced Recovery makes several recommendations for adult colorectal surgery that may apply to paediatric patients, including avoidance of fluid administration for intraoperative oliguria (but not anuria), administering fluid to address specific clinical problems and avoiding fluid administration for treatment of an isolated abnormal haemodynamic value.
      • Thiele R.H.
      • Raghunathan K.
      • Brudney C.S.
      • et al.
      Correction to: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery.
      ERAS principles such as reduced fasting and avoiding MBP have decreased the intravascular volume deficits, and fluid needs and administration must be adjusted accordingly.
      New technologies can help assess a patient's fluid responsiveness (oesophageal Doppler, non-invasive cardiac output monitoring, plethysmography variability index, aortic peak blood flow velocity). The goal of these technologies is to provide a metric to classify patients in whom fluid administration will improve cardiac output and optimise tissue perfusion, and in whom preload therapy is unnecessary and will result in fluid overload. In mechanically ventilated adults, dynamic indices of preload that rely on respiratory variation in stroke volume are better able to predict fluid responsiveness than static variables. Further investigations in children are required to guide fluid administration, assessment and optimal maintenance of euvolaemia.

       Regional anaesthesia

      The adjunctive use of regional anaesthesia during procedures requiring general anaesthesia has many potential advantages. Although most commonly thought of as an effective means of postoperative analgesia, regional anaesthesia may decrease intraoperative requirements for intravenous and volatile anaesthetic agents, thereby providing a more rapid awakening and earlier extubation. Regional anaesthesia can also attenuate or potentially ablate the harmful effects of the surgical stress response. Afferent neural blockade attenuates pro-inflammatory and metabolic responses to stress and reduces insulin resistance. High-quality evidence in adults suggests additional benefits of neuraxial analgesia include accelerated return of GI transit (decreased time to first flatus and first stool) after abdominal surgery. In open surgeries, an epidural infusion containing local anaesthetic may decrease the length of hospital stay (equivalent to 1 day).
      • Guay J.
      • Nishimori M.
      • Kopp S.L.
      Epidural local anesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting, and pain after abdominal surgery: a Cochrane review.
      In neonates major abdominal surgery includes intestinal resection surgery, congenital diaphragmatic hernia, gastroschisis and omphalocele. One means of reducing exposure to drugs that may cause neuronal apoptosis is to use neuraxial anaesthesia as an adjunct to general anaesthesia.
      Various researchers have also demonstrated several potential advantages of peripheral nerve block techniques in paediatric patients for improving postoperative analgesia and reducing adverse effects related to opioids. Examples on these include transversus abdominal plane, erector spinae plane, paravertebral, rectus sheath and quadratus lumborum blocks.
      The paediatric regional anaesthesia network (PRAN) is a multi-institutional centralised database that collects prospective data on all regional anaesthetics given at participating centres, to study the incidence of complications of paediatric regional anaesthesia. Data on 14,917 regional blocks were gathered between 2007 and 2010, and all intra- and postoperative complications were tracked until resolution. No deaths or complications with sequelae lasting more than 3 months occurred.
      • Polaner D.M.
      • Taenzer A.H.
      • Walker B.J.
      • et al.
      Pediatric regional anesthesia network (PRAN).
      As such, regional anaesthesia, and specifically epidural or combined spinal–epidural (CSE), is safe and may have physiological benefits in ERAS protocols.

       Multimodal, opioid-sparing analgesia

      Options for multimodal analgesia to reduce opioid requirements in children include paracetamol, midazolam, gabapentin, dexamethasone, clonidine, dexmedetomidine and NSAIDs. Reduction in parenteral opioid requirements potentially contributes to faster return of gut motility. Adjunct therapies can be administered i.v., orally, rectally or as components in regional blockade to prolong postoperative analgesia. One study showed that addition of intravenous dexamethasone 0.1 mg kg−1 in paediatric patients undergoing caudal analgesia with ropivicaine reduced pain scores for up to 48 h and decreased the number of oral analgesics required after orchidopexy.
      • Kim E.M.
      • Lee J.R.
      • Koo B.N.
      • Im Y.J.
      • Oh H.J.
      • Lee J.H.
      Analgesic efficacy of caudal dexamethasone combined with ropivacaine in children undergoing orchiopexy.
      I.V. paracetamol can significantly reduce postoperative care unit LOS, oversedation and total opioid consumption.
      • Hong J.Y.
      • Kim W.O.
      • Koo B.N.
      • Cho J.S.
      • Suk E.H.
      • Kil H.K.
      Fentanyl-sparing effect of acetaminophen as a mixture of fentanyl in intravenous parent-/nurse-controlled analgesia after pediatric ureteroneocystostomy.

       Avoidance or early removal of surgical drains and tubes

      Nasogastric tube placement post laparotomy is intended to protect patients from abdominal distension and subsequent postoperative nausea and vomiting, aspiration, anastomotic leaks and wound complications. This concept has been challenged in adult patients, and robust level 1 evidence exists to support the avoidance of routine postoperative gastric drainage in adults after colorectal surgery. A systematic review and meta-analysis of NG decompression from seven adult studies with a total of 1416 patients after elective colon and rectum surgery revealed no difference in time to return of GI function and increased morbidity of pharyngolaryngitis and respiratory infection with NG decompression. Routine NG tube decompression was therefore not recommended after elective colon and rectum surgery.
      • Rao W.
      • Zhang X.
      • Zhang J.
      • Yan R.
      • Hu Z.
      • Wang Q.
      The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis.
      Nasogastric tubes were assumed to be required as children swallow large amounts of air when distressed and crying, but evidence exists for avoidance of routine NG tubes in paediatrics. One study found that there was no difference in postoperative complications after laparotomy for a variety of upper and lower GI surgeries regardless of whether or not an NG tube was placed.
      • Sandler A.D.
      • Evans D.
      • Ein S.H.
      To tube or not to tube: do infants and children need post-laparotomy gastric decompression?.
      A significant decrease in time to first feed, first stool and discharge was found in patients without NG tubes. However, children who did not have postoperative NG decompression did have a higher incidence of postoperative vomiting (22% vs 11%). Historically, the postoperative ileus that frequently accompanies appendicitis and other complicated surgeries was frequently cited as an indication for NG tube placement. Current literature challenges this concept. One study suggests that children with perforated appendicitis have reduced time to first oral intake (3.8 vs 2.2 days), and reduced LOS (6.0 vs 5.6 days) if an NG tube is not inserted.
      • Peter S.D.S.
      • Valusek P.A.
      • Little D.C.
      • Snyder C.L.
      • Holcomb G.W.
      • Ostlie D.J.
      Does routine nasogastric tube placement after an operation for perforated appendicitis make a difference?.
      As such, routine NG drainage in paediatric patients is not recommended.
      The utility of peritoneal drainage has also been challenged. Peritoneal drainage was routine for many surgeries with significant intra-abdominal contamination, in addition to pancreatic and biliary surgeries. The rationale for drain placement after biliary surgery is to facilitate early identification of biliary leaks or haemorrhage and potentially obviate the need for a radiologically placed drain.
      There are few indications in the contemporary era for routine drain placement. There is no evidence supporting the placement of drains at the time of removal of a perforated appendix. Even in complex biliary and pancreatic reconstructions, leaks are rare and interventional drain placement, when required, is usually sufficient to manage these uncommon complications. Moreover, the drains themselves, aside from being frequently unnecessary, can also be harmful. A surgical drain may be a source of infection and may oppose the goals of minimally invasive surgery, such as reduction in postoperative pain. A randomised study of 100 children undergoing laparoscopic choledochal cyst excision Roux-en-Y hepatojejunostomy (RYHJ) demonstrated that the group treated without drainage had shorter time to resumption of normal activity, LOS and decreased pain scores. No patients in either group developed biliary, pancreatic or intestinal leaks in the 12 month postoperative follow-up period.
      • Diao M.
      • Li L.
      • Cheng W.
      To drain or not to drain in Roux-en-Y hepatojejunostomy for children with choledochal cysts in the laparoscopic era: a prospective randomized study.
      Drain placement is required to manage rare biliary and pancreatic leaks. With the increased availability of interventional radiology support, the need to place these drains at the time of surgery has decreased substantially. A review in 2018 assessed the benefits and harms of routine abdominal drainage after pancreatic surgery in adults, and concluded that it was unclear whether routine abdominal drainage had an effect on mortality at 30 days or postoperative complications after pancreatic surgery. Routine abdominal drainage may slightly reduce mortality at 90 days. The evidence for this conclusion was moderate in quality.
      • Rao W.
      • Zhang X.
      • Zhang J.
      • Yan R.
      • Hu Z.
      • Wang Q.
      The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis.
      In summary, the available literature on peritoneal drainage suggests that routine drainage is often unnecessary in children. However, the quality of evidence is low and there are situations where operative drainage is warranted or even life-saving. In these cases, early drain removal is recommended if feasible.

       Prophylaxis for postoperative nausea and vomiting

      ERPs best address postoperative nausea and vomiting (PONV) through a multimodal approach. This approach includes preoperative oral hydration, minimal use of volatile anaesthetics and opioids, prophylactic use of antiemetics and tailored PONV therapy. Prevention of PONV begins in the preoperative period. Strategies to reduce baseline risk of PONV in children include avoidance of volatile anaesthetics and nitrous oxide by utilisation of propofol for induction and maintenance, regional anaesthesia to avoid general anaesthesia, multimodal analgesia to minimise intra- and postoperative opioids, and adequate hydration. Risk scores for PONV, such as the paediatric specific Eberhart risk score, should be used to help tailor antiemetic therapy to each specific patient. The 4-point Eberhart scale assigns one point for each of: surgery longer than 30 min, age older than 3 yr, strabismus surgery and history of PONV in relatives. When none, one, two, three or four independent predictors are present, the risk for PONV is approximately 10%, 30%, 50% or 70%, respectively. 5-Hydroxytrytamine type 3 (5-HT3) receptor antagonists, specifically ondansetron 0.1 mg kg−1, are commonly used antiemetics for both prophylaxis and rescue treatment of PONV. Other first-line prophylactic antiemetics include dexamethasone 0.15–0.3 mg kg−1 and aprepitant 40 or 80 mg. Aprepitant is a neurokinin-1 receptor antagonist with a half-life of approximately 9 h. This potent antiemetic is optimally given 30–60 min before induction of anaesthesia. The safety and antiemetic efficacy of aprepitant has been well established in the paediatric oncology population. There is evidence for antiemetic prophylaxis with aprepitant in high-risk adult surgical populations.
      • Bourdaud N.
      • Devys J.M.
      • Bientz J.
      • et al.
      Development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients: the VPOP score.

       Early feeding

      The first ERAS protocols in adults challenged the initial dogma of delayed feeding after intestinal surgery to allow anastomoses to heal and reduce nausea and vomiting. Despite initial concerns, early feeding protocols in patients after GI surgery have consistently demonstrated decreased length of hospital stay and decreased rates of infection. The same benefits of early feeding have been demonstrated in paediatric patients although general practice has yet to catch up. There are benefits to early feeding that are of particular importance for the paediatric patient. Nutrition in an infant must support growth and development in addition to anastomotic and wound healing. A prospective, randomised trial published in 2013 of 150 infants randomised to ad libitum vs protocol feeds found that ad libitum feeding after pyloromyotomy allowed infants to reach goal feeds sooner than the protocol group.
      • Adibe O.O.
      • Iqbal C.W.
      • Sharp S.W.
      • et al.
      Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: a prospective randomized trial.
      A meta-analysis of 14 studies published in 2015 comparing ad libitum feeding to structured feeding after pyloromyotomy demonstrated that ad libitum feeding is associated with shorter LOS (mean difference, 4.66 days). Although emesis was more likely in infants on a rapid than a gradual feeding regime, emesis was not found to have a negative effect on overall patient outcome.
      • Sullivan K.J.
      • Chan E.
      • Vincent J.
      • Iqbal M.
      • Wayne C.
      • Nasr A.
      Feeding post-pyloromyotomy: a meta-analysis.
      Even for neonatal patients after intestinal resection, early feeding has been associated with a shorter LOS and decreased time until first stool. Early postoperative feeding may not be appropriate for all patients; for example infants who have undergone post bowel resection for volvulus or necrotising enterocolitis with ischaemic bowel may require a different approach.

      Strategies for implementation and future directions for paediatric ERAS

      Few ERAS guidelines have been applied to children, and very few have been designed for children. Surrogate evidence from adults has been used to guide paediatric ERAS in areas in which paediatric evidence is lacking. Many elements in adult ERAS protocols lack high-quality RCT evidence for use in children (duration and timing of perioperative antibiotics, use of postoperative Foley catheters and use of MBP).
      • Brindle M.E.
      • Heiss K.
      • Scott M.J.
      • Herndon C.A.
      • Ljungqvist O.
      • Koyle M.A.
      Embracing change: the era for pediatric ERAS is here.
      At the same time, there may be a lack of the equipoise required to perform paediatric RCTs, as strong but indirect data support the benefits of individual ERAS elements (e.g. timing of perioperative antibiotics).
      • Rove K.O.
      • Edney J.C.
      • Brockel M.A.
      Enhanced recovery after surgery in children: promising, evidence-based multidisciplinary care.
      Implementation of ERAS protocols can be challenging as there are numerous barriers to their effective use. Many features of ERAS protocols are not intuitive. Routine perioperative practices and the perception of best care can vary widely within an institution and often lag behind latest evidence. Enhanced recovery after surgery implementation requires a team of motivated health professionals that catalyse the education of surgeons, anaesthetists, nurses, patients and their families in order to influence culture and advance the implementation of new, impactful protocols.
      Complete adoption may not be required to achieve many of the benefits of ERAS. The application of even a few elements can increase patients' comfort and parental satisfaction and reduce LOS. For example in one study, minimally invasive techniques could not be applied in 48% of thoracic procedures, but these paediatric patients could still benefit from other ERAS elements, including early postoperative mobilisation and nutrition.
      • Reismann M.
      • Arar M.
      • Hofmann A.
      • Schukfeh N.
      • Ure B.
      Feasibility of fast-track elements in pediatric surgery.
      Exploring the relevance of adult ERAS protocols for an expanded range of paediatric conditions and developing new, paediatric-focused ERAS elements will increase the benefits of ERAS for children. It is notable that most elective paediatric surgeries are performed on ASA 1 and 2 patients who are discharged on the same day as surgery. Simple ERAS initiatives, such as encouraging clear fluids to be taken by mouth up until 1 h before surgery and administering regularly scheduled paracetamol and ibuprofen after operation, can have a significant impact on patient comfort and morbidity. These practices could be easily adopted across large surgical systems that care for children.
      The interest in ERAS in paediatric surgery is rapidly expanding. Teams of international perioperative experts have begun to implement ERAS protocols in children based on available evidence and consensus recommendations.
      • Short H.L.
      • Taylor N.
      • Piper K.
      • Raval M.V.
      Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel.
      Neonatal ERAS protocols will look dramatically different than protocols in adults and adolescents. A neonatal guideline for intestinal resection surgery contains elements specific to the needs of neonates including early introduction of breast milk, rational antibiotic administration, urinary sodium monitoring and mucous fistula feeding for patients with stomas.
      • Gibb A.C.N.
      • Crosby M.A.
      • McDiarmid C.
      • et al.
      Creation of an Enhanced Recovery after Surgery (ERAS) guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study.
      Specific recommendations related to anaesthetic management include multimodal analgesia and the use of anaesthetic protocols to maintain homeostasis. The first World Congress for Paediatric ERAS was held in November 2018 in Virginia, USA, and an international working group for Paediatric ERAS Surgery within the ERAS Society has been established.
      ERAS requires education and engagement from numerous multidisciplinary teams throughout the perioperative periods. Paediatric ERAS protocols will continue to develop in numerous surgical areas of relevance to children. Anaesthetists have an essential role in the creation and dissemination of paediatric ERAS.

      Declaration of interests

      The authors declare that they have no conflicts of interest.

      MCQs

      The associated MCQs (to support CME/CPD activity) are accessible at www.bjaed.org/cme/home for subscribers to BJA Education.

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      Biography

      Katrina Roberts BSc is a resident anaesthesiologist completing her training at the University of Calgary. Her interests include quality improvement and patient safety.
      Duncan McLuckie DA FRCPC is an attending paediatric anaesthesiologist at the Alberta Children's Hospital and a clinical assistant professor at the University of Calgary. His interests include the development of protocols and care bundles for paediatric patients undergoing common surgeries.
      Mary Brindle MPH FRCSC is a paediatric surgeon at the Alberta Children's Hospital, Associate Department Head and Health systems researcher at the University of Calgary. She has done extensive work in surgical quality and safety care pathways, both in research and in clinical practice. Dr Brindle has helped to spearhead the development of an international paediatric ERAS collaborative, and is the first lead of an ERAS Society sponsored guideline addressing neonatal patients. She has written and presented on her work and co-chairs the guidelines and standards group for ERAS.