|Year : 2020 | Volume
| Issue : 1 | Page : 91-99
Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery protocol
Aliaa R.A Abdel Fattah1, Ahmed A.M El-Rouby2
1 Department of Pediatric Surgery, Faculty of Medicine, Alexandria University, Alexandria
2 Department of Anesthesia, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||12-Sep-2018|
|Date of Acceptance||11-Apr-2019|
|Date of Web Publication||16-Apr-2020|
Aliaa R.A Abdel Fattah
Lecturer of Anesthesia Faculty of Medicine Alexandria, University, Alexandria
Source of Support: None, Conflict of Interest: None
Introduction Pediatric emergency abdominal surgery is accompanied by high level of morbidity and mortality. Many protocols had been used to improve the outcome in these situations; from them fast track or enhanced recovery after surgery (ERAS) protocols gained high level of importance. Few studies investigated its application in emergency pediatric diseases.
Aim of the work The aim of or work was to study the applicability and the outcome of ERAS protocol applied in emergency pediatric abdominal surgery.
Material and Methods 60 pediatric patients with abdominal emergencies were randomly distributed into two groups. Group A was subjected to ERAS protocol and group B was managed by the conventional protocol, success was measured by Hannover criteria.
Results Most of the parameters of the protocol were applied except for some of the preoperative items due to the nature of the situation. In comparison to the conventional protocol; ERAS protocol resulted in better outcome regarding better pain control, shorter hospital stay being 1.93±2.23 day in group A and 4.23±2.21 day in group B (P<0.001) and earlier return to full oral feeding within 2 days postoperative in 87% of patients in contrast to only 23 % in group B (P<0.001). More than 90 % of parents classified this management plan as excellent. Post-operative vomiting didn’t show significant difference between ERAS group and conventional group and didn’t affect the outcome significantly.
Conclusion ERAS is applicable in emergency pediatric abdominal surgeries resulting in better outcome of this situations which have high rate of morbidity and mortality.
Keywords: abdominal emergency, fast track, pediatric surgery
|How to cite this article:|
Abdel Fattah AR, El-Rouby AA. Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery protocol. Res Opin Anesth Intensive Care 2020;7:91-9
|How to cite this URL:|
Abdel Fattah AR, El-Rouby AA. Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery protocol. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 May 31];7:91-9. Available from: http://www.roaic.eg.net/text.asp?2020/7/1/91/282592
| Introduction|| |
Enhanced recovery after surgery (ERAS) or the fast-track protocols are evidence-based protocols applied to standardize and optimize the perioperative care to reduce the surgical trauma, physiological stress, and organ dysfunction, which accompany surgeries, to enhance the postoperative recovery, reduce hospital stay, and improve the surgical outcome. ERAS protocols are not one size fits all, as modifications could be carried out according to the situation .
ERAS was initiated by the Danish colorectal surgeon Kehle from the Havidovre Hospital in Copenhagen, Denmark, in 1990s. They published it for the first time in 1995 ,.
ERAS protocol was studied several times in adult surgery, but few studies could be reported about its application in pediatric abdominal surgery especially in emergency situations .
Emergency surgery is considered a key hospital service carrying high rate of morbidity and mortality. Many measures have been applied to improve this outcome; one of them was ERAS protocols .
Application of ERAS in emergency surgery remains uncertain mostly owing to the challenge in applying its parameters in this situation like preoperative fasting which will not be applicable. However, the important key point of optimal fluid management and CHO load could be applied. So, a tailored protocol based on the type of emergency is likely to be used .
ERAS was first applied in emergency surgery by Loshiriwat  in some cases of emergency colorectal surgery. The outcome of ERAS was measured by the morbidity and mortality, length of hospital stay, and time to return to normal activity.
Emergency pediatric surgeries have also high rate of morbidity and mortality even more than elective cardiac surgeries owing to multiple factors, including patient factors, staff members, and access to hospital. Application of fast-track protocol in pediatric emergency abdominal surgeries aims at improving their outcome .
| Aim|| |
The aim of the study was to assess the success of application of ERAS protocol in pediatric emergency laparotomy.
| Materials and methods|| |
Our randomized controlled study included patients in pediatric age group with variable types of abdominal surgical emergencies during the period between January 2017 and January 2018.
The study patients were randomly distributed into two groups; the first group was the study or interventional group (group A) and the second group was the control group (group B). Patients of group A were subjected to ERAS protocol tailored to the emergency situation as shown in Reismann et al.  and group B was subjected to conventional protocol.
- Preadmission counselling: after complete explanation of the management plan for the parents or caregivers and the advantage and disadvantage of ERAS protocol with the possibility of readmission, a written consent was signed.
- Preoperative fasting, fluid replacement & bowel management: can’t be applied.
- Antibiotic prophylaxis and premedication: patients of group A were injected on induction by a single dose of third-generation cephalosporines (50 mg/kg).
- Anesthesia: all of the studied patients were subjected to controlled general anesthesia induced by sevoflurane inhalation in combination with fentanyl 1 μg/kg and rocuronium 0.6 mg/kg injection. This was followed by endotracheal intubation and maintenance by sevoflurane or isoflurane.
- Epidural anesthesia: caudal epidural anesthesia was added to group A patients with 1 ml/kg of 0.125 bupivacaine after local cleaning using needles of appropriate size under sterile conditions.
- Avoid salt and water overload: fluid management was calculated as 4 : 2 : 1 rule as shown in [Table 1]. An additional dose of 6–10 ml/kg/h was added to compensate for evaporation from the open wound, and more boluses were given depending on the extent of bowel trauma and accompanying sepsis.
- Maintain normothermia: this was accomplished by warming with a blanket under close monitoring of body temperature.
- Abdominal drain: avoidance of abdominal drain as far as we can was attempted in group A patients.
- Minimal surgical manipulation: minimization of intraoperative intestinal manipulation was attempted as the situation permits in group A in the form of intra-abdominal reduction of intussusception without extra-abdominal delivery, local delivery of the bowel loop to be resected, and rapid repositioning of intestine into the abdominal cavity if the bowel was formally explored.
- Nasogastric tube (NGT): avoidance of NGT as far as we can was attempted in group A patients.
- Prevent nausea and vomiting: on regular basis, antiemetics in the form of ondansetron 0.15 mg/kg intravenously and metoclopramide 0.1 mg/kg intravenously.
- Early start of oral intake: all the patients in group A were encouraged to start oral fluids on first postoperative day with gradual increase in volume and consistency till approaching full oral feed on second postoperative day.
- Stimulation of gut motility: patients of group A had rectal suppositories as a routine rectal stimulation on first postoperative day.
- Early removal of catheters: catheters in group A were removed as fast as possible.
- Early ambulation: children who are able to walk were encouraged to move around by the night of operation.
- NSAIDs: postoperative analgesia was in the form of NSAIDs with avoidance of opioids.
- Success of application of ERAS: success of application of ERAS was measured by Hannover criteria as described by Reismann et al. .
- Pain monitoring: pain was monitored by FLACC behavioral scale for toddlers with age group of 2 months to 7 years,  as shown in [Table 4]. and by visual analogue scale for children older than 7 years , as shown in [Figure 1].
- FLACC behavioral scale: parameters of FLACC behavioral scale are shown in the [Table 1],[Table 2],[Table 3],[Table 4].
- Visual analogue scale.
| Results|| |
All of studied patients had emergency abdominal diseases, with laparotomy done for all of them. Each group included 30 patients; group A (study group) had been subjected to ERAS protocol as the plan of care and group B (control group) had been managed by the conventional routine protocol.
There was male predominance in the two groups with age at operation ranging between 2 months and 10 years, as shown in [Table 5]. Neither age nor sex difference showed statistically significant relationship with the outcome.
The disease, the procedure done, and the number of patients having the same disease were fixed in the two groups as shown in [Table 6].
All of the studied patients had been counselled about the protocol and informed of the probability of readmission preoperatively. Under cover of a single-dose preoperative third-generation cephalosporin prophylaxis, general anesthesia was started with regular fluid administration.
Caudal epidural anesthesia was started in all patients of group A with close maintenance and monitoring of body temperature. This was followed immediately by the start of surgical procedure.
Completion of the procedure was successfully achieved with minimal intraoperative manipulation in 22 (73.3%) patients of group A. However, formal exploration was done in the remaining eight (26.7%) patients to complete the procedure safely. This variation showed statistical significance by χ2-test (χ2=5.554, P=0.035).
Four patients of group A with appendicular abscess had an abdominal drain postoperatively, and this was removed on third postoperative day. However, 26 patients did not have an abdominal drain including those with resection anastomosis. On the contrary, nine patients had an abdominal drain in group B including the four patients with perforated appendicitis and five patients with resection anastomosis. Drain in group B was removed only after complete cessation of any exudate; this difference showed no statistical significance (χ2=2.455, P=0.209).
Postoperative stimulation of gut motility
Rectal stimulation was started on first postoperative day in 50% of patients of group A; the remaining patients did not receive suppositories as they had their first bowel motion spontaneously either on day of operation or early on the first postoperative day. Only three patients with delayed postoperative bowel motion received rectal suppository. Stimulation of gut motility showed statistically significant relationship with the outcome as shown in [Table 7].
First bowel motion
Patients of group A had their first bowel motion from 0 to 3 days postoperatively; however, those of group B passed stools from 1 to 5 days postoperative. This difference was not statistically significant (Mann–Whitney U, Z=−1.088, P=0.276), as shown in [Table 9].
Insertion of nasogastric tube postoperatively
All patients of group A did not use NGT routinely postoperatively. However, it was inserted in four patients after start of oral fluids on first postoperative day, who had bilious vomiting in three patients and abdominal distension in the fourth patient. However, two-thirds of patients of group B had routine NGT postoperative. This difference in rate of NGT insertion showed statistically significant difference, as shown in [Table 8] (χ2=17.778, P<0.001).
|Table 8 Effect of postoperative nasogastric tube on enhanced recovery after surgery protocol|
Click here to view
Patients of group A who vomited postoperatively had ∼250 ml of bilious suction after insertion of NGT. However, patients of group B who had routine NGT postoperative had only ∼200 ml of suction; the difference in amount of suction between the two groups was statistically significant (Mann–Whitney U, Z=−3.231, P=0.001) as shown in [Table 9].
|Table 9 Gut response to application of enhanced recovery after surgery protocol|
Click here to view
Postoperative start of oral feeding and prevention of nausea and vomiting
Start of oral fluids was attempted in all patients of group A on first postoperative day with regular administration of antiemetics. Twenty-seven patients tolerated that well and gradually increased fluid volume and consistency progressing into breast feeding or semisolid food on second postoperative day according to their age. Three patients did not tolerate oral feeding and had bilious vomiting after start of oral fluids and another patient had abdominal distension. NGT was inserted in these four patients and removal of it was done after cessation of bilious suction on second postoperative day. Restart of oral fluids was initiated on second postoperative day in two patients, on third day in one patient, and on fourth day in the last patient who had adhesiolysis.
Start of oral fluids in group B had not been initiated routinely except after first bowel motion. This difference was statistically significant as shown in [Table 9].
Early removal of catheters
Attempt of early catheter removal was undertaken in the four patients who had an abdominal drain in whom the drain had been removed on third postoperative day. Removal of the NGT was done on second postoperative day in the four patients in whom it was inserted on the first postoperative day.
Early ambulation was encouraged by the night of operation in elderly children among the study group.
Pain control postoperative was accomplished by the epidural analgesia in association with NSAIDs in all patients of group A. Assessment of pain score 2 h postoperatively and on first postoperative day revealed better control in group A than in group B with statistical significance as shown in [Table 10].
Frequency of application of enhanced recovery after surgery items
Most of the items of the protocol had been applied to the study group as shown in [Table 11]
|Table 11 Frequency of application of enhanced recovery after surgery items|
Click here to view
Hannover criteria for success of enhanced recovery after surgery protocol
Assessment of ERAS protocol by Hannover criteria revealed its success regarding pain control, earlier start of oral feeds, shorter hospital stay being 1.93±2.23 day in group A and 4.23±2.21 day in group B (P<0.001), and parent satisfaction. However, time of first bowel motion and complications including vomiting did not show significant better results in the intervention group as shown in [Table 5],[Table 6],[Table 7],[Table 8],[Table 9],[Table 10],[Table 11],[Table 12].
Postoperative complications and readmissions
Four patients in group A developed postoperative complications; two of them had wound infection, one patient had abdominal distension, and the last patient had bleeding through rectum.
This number raised to eight patients in group B with four patients developed pyrexia of unknown origin, one patient had UTI, two patients had abdominal distension and the last patient had postoperative adhesive intestinal obstruction. This patient was readmitted 1 week later and re-exploration was done revealing intestinal adhesions and adhesiolysis was done.
The difference in rate of postoperative complications did not show statistical significance (χ2=1.667, P=0.33).
Only two (6%) parents of group A ranked ERAS as unsatisfactory plan; they did not agree with early discharge and preferred longer hospital stay thinking that this would reduce the rate of complications.
| Discussion|| |
Owing to the high morbidity and mortality accompanying pediatric emergencies and owing to the better pathophysiological body response to trauma in pediatric age group than in adulthood; application of ERAS in these situations took control of huge part of researchers’ thinking. This aimed at enhancing recovery in those situations, reduction of postoperative hospital stay, and acceleration of the return to normal daily activity ,,. This thinking was aggravated by the fact that application and standardization of ERAS protocol had led to major improvement in surgical outcome in the past years ,.
Although many surgeons believed that it is safe to apply ERAS protocols in emergency situations, compliance with it is slowly improving in surgical practice and some of them prefer to avoid this protocol in emergencies explaining the lack of communication with the child and parental refusal in most cases . Few studies discussed application of ERAS in emergency pediatric laparotomies; however; many authors discussed streamlining of patient care using this protocol .
The study compared 30 patients with ERAS protocol applied in emergency pediatric abdominal operations with a control group of the same number; this is considered fewer than the limited published data about this topic like in an Italian study which studied 47 patients. This may be attributed to specification of our study to the emergency situation only .
Neither the success of some parameters of ERAS protocol nor failure of other parameters had been affected sex or age difference. This was previously proved by Hampers et al. . However, Vlug et al.  reported female sex as a predictor of reducing length of hospital stay in ERAS in his study.
Preoperative antibiotics did not affect the rate of complications significantly. Other studies also proved that this item in fast-track surgery does not affect the morbidity nor mortality, although this may significantly reduce patient discomfort and length of hospital stay .
Reducing intraoperative manipulation improved the outcome in patients subjected to ERAS protocol significantly in this study. There is a generalized consensus that laparoscopy reduces surgical stress and ileus and pulmonary complications. However, taking optimum perioperative care in open surgery proved no significant difference with laparoscopy. Therefore, inability to use laparoscopy in some emergency situations should not discourage implementation of ERAS protocol in such situations. Minimal tissue manipulation, shorter operating time, and a better surgical technique are pre-requisites as for any surgery .
There is a great emphasis that the use of abdominal drain in fast-track surgery should be elective rather than routine to shorten the hospital stay . This study revealed no statistically significant difference, as the use of it was frequent in group A patients. This may be attributed to the remaining fear of morbidity which may accompany this emergency situation.
Elective rather than routine insertion of NGT had affected the success of ERAS protocol significantly. This is attributed to the fact that routine use of tubes postoperatively delays ambulation .
This elective use of NGT rather than routine insertion is also followed by earlier start of oral feeding which proved to reduce anastomotic leakage, wound infection, other infections, pneumonia, and mortality. All of the previous lines will reduce the length of hospital stay ,.
Postoperative pain score was significantly controlled in group A patients than in group B depending upon routine regional anesthesia and regular NSAID postoperatively.
There were limited data regarding the effect of regional anesthesia in fast-track emergency pediatric abdominal surgery; however, it was proved that caudal epidural blocks are a safe and effective method for subumbilical day-case pediatric surgeries. These patients have a shorter hospital stay, and adverse effects may not be noticed at home. Caudal block has the importance in decreasing consumption of systemic analgesics and impulses of surgical stress of laparotomy, and hence fastens recovery .
Rectal suppository, bowel motion, oral feeding, and vomiting
Induction of bowel motion and early start of oral intake in this study contributed to the success of ERAS protocol significantly. Moreover, patients who vomited after early start of oral feeding in group A did not affect the outcome significantly. The aforementioned statements confirm the idea that early induction of bowel motion, start of oral intake regardless of the time to first bowel motion, or even vomiting after oral intake will fasten recovery and lessen postoperative hospital stay. This was similar to the findings of Nanavati et al.  in their study.
This was previously explained by Mattei  in his text about the fast-track protocol in pediatric surgery, as it was traditionally taught that postoperative ileus is mandatory and should not be hastened or modified especially in patients with abdominal surgery like bowel surgery. It was treated by bowel rest and gastric decompression with NPO till the NGT stops green suction and the patient passes his first flatus or bowel motion when the patient was allowed to start oral fluids. This was considered even beneficial as it was believed that early induction of bowel motion or start of oral feeding which again induces bowel motion may place the patient at risk of bowel obstruction, anastomotic leakage with peritonitis and sepsis. Definitely, this protocol increased the hospital stay and time to resumption of oral intake to 3–14 days with all of its morbidities. However, with application of fast-track protocols in 1980s, it was found that patients with early induction of bowel motion and early start of oral intake not only had any morbidities but also had better outcome regarding faster recovery, earlier discharge, and rapid return to their daily activities.
The length of hospital stay in the study group was significantly lower than the control group. However, both of them were lower than the recorded data in the German diagnosis-related group data for all procedures . This may be attributed to the fact that the roles of G-DRG are against early patient discharge .
The rate of postoperative morbidities was not affected significantly by the application of ERAS protocol in emergency situations in this study. Several studies proved that there was no difference in the rate of postoperative complications between fast-track protocol and traditional protocol in perioperative care .
Our research resulted into successful application of ERAS protocol in pediatric abdominal surgical emergencies. Frazee et al.  hypothesized in their study feasible and successful application of fast-track protocol in case of suppurative appendicitis.
| Conclusion|| |
Application of fast-track protocols in pediatric acute abdominal surgical emergencies is feasible and safe provided that it is done under close observation in specialized pediatric center. More studies and health education programs are recommended to standardize this principle and to educate parents and healthcare givers about its importance. This is attributed to the fact that lack of awareness about this protocol as well as apprehension and fear from its application is considered the main barriers to it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kehlet H. Principles of fast track surgery. Multimodal perioperative therapy programme. Chirurg 2009; 80:687–689.
Bardram L, Funch-Jensen P, Jensen P, Kehlet H, Crawford ME. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995; 345:763–764.
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606–617.
Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 2016; 202:165–176.
Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery. JAMA Surg 2017; 152:292.
Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146:571–577.
Lohsiriwat V. Enhanced recovery after surgery vs conventional care in emergency colorectal surgery. World J Gastroenterol 2014; 20:13950–13955.
GlobalSurg Collaborative. Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries. BMJ Glob Health 2016; 1:e000091.
Reismann M, Arar M, Hofmann A, Schukfeh N, Ure B. Feasibility of fast-track elements in pediatric surgery. Eur J Pediatr Surg 2012; 22:40–44.
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997; 23:293–297.
Drendel AL, Kelly BT, Ali S. Pain assessment for children: overcoming challenges and optimizing care. Pediatr Emerg Care 2011; 27:773–781.
McHoney M, Eaton S, Pierro A. Metabolic response to surgery in infants and children. Eur J Pediatr Surg 2009; 19:275–285.
Teitelbaum DH, Coran AG. Perioperative nutritional support in pediatrics. Nutrition 1998; 14:130–142.
Schukfeh N, Reismann M, Ludwikowski B, Hofmann AD, Kaemmerer A, Metzelder ML et al.
Implementation of fast-track pediatric surgery in a German nonacademic institution without previous fast-track experience. Eur J Pediatr Surg 2014; 24:419–425.
Leeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB. Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg 2016; 51:2126–2129.
Hasenberg T, Keese M, Längle F, Reibenwein B, Schindler K, Herold A et al.
“Fast-track” colonic surgery in Austria and Germany − results from the survey on patterns in current perioperative practice. Colorectal Dis 2009; 11:162–167.
Mattioli G, Palomba L, Avanzini S, Rapuzzi G, Guida E, Costanzo S et al.
Fast-track surgery of the colon in children. J Laparoendosc Adv Surg Tech A 2009; 19:S7–S9.
Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Fast track and the pediatric emergency department: resource utilization and patients outcomes. Acad Emerg Med 1999; 6:1153–1159.
Vlug MS, Bartels SAL, Wind J, Ubbink DT, Hollmann MW, Bemelman WA. Which fast track elements predict early recovery after colon cancer surgery? Colorectal Dis 2012; 14:1001–1008.
Chopra SS, Schmidt SC, Fotopoulou C, Sehouli J, Schumacher G. Evidence-based perioperative management: strategic shifts in times of fast track surgery. Anticancer Res 2009; 29:2799–2802.
Nanavati A, Prabhakar S. Fast-track surgery: toward comprehensive peri-operative care. Anesth Essays Res 2014; 8:127. [Full text]
Nanavati AJ, Prabhakar S. A comparative study of “fast-track” versus traditional peri-operative care protocols in gastrointestinal surgeries. J Gastrointest Surg 2014; 18:757–767.
Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323:773–773.
Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221:469–478.
Beyaz SG, Tokgöz O, Tüfek A. Caudal epidural block in children and infants: Retrospective analysis of 2088 cases. Ann Saudi Med 2011; 31:494–497.
] [Full text]
Mattei P. Fast-track protocols. Fundam Pediatr Surg 2011; 12:37–40.
Reismann M, von Kampen M, Laupichler B, Suempelmann R, Schmidt AI, Ure BM. Fast-track surgery in infants and children. J Pediatr Surg 2007; 42:234–238.
Frazee R, Abernathy S, Davis M, Isbell T, Regner J, Smith R. Fast track pathway for perforated appendicitis. Am J Surg 2017; 213:739–741.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]