2025 Pediatric Surgery Update Course - Updates in Enhanced Recovery After Surgery (ERAS) Protocols

All right, we're going to move on to the hot topic of Eras. Did we have? Yeah, all right. Go ahead. So here's Miracodal from Cincinnati Children's. All right, we have a ton of people coming up because we're going to talk about lots of different things Eras related. But we are going to start with Ben, Dr. Ben Hamm, who's going to go over some principles of Eras, just so everybody's on the same page, and then we'll launch into the lots of different ways in which you can use these tools. So we'll cover a few different areas, neonatal Eras, colorectal Eras, thyroid, and oncology, ERAS. But we also wanted to just take a moment and discuss that all these principles that we'll talk about for these specific surgeries. Can we also apply them just in general to every kid we take care of, or nearly every kid? So first case, a case is being scheduled from clinic at your institution. The new resident is working on scheduling the patient and pre-op orders. So which of the following is true at your institution? Eras, ERAS principles have been incorporated into scheduling, patient education, pre-op and post-op order sets for no surgeries, some pediatric general surgeries, almost all pediatric general surgeries but not others, almost all pediatric surgical sub-specialties or E. What is ERAS? What about in the room? Can folks raise their hands? Who is doing some version of ERAS in some cases that your institution? Is there anybody in the room not doing any ERAS at all? About half and half. So looking at the poll, it looks like almost half are for some pediatric general surgeries, 16 percent, almost all pediatric general surgeries but not others. D is currently, looks like about 12 percent, almost all pediatric surgical sub-specialties 10 percent, what is ERAS? So some opportunities there and about 15 percent not for any surgeries. So I know, Mayhul, we'll talk some about for colorectal surgery. As we were going through everything with the trial, we worked to incorporate it not only for pediatric colorectal surgeries but also for any patient coming through clinic. So we built the same things in terms of optimizing clear liquids, pain control, avoiding opiates, et cetera, into all of our pre-op scheduling. And then also as we did it, we had other departments also be like, oh, what are you doing? Can we be involved in that too? And so plastic surgery, it's in the orthopedic surgery, order sets and several others too. Which just brought up a point just to make sure we could say what ERAS is for the world here. So it's enhanced recovery after surgery. Right now. Yeah, okay. Right there. Yeah. Enhance recovery after surgery. And it consists of many elements and principles and various papers will delineate specific ones, but they can be applied to most all elective surgeries. And in order to be successful with it, it does require significant system design, education, and reinforcement of that education. And I know some have worked to decrease opioids after appendectomy. At our center many, many years ago, it was 84%. And then I know David worked to decrease that with some ERAS principles. And then most recently in our NISQP report, we were down to 0%. Yeah, about one more minute, then. And so here are some common ERAS components. I'll put these up there, but not going to go through all of them. But many different things can be done to try to speed up the patient's recovery, get them home quicker and get them back to being kids. And so these things have the potential to improve care across the spectrum of pediatric surgical sub-specialties. And it takes a lot of work in terms of scheduling, building the system, patient education, and getting your team on board in order to be effective with these. Perfect. Thank you, man. All right, we are going to move through some topics and actually give you examples of different ways in which people have used these principles to improve outcomes for their patients. So I think first, oh, that's backwards, sorry. Dr. Hoffman. Hi, I'm Cassie Hoffman. Nice to meet you guys. I'm from Akron Children's. And I am going to be presenting ERAS for NUNATES, our smallest patients. So here's our clinical scenario. We have a 10-day-old female within testinal atreasia. She's scheduled for an X-LOP primary repair currently in the NICU, vital center stable and she's on room there. So here's our poll. Is this patient a candidate for NUNATES or ERAS? No. This NUNATES is undergoing an X-LOP, so it's an open abdominal procedure. Absolutely not. Yes. B. Or C. Unchir. It's difficult to manage NUNATES periodically. So for folks in the room, are you guys using ERAS for your NUNATES? Is anyone doing ERAS for NUNATES? The folks behind me are. No one else? It actually looks confused about the question. All right. So I see a lot of yeses and undershores. About 52 percent. Yes. 28 percent. Unchir. Or 30 percent. Unchir. And then 16 percent is absolutely not. Okay. So the answer is yes, according to our literatures. So the World Journal of Surgery came out with a consensus guideline around 2020. Okay. So this was for intestinal surgery only for NUNATES. And then after that, there was a more broader guidelines that were developed just for ERAS in essentially all neonatal surgery. So there's multiple consensus guidelines that exist for these neonates that are undergoing surgery and how do we apply ERAS for our smallest patients. So this is from our World Journal of Surgery guidelines. We have our pre-app guidelines. Okay. So we're going to have our antibiotic prophylaxis. We have our conservative transfusion guidelines. And then we have this big thought about perioperative team communication and how that's going to be one of the major goals of establishing this at our institutions. Interop care. It's still multidisciplinary. Now we're with ANSIUJA. We have opioid sparing in OJJA. We're going to have regional techniques that we are establishing at our centers. We also have that scheduled Tylenol perioperative fluid management just as we have with our older patients. We're preventing hypothermia. And then we're getting that primary anesthmosis. And then post stop again with our NICU team. What we're developing collaboratively. We have that essential handoff right where our communication is essentially key for this. We're doing our multimodal opioid sparing in OJJA. Hopefully we were able to do some sort of regional technique. We still have that scheduled Tylenol. We're going to have our perioperative antibiotics. We're stopping in less than 24 hours of surgery. We have our post stop nutritional plan. And then we also have parental involvement, which is huge, right? We're getting the parents involved, right? Once we get up to the NICU with that handoff. I have lots of questions. Some of which I think you'll probably get to. But what are you doing for regional in the tiny taps? I'm going to get told. Okay. Okay. Sorry. I'm going to be quick. Okay. So I wanted to first go over the quality and the strength of the evidence because before I talk about what we do, I think it's really important to dive into the literature and show that this is why we're doing it. So in the 2020 World Journal of Surgery, consensus guidelines for intestinal neonatal surgery, we are going to have moderate evidence for regional anesthesia and also high. So we have in this box, we have, sorry, I was going to spoke, high quality, strong evidence for the regional and then the opioid sparing is the moderate and strong. So regional anesthesia, what are we doing? That's our next one. All right. So let's play anesthesia. Some anesthesiologists may or may not be really comfortable blocking the onates and using facial plane blocks. My ideal facial plane block for an neonate would be the QL block. Why? Because it has great dermatomal coverage. It can be T6 L1 to 2 depending on how you dose it. And then it also isn't going to have any sort of limitations with anti-coagulation. So if you're worried about coagulability, this is still a fine block to do. And so let's say this is from one of the papers with the guidelines and implementation, I guess, blocks or what are we going up again? So this quote that I added, I hate words on slides, but I thought this is extremely important. I guess the one thing that maybe I might not have done would have been the regional blocks. There's a bit of discussion area. That's a bit of a discussion area. But then I found a colleague who was quite keen on doing regional blocks and he was quite willing to help. So that was great. But that may or may not be feasible. This is a quote from an anesthesiologist from one of the guideline and implementation papers. So then my response to that is, what about the original grades of regional anesthesia and neonates, such as this vinyl and the caudal? And then if you want your caudal to last, you can always put prosthetics in it. About two minutes. I am really quick. Sorry. I'm trying to move fast. So the caudal. I think pretty much everyone can do this block that's a pediatric anesthesiologist. If they have trouble, we can always go in with ultrasound to do the caudal and do landmarks. So this is what we call the frog eyes view. It has our corner on either side and then we have our sacrocauclegeoligament in between. Before we would go for that block. So if someone's having issues, we can always get our short axis view and then go in long axis and make sure that their injection is appropriate. Spinal. So original, great number two. This obviously isn't going to be for every case. It's not going to be for every abdominal case, especially. And you are limited on surgical time, right? We've got to be ready to cut if we're doing a spinal. And the surgery can't be longer than 120 minutes. Ideally 90. So it's not for every patient and it's only for certain surgeries and it has to be well indicated. To prolong or not to prolong. Let's say we have an anesthesiologist that doesn't feel comfortable doing fascial plane blocks, that's fine. I guarantee they're probably comfortable doing a caudal. I'm an anesthesiologist, I can say that though. But we can make the caudal last. Okay, so you can still get a big bang for your buck if you put prosthetics in a caudal. It can prolong the caudal. This table specifically is from a meta analysis in kids less than one year by original anesthesia and pain med in 2021. So it's not that new. People probably know about this. And also most of your institutions probably run prosthetics infusions and the NICU now. That's something that's really started in the past few years. And so they have a lot less hesitancy to use that drug and to put that in our original. Okay, sorry. I'm running. All right, buy in. It's hard. And I already want to over smoke the implementation issues. Awesome. Thanks, Dr. Hoffman. Super appreciate it. Okay. I think Dr. Rahal. Thank you. I think that's fine. Yeah. All right. Thank you. And that's a really hot. I would say that if all the things that we're trying to do in terms of enhanced recovery after surgery, the neonatal population is probably the next big frontier. And we absolutely more data and evidence. But it's challenging. And a lot of the challenges relate to the implementation woes. When we talk about enhanced recovery as surgeons, we as pediatric care providers are oftentimes getting our inspiration from our adult colleagues who are years and years ahead of us. So for us, it's not a foreign concept. I would say even for our anesthesia colleagues, it's not that big a leap to embrace some of the enhanced recovery principles. But really keep in mind that our neonatology colleagues, they do not know what E-REST stands for. They do not know what enhanced recovery means. The concepts that underpin enhanced recovery protocol are really challenging in a complex environment like a NICU. And so as we go on this journey, and that was a really fantastic talk, I would say to everyone is going to be a journey. That's going to be a step-by-step thing that we're going to have to work through. I'm going to pivot and talk about where it's a little bit of an easier cell. This idea of colorectal or GI surgery. And I'm going to share with you some data from a recently completed 18-center step wedge randomized clinical trial that we just wrapped up earlier in the summer. And I presented some of these data at APSA in May. And so this will rehash a little bit of that. So the topic here is maybe we're going to talk about the current state, talking about some of these enhanced recovery principles and then share with you that trial data. So here's the clinical scenario, which I think is a very real situation that could happen even today in 2025. 13-year-old Crohn's disease has a stricture that's refractory to medical management and now needs an elective intestinal surgery, a leosecial perception. Coming into surgery, she's lost some weight. She's told by the pre-op nursing team that calls her the night before surgery that she can have nothing to eat her drink after midnight. We usually, during a treat or pain with opioids in the OR and after surgery, she has an NG2, a folly that stays in place at the end of the case. She's told that she can't eat her drink anything until she passes gas. She's given IV fluids and boluses overnight and she's in the hospital for about a week, right? So this is kind of an imaginous current state of affairs. So here's the poll for the audience. One of the most challenging aspects of implementing an enhanced recovery after surgery protocol at your hospital. Is it that we're having issues with early advancement of diet? Is it family engagement and education? Is it getting these patients up and moving after surgery? Or is it just changing the overall culture? Can I pick one that's not on your list? I make our team turn off IV fluids on post-up day one and it makes everybody profoundly uncomfortable because the kid may not be drinking gray or may not be necessarily taking a great diet and people are really nervous about not having the fluids running. Absolutely. Even though that's one of the principles. So I assume we're in the changing culture, probably bucket. I like it. I like it. Changing culture. Yeah. All right. I'm not sure if we have audience. Okay. Here we go. Changing culture is the dominant one. It's actually a trip question. The answer is all of the above. These are all challenges that people face when trying to implement enhanced recovery. And so once again, I'm going to tell you a little bit about this trial, 18 centers across the U.S. we enrolled about 600 patients, 10 to 18-year-olds undergoing elective GI surgery. We picked this because this was the closest approximation to what the adult literature was telling us. So this was very much so a segue to introduce enhanced recovery to us as the pediatric care providers. And so I'm going to tell you some lessons that we learned from this trial that are going to really hit home, I hope. The first one is this idea of decreasing pariopathy fasting and ban alluded to this in the introductory comments about this field. But in general, what we're talking about is a horizontal integration rather than trying to reinvent the wheel for each and every procedure or specialty that we wanted to implement in enhanced recovery protocol at Lurie Children's where I were, we were able to get our anesthesia colleagues, to work with our nursing colleagues, and to change the overall policy to where we were now going to allow patients and educate patients and counsel patients across the enterprise for all of our surgeries that they could have clear liquids up until an hour before surgery. And so rather than once again reinventing the wheel, this horizontal integration is a great lesson learned and helps with implementation. This is colon man. This is from a LeBonor Children's in Memphis. They were one of our participating sites and they worked with the patient stakeholder group and came up with colon man and this was put up in every patient's room. And as the kids progressed through their hospitalization, you progressed through the colon and eventually you were discharged. So this is fantastically cute. It works on multiple levels. But this is where you can really find ways to integrate the enhanced recovery principles with your patients and families and have them be a part of the stakeholder group. Our colleagues down at Children's Memorial Hermann Hospital in Houston, Texas, they were struggling with getting these patients up and amulating soon after surgery. We knew that they needed to do it but the patients just weren't motivated. And so we wanted to maybe we suggested, well can you get your physical therapist to come by and see them but they had a posity of physical therapy availability. Well they did have, were these wonderful child life support dogs that would come by and the kids would get out of bed and walk the dogs and they were highly motivated to do that and it was something that was, I would say embraced by the patients and families. Ultimately the social workers or the child life support workers would actually leave a note in the chart saying how far the patients walked and how many times a day they took the dogs for a walk on post-op day one which then met the need of being able to check the box for compliance with the early emulation metric. And then last this is a screenshot of some pictures from Cohen Children's in New York where they celebrated the launch of the enhanced recovery protocol at their institution. They had the C-suite really buy into this, they made T-shirts, they had cake and balloons and the lobby and they really made it a big deal because it is a big deal to really change the paradigm and this is how you change culture. You make it a priority for all of the people from the frontline staff to the patients and families and everyone involved and it really does help you celebrate success. So the trial data really quickly how much time do I have? One minute, trial data in one minute. 600 patients enrolled across a five year time span, they were undergoing I would say some real deal surgeries, proctocallectomies, illicitectomies etc. And what you can clearly see is here is the distribution of the number of elements that patients received and the take home point here is that median of 13 elements of all the different bundles of enhanced recovery that are out there. When we put ours together what we saw is that when you reach that threshold of 13 elements being delivered to a patient on a day to day basis we could actually see a significant decrease in length of stay associated with that. And in addition to the length of stay improvements with 13 elements or more we see that we see the number of patients that have a prolonged length of stay of seven or more days the proportion to have that decrease significantly the number of the amount of opioids that we're exposing these patients to decreases and our complication rates are actually lower. So quick question, I don't know if you're going to get to it but when ERAS came out like I love the idea of every single thing and at the same time many of us were like really skeptical but do-em-bowl preps. And that's like kind of the elephant in the room maybe on colorectal ERAS. But there was a time not long after ERAS came out that there was an evolving kind of fuzzy set of data showing that if you bow prep in some way including oral antibiotics there seems to be moving in the direction of better outcomes. But early ERAS was like no prep. So is this the evolved ERAS with colorectal including a prep or no prep? For this study we made it dealer's choice because there is a lot of literature swinging one way or the other. The reality is that you should not do a mechanical prep without the oral prep added in. Without an antibiotic oral. That's right. So if you're not going to do Neomycin flagell or whatever your choice is for antibiotics orally leading up to the time of surgery you should not be doing mechanical prep. That's for SSI and an astymotic leak rates. In general though what we found is the same thing that you talked about which is really you should do what you feel comfortable doing. There is a lot of fluid shifts that occur with the mechanical bow prep and then going back to Miras earlier point about IV fluids and the need for boluses we do think that limiting the fluids will enhance the recovery. So that's all part and parcel. Same clinical scenario, fast forward I'm not going to read through all the details but there's a way to mitigate each of the things that I talked about when I introduced this 13 year old girl to you all earlier and ultimately the hope is that by doing all these little things you put them together in the bundle and implementing the bundles the real challenge. But if you can implement that bundle your outcomes will be better. Thank you. Awesome. All right. Good thing. Dr. Aldrin's next. I think yes. Here you go. Dr. Aldrin's going to talk to us about thyroid. All right. I'm sure I do. So you may think why is ERS important for thyroid? We do pretty good. They spend the night like who cares. There's probably only maximum 30 patients a year you might see compared to our other discussions on neonatal and colorectal. But you know thyroid is important surgery if we can make progress we need to make progress. And as my whole mentioned we do kind of follow the guidelines and the steps of our adult colleagues and they're doing a lot of outpatient thyroid surgery and so why is this not a say for appropriate application for pediatrics? And so I'll just go through this a little bit too. We all know particularly for some of the rare diseases at surgical volume and outcomes is surgical volume impact outcomes. And particularly this has been shown for thyroid ectomy. And I won't go through these but just to remind everybody that. And so here's a particular clinical scenario you have a 15 year old female who's referred to Endocrine for amenorrhea and some fatigue. Pretty normal vital signs on exam. She has an enlarged neck left neck with a four centimeter palpable nodule that's appreciated. So labs and ultrasound are obtained. She's mildly hyper thyroid and here's her ultrasound which shows a thyroid nodule and her nuclear med scan shows that this is active. So you have a 15 year old with a hyperactive autonomous nodule. And so she's referred to your office and in your mind she's a candidate for same day surgery but you want to ask your colleagues. And so how would you manage this patient? Total thyroid ectomy and observe. That thyroid and observe overnight. Left thyroid is an outpatient or because of her amenorrhea just refer her to a gynecologist and follow the nodule. I'm just even curious how many people in this room have somebody in their practice who does thyroid or how many people do they're? Yes. Do a lot of people have ect folks who do thyroid's at their institutions? No. Okay. So I'm expecting. Yeah. And while the poll is going in I think I'll make a comment on that because I do think it's really important for some of these rare diseases. We were talking about a suffigial surgery earlier. If you have the capabilities and you have the set up at your institution and not everybody does, but to make these as sort of subspecialist. And so at our institution we actually partner with our ENT colleagues. We have one ENT surgeon and myself who do the cases together and collaborate together and it's a really nice program. Okay. So I think most people would do the left thyroid ectomy and observe overnight. So I'm glad that that was the majority of the answer, but there's a good number of patients, people that would send the patient home. So useful topics that we'll kind of go through. And so at our institution we would do a left thyroid ectomy as an outpatient. And so standardizing care improves outcomes across a lot of surgical diseases. At our institution we developed an epic order set that basically starts from clinic all the way to post-op care. And someone had mentioned buy-in, I think Dr. Hoffman had mentioned buy-in and this really includes from clinic nursing to anesthesia staff to the parioperative nurses. And so with the ultimate goal to facilitate same and safe day discharge and enhanced parent and patient satisfaction. And so that was kind of our goal. And many institutions maybe doing this, we just recently published on this a single center study which we hope to kind of collaborate with some other institutions and see if we can show the same patient satisfaction among, you know, varying types of practices. But enhanced recovery for a single-lope thyroid ectomy with the goal of being compliant with these process measures to about 80 percent and facilitate same day discharge. And so the key drivers for our quality improvement plan for here was minimize variation in care, optimal, and it's analogies. So they're comfortable going home and then of course minimizing complications. And these are our interventions again starting with developing clinic order set, nursing education and really just setting the stage for the family and the patient that, you know, we expect you to go home, you know, except for a few particular instances that we would go over. I think one of the important factors is adding a preoperative selective COX2 inhibitor. We use celibrex and particularly we start that the night before in the morning of surgery and continue that twice a day and the patient can stop that when they no longer need it. But instead of giving intraoperative NSAIDs or things that, you know, might not work in time, they've sort of been loaded with that. And then multimodal pain control with minimization of opioids in the operating room and then the periop or postoperative care. Okay. I'm almost done. This is our study and essentially we had 100 percent compliance. We had one patient that did require staying overnight. And this was just over a year. So it's a young study. But we had one patient stay overnight who had some substance abuse in the past and had some postoperative nausea. And so we just elected to watch her overnight. Importantly, no complications. Any significant change in our length of stay, no change in emergency room visits or urgent care, essentially none. We implement a postoperative phone call 48 hours just to touch base with the family and the patient, make sure they're doing fine. And everybody was extremely, you know, 16 patients in this, my small study and everybody was very happy by going home. So and essentially, you know, practice guidelines, standardization and all phases of perioperative care can improve outcomes or improve patient satisfaction if it still takes same day discharge. So awesome. Thank you. I have the last topic for this session, which is oncology stuff. And I'm going to blaze through this because we've talked a lot about these principles. But this is a patient with a 10 centimeter right renal tumor who undergoes an up front and refractomy for management of their renal tumor. So what would, Siri would like to know if I need anything, unfortunately. But what would people do in the room here? Would folks use the arrests for this, would folks use the arrests for this case? Yes. Siri has a lot to say today. Okay. So if this, so this is the poll that we have and it really looks like the majority people that actually start clears on post-up day zero, I will say that when we started doing ERAS for oncology cases about three or four years ago, this is a big deviation for us from what we had been doing before. And so it was a real change in practice for us. I will do that case robotically. Dr. G is working on his interrupts bill. So he's going to do a 10 centimeter renal tumor robotically. So we can start, we will start clears on post-up day zero and then work to advance. And I think that's been a huge change for us. So these are our, what we use, this is actually a study that was created by Kyle Rove out of Colorado and Cincinnati, St. Jude's and Colorado were the three sites that participated in this. And so these were the guidelines. They're very similar to what everybody's been talking about in terms of opioids, fluid reduction, early feeding and then regional pain management. And so I'm not going to spend time going through all these. But what we found were very significant improvements. So these were abilities to reduce by just having the protocol and asking people to follow it. We were able to reduce opioids in the operating room. We were able to get to early feeding and to reduce post-operative opioids. And then we actually saw significant reduction in complications for these patients as well over the course of their stay. And then obviously here is significantly improved pain scores. And so this was the neuroblastoma subset of the population as a whole. But so for a lot of these big abnormal tumors, we're going ahead and doing URAS with early feeding and are like this day. While it wasn't significant in this cohort, I think over time, we've gotten much closer to a three day sort of post-operative link of stay as opposed to the five, six, seven days that we used to have these kids stay on service. So I think worth remembering that URAS is feasible for big abnormal operations, even the large retroperitoneal dissections or big tumors. And that using the regional anesthesia and minimizing opioids is key to that. And then using that to actually improve outcomes. So as many have said, we see better outcomes in these patients. So reduce complications shorter like this day. And then earlier folks were able to get to chemo earlier, which for especially things like neuroblastoma is key to their long-term survival. So I'm going to turn it over to Dr. Huntington to wrap us up. So I was just going to say, I think my takeaway from this session is we've gotten really good at doing URAS for the patients that we are comfortable doing URAS. And we've excluded some populations like Don Collegey patients, the neonatal patients. I think this patient should be included in everything that's been presented all the literature seems to show, sorry, that they should be. And I feel like I've been doing it for oncology because I stole everything Jenny does in her practice. The neonatal self, I feel like when we round in the NICU, I get in this time machine. And I go back to the surgeons when I was a medical student who say, you have to wait for the NG to be clear and then having bowel function. And I'm not really sure they should be excluded to that degree. And it seems like the literature supports that. And then the final thing I would say, if you're starting these things, don't do it alone. Ask these people because that's extremely helpful. All right. Thank you guys so much. This was phenomenal. You got a lot done in a short amount of time. Good job. We are going to take a... Yeah.