Studying ERAS in a Pediatric Population

Enhanced recovery after surgery (ERAS) has been studied extensively in adult populations, and its principles and practice continue to expand to even more specialties as the evidence base accumulates with respect to its benefits to patient care and the ever-growing demand for the provision of quality of care. However, there have been few studies to date related to how ERAS works with pediatric populations.

The Division of Pediatric Urology is currently participating in a multicenter, multidisciplinary study with four other institutions to analyze the benefits and out-comes of applying ERAS protocols to pediatric bladder and bowel surgery patients. Leading the study at UPMC Children’s Hospital of Pittsburgh is Rajeev Chaudhry, MD, assistant professor of urology in the Division of Pediatric Urology.
At UPMC Children’s, the study is a close collaboration between pediatric urology and pediatric anesthesiology, as well as with partners in nursing and other areas. “Having a group of close collaborators from anesthesiology and nursing is not only a key part of the study, but a key part of our ERAS work in general as we continue to evolve our understanding of what techniques and practices provide the most benefit to our patients in all aspects of the pre, surgical, and postoperative environments,” says Dr. Chaudhry.

Patient recruitment for this new study actively began in the spring of 2018, with the goal of 10 patients per year at each of the five participating institutions. However, the idea for the study came about over the last two years in ongoing conversations between Dr. Chaudhry and his colleagues at the other participating centers. “I think we all realized that in recent years we’ve been implementing different aspects of ERAS in our practices because of the successes seen in the adult world, and those have translated into benefits for our patients. But that is, of course, largely anecdotal evidence. This study will begin to add the hard data we need to show in order to change practice on a broad basis,” says Dr. Chaudhry.

Protocols and Practices: Before and After ERAS

The use of ERAS in pediatric bladder and bowel surgery patients at UPMC Children’s hasn’t been an overnight switch. Dr. Chaudhry and his colleagues have been using and transitioning to various aspects of ERAS for several years.

Complex surgical cases, for example an individual with spina bifida and neurogenic bladder, by their very nature are an ideal population on which to use ERAS measures and study their benefits. These cases tend to be complex, require extensive intraoperative IV fluids, and usually require postoperative pain control measures.

“We used to admit many of these patients preoperatively for bowel preps, because with many spina bifida cases with neurogenic bladder, they also have neurogenic bowel. They would receive NG tubes to administer the prep, but oftentimes it was not effective and the patient would end up with fluid and electrolyte imbalances and dehydration, which further complicates the surgery and extends the postoperative recovery period, so we stopped administering the bowel preps in these circumstances,” says Dr. Chaudhry.

Gut motility, and its early return, is an essential component of the ERAS measures. “There have been a lot of studies showing benefits to feeding the gut prior to and immediately after surgery as a way to promote early and better motility. One of the biggest reasons for discharge delays in these complex cases is postoperative ileus. To combat this, we have started our patients on small amounts of a clear electrolyte beverage a few hours before surgery, and we put them on a clear liquid diet immediately after surgery. The belief is that, again, the earlier you can promote gut motility and return to normal bowel function is a benefit. We’ve also eliminated the use of NG tubes postoperatively, as we think they may actually delay the return of gut motility. We try to avoid them intraoperatively, as well if at all possible.”

With respect to anesthesia and postoperative pain control, much has changed. “Working with our anesthesia colleagues in this area has been immensely important to our changes in care. We will try to avoid using opioids as much as possible for a variety of reasons, but mainly because of the potential bowel issues they can cause. We discuss preoperatively what may be best for the patient based on their anatomy and physiology. Our pain anesthesiologists have a broad armamentarium at their disposal, and they are critical in helping to manage the patient and evolve our ERAS protocols. We also work with them to manage fluids, because too much can lead to bowel edema and delay return of function. It’s really a multifaceted approach that considers the specifics of the patient balanced against returning them to normal function in the best ways possible,” says Dr. Chaudhry

Study Outcomes and Metrics

Primary outcomes measures of the ERAS study include length of stay, 30- and 90-day morbidity, rates of complication, and readmission rates. “Length of stay will likely be hard to measure because it is intimately tied to the return of bowel function, which for all intents is still quite a subjective measure,” says Dr. Chaudhry.

However, as the study progresses over the coming years, the ability to measure and analyze other aspects of the ERAS protocols will present themselves to the research teams. “We should be able to look at the anesthesia protocol and compare it to what was being used prior to the start of the study, how we may be able to reduce the usage of opioids and their accompanying side effects, and likely many other aspects from all of the data the study sites are collecting.”

Study Sites

Children’s Hospital Colorado
Children’s Hospital St. Louis
Children’s Mercy Kansas City
Cincinnati Children’s 
UPMC Children’s Hospital of Pittsburgh