Hey, this is Todd Ponsky and Rogerardo. You may have noticed that it kind of feels impossible to stay up to date these days in pediatric surgery, and the reason you feel that way is because pediatric surgery knowledge. Is growing exponentially. It is impossible to stay up to date. So several hospitals, including Cincinnati Children's Hospital, Akron Children's Hospital, Mercy Children's Kansas City, and Buffalo Children's Hospital, pediatric surgeons from across the globe, along with ABSA and the Journal of Pediatric Surgery. Have come together to identify what are the most important points, groundbreaking research that have come out in the past year. We present these topics together in a fun, interactive virtual conference that's free to anyone who joins. This past year's update course really pointed out a lot of key insights into new trends in pediatric surgery. And one of those was enhanced recovery after surgery, or as a lot of us know it, ERAS. So, in this podcast, we have a presentation from Doctor Mary Brindle from Alberta Children's Hospital and Doctor Kurt Heise from Children's Healthcare of Atlanta. It takes us through all the key points that were made in last year's annual pediatric surgery update course. Clinical practice updates in ERAS. We hope you enjoyed the podcast. All right. Uh, Kurt and I have really been looking forward to, to this as being, uh, uh, and for a while, um, almost lone pediatric ambassadors to ERAS in, uh, Pediatric surgery, but this is changing certainly, and uh I think this is kind of expanding and increasing in the pediatric surgical world. Uh, we figured the very best way of talking about enhanced recovery after surgery in pediatric, uh, in pediatric general surgery is to really provide a bit of a case example. So I'm going to hand this over to Kurt to get us started. So, uh, JG is a 16 year old gal who has a tight ileocecal, a tight TI stricture, and She's lost some weight, hadn't been nutritionally managed very well, so she was sent to our clinic for questions about ileocystectomy. We gave her an explanation of the operation and then and also about enhanced recovery. We put her on protein shakes and scheduled her for a few weeks later. She was on the day of her operation, she came to the hospital drinking high carbohydrate, clear liquids. Um, unfortunately, I got the short straw that day and there was a liver transplant in my room, so instead of starting early in the afternoon, she started at 6 o'clock. Because ERAS was written on the board next to her name, the day surgery nurses gave her clear liquids during the afternoon. So, and they stopped it an hour before the operation, so she came into the operating room well hydrated. She was given a block and pre-op medications and she had a single site procedure. An ERAS anesthesia protocol was invoked, and her total IV fluids for the case was less than 4 ccs per kilo per hour. When we finished her stapled resection, um, she, we had a closing protocol. We changed the instruments and gloves. postoperatively, we put her on multimodal analgesia with Tylenol, Toradol, and Neurontin. Uh, we allowed her to drink immediately and she started to snack that night. So then the next day she is hep locked, start on a regular diet, eating well, pain is well controlled, getting up, walking around with PT, having bowel movements. All of the pre-op checklist items were clicked all the way down the box. So as you can guess, she went home that evening, um, after a partial colectomy. So at our institution, we've instituted a protocol across all surgical patients, which is discharged when physiologically ready as opposed to waiting for some, uh, for the surgeon to come by and say, yes, you're ready to go home. That's Doctor Dan von Almen. He's the surgeon in chief at Cincinnati Children's Hospital. My answer for my own personal patient would be absolutely, and I've done this, you know, to do the patient when they're ready to go home, you send them home. But keep in mind that we're not just treating the patient, we're treating the parents too. Have you ever had patients who felt like they weren't ready to go home mentally when physiologically they had met all their discharge goals? Of course. Um, I think we probably all have, and if it's not the patient, it may be the parents, and, uh, I, I would suggest that as pediatric folk, we tend to, uh, we tend to be a little more lenient, at least I have been with, uh, saying, sure, you want to stay overnight, you can stay overnight, we'll send you home in the morning. But in the adult population, there's literature to support that mobilization and early PO intake are the most important drivers to an early discharge. That's only after one other important factor talking with the families about what these discharge goals would be. So it's about setting expectations not just for the patient, but for our patients, the families too. Having this pre-op optimization period and heavy counseling is really important. Would any of you guys give oral supplements beforehand to change the trajectory of their visceral proteins? Trying to set me up there, Kurt. So in my, in my previous institution, we for sure my patient would go home. That's Doctor Mark Wolkan. He's the chair of surgery at Akron Children's Hospital. The protein supplements ahead of time, as you and I hadn't really talked about that before, but I think that's just about normal nutrition, getting your patient ready for surgery. Doctor Wolkan does a lot of bariatric surgery. One of the hardest things in the obese patients is getting the anesthesiologist buy-in to giving the, the preoperative carbohydrate load. We'd let them drink up to 4 hours before, but they wouldn't let us get too close. But in our bariatric population, uh, after sleeve gastrectomy, we're able to get over half of our patients out on the first post-operative day. So, it's about buy-in, particularly with anesthesia. And I mean, as surgeons, is there anything we love more than blaming anesthesia? I mean that's a joke, of course, but we do need them for one of the most important parts of ERAS, and that's pain control. Early in our practice, we had a marginally functioning pain team, and we invited them in to the ERAS club and got them involved. We gave them a lot of opportunities to regional blocks. They actually tried epidurals for about a year, but they found that the patients were really slowed down with their discharge, so They had to change it up instead. QL blocks, rectus sheath blocks, or tap blocks. And that way, the patient can mobilize a lot earlier and then you've got to consider the multimodal pain control. By giving the premeds on the morning of the operation or the day before the operation and giving them a block. Dr. Heist says they are able to do big surgeries, I mean colectomies, craniofacial reconstructions, all without the use of narcotics. Right at the beginning, I gave grand rounds to the anesthesia department. I did it twice and the chair was there for these presentations. She was very excited about this, and so I got a lot of support right at the beginning. So he gets buy-in from the anesthesia department and then he moves on to the nursing team and they get buy-in from their NPs. Then they're able to make these big institutional changes like NPO times, and then they get patient buy-in, family buy-in. But to really move this forward at your institution, you have to have a really good grasp on what exactly ERAS is. But if we actually look at it as the, as the overall big picture, it's a multidisciplinary, multimodal, evidence-based way of delivering care to patients. So what are the goals? The goals are to optimize patient physiology throughout the entire perioperative pathway. The strategy decrease um operative trauma. Inflammatory response and stress. And then within that, the tactics, Optimizing fluid and analgesia, mobilizing early, feeding early. And then these all get bundled up to work synergistically, and that takes us to our outcomes. They heal faster, they go home earlier. They have fewer complications. And not just surgical complications, Doctor Brindle talks about how they have a decrease in all types of complications. So you have all these benefits, and a lot of times the naysayers will say, yeah, you get these patients out really fast and that's great, but what about, Re-admission rates. This kind of holistic process, this involvement, this um focus, not necessarily on just getting patients out, but on that full spectrum of care should when done well, decrease the readmission rates. This is such a, a massive team approach that, um, that's why people struggle with getting it started. That's Todd Ponsky, a surgeon at Cincinnati Children's. I like to give a carbohydrate drink as I learned from Kurt a few years ago at the update course. I, but I'm too terrified to do it because if it happens to be a single anesthesiologist that's on that day, and they're not up to speed, then I, I just totally ruined everyone's day. So, I, Todd, just like you, the people at our institution were anxious that if a patient misbehaved or something like that, that it would slow the cases down and they'd be behind. But Doctor Heiss and his team at Emory actually found the opposite was true. So that takes us to the next point that Doctor Brindle make, is let the data kind of just speak for itself. Over the course of years with um additional ERS elements that were adopted, um, additional work for implementation, That there's decreased intraoperative fluids that are given, decreased in uh intraoperative and postoperative narcotics, decreased time to, um, getting on a full diet, and along with that, these patients get better faster, they're happier, they go home quickly. So there you have it, a talk about ERAS from two experts in the field, with some practical ways to implement it at your own institution. Now, specifically, if you're interested in a neonatal ERAS, Doctor Brindle also authored a recent paper, where they explain their whole bundle that they made from scratch. If you're listening to this in the stay current app, just scroll down, I put the link right there under the media player. So, what do you do? Do you have an ERA protocol at your institution, or maybe you don't and you want one, or it needs to be improved. Leave a comment or start a discussion in the Stay Current app. Connect with other surgeons who have done it. Until next time, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.
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