Implementing "enhanced recovery protocols (ERPs)," or bundles of consensus-based interventions that span the surgical experience, improved outcomes for children undergoing gastrointestinal surgery, according to a multicenter clinical trial published in JAMA Surgery. Overall, time to regular diet after surgery decreased, and opioid use was reduced by 50%. Children who received 13 or more ERPs had shorter hospitalizations after surgery and fewer complications.
"This is a first-of-its-kind clinical trial in children's surgery," said lead author Mehul V. Raval, MD, MS, MBA , Head of the Division of Pediatric Surgery at Ann & Robert H. Lurie Children's Hospital of Chicago, as well as Associate Professor of Surgery and Pediatrics at Northwestern University Feinberg School of Medicine. "ERPs have been shown to improve outcomes for adults undergoing surgery for nearly 20 years, yet adoption for children has lagged with most studies having modest sample sizes and coming from single hospital experiences. Our study was a robust look at implementation of these bundles for nearly 600 surgical patients across 18 pediatric centers. We are excited to show that ERPs lead to better outcomes for children after surgery."
ERPs include practices such as letting patients drink clear liquids like apple juice on the morning of surgery, using minimally invasive techniques when possible, encouraging patients to eat and walk as soon as they can after surgery, and using multimodal approaches to pain management around the time of surgery, such as reliance on local or regional nerve blocks to help numb the surgical incision areas.
"We have realized that opioid stewardship is a very important aspect of pain control after surgery, and this is where ERPs can be a huge benefit with input from surgeons, anesthesia, nursing teams, child psychology and patient-families," said Dr. Raval. "After hearing from patients that many of their concerns were not pain but anxiety and stress, we developed deep breathing videos and incorporated mindfulness into our surgical experiences. Using non-opioid pain medications routinely also decreased opioid use. The bundling of these many levers helps us be better stewards of opioids and ERPs are a great way to make this a reality for every patient and family."
Dr. Raval and colleagues also noted that hospitals with the strongest quality improvement culture and commitment to the ERPs, as well as those that integrated the ERPs into the electronic health records, had most success with implementation.
The randomized clinical trial included children 10 to 18 years of age undergoing elective gastrointestinal surgery from September 2019 to June 2024. Nearly three-quarters of patients had inflammatory bowel disease.
"We are already expanding the use of ERPs for children undergoing a wide variety of surgical procedures," said Dr. Raval. "We also are applying many of the ERP components to younger children, including newborns undergoing surgery."
Dr. Raval holds the Orvar Swenson Founders' Board Chair in Pediatric Surgery at Lurie Children's.
Ann & Robert H. Lurie Children's Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children's hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children's resources are devoted to serving their needs. Research at Lurie Children's is conducted through Stanley Manne Children's Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children's is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation's top children's hospitals by U.S. News & World Report.
