Development of an Enhanced Recovery Protocol Following Pediatric Surgical Procedures: A Change in Practice

Purpose:
To identify appropriate nursing and medical interventions to enable enhanced recovery following pediatric orthopedic and cleft lip and palate surgical procedures. To promote a holistic, interdisciplinary plan of care that effectively alleviates fear and manages post operative side effects.

Relevance/Significance:
Limited nursing research has been published examining the interdisciplinary approach to ERAS in the pediatric surgical patient population. The concept of ERAS was pioneered by Danish surgeon Henrik Kehlet in 1997 and was used primarily in patients undergoing colorectal surgery. Studies have been completed in the adult population with enhanced recovery documented in a variety of surgical settings with an improvement in post op pain control, nausea and vomiting and earlier mobilization.

Strategy and Implementation:
Development of ERAS pathway that involved participation from all members of the interdisciplinary care team. The pathway optimizes pre-operative assessment including patient and family education and counseling to manage patient and family expectations regarding surgical and post-operative recovery expectations. Identification of family and community support systems and functionality of those resources. Input from primary care provider regarding co morbid conditions and interventions being managed by PCP. Pre Op appt. with anesthesia and nursing. Families instructed on fluid intake and a liberal NPO policy. Day of surgery, administration of non narcotic pain-sparing medications are administered. Post op care includes aggressive management of pain including dexmedetomidine, NSAIDS, muscle relaxants and regional blocks. Planned mobilization occurs with PT and OT actively involved. Post op conference includes IDT communication and assessment of goal completion prior to discharge.

Evaluation:
Evaluation metrics included a reduction in post-operative opioid PCA utilization, a decrease in post-operative nausea and vomiting, an improved pain level score and increased ambulation following orthopedic procedures. In repeat orthopedic cases, patients and families verbalize an increased readiness for further surgical interventions with the ERAS Protocols in place.

Implications for Practice:
ERAS should be expanded to include use in a variety of surgical cases with specific protocols developed and individualized for specific diagnosis, and evaluation of patient/family perception of recovery and compliance with ongoing surgical interventions in the chronic pediatric patient population.