Learning objectives

By reading this article you should be able to:

 Compare the differences between enhanced re- covery after surgery (ERAS), perioperative surgical home and fast-track
surgery.
 Explain the various components of an ERAS pro- tocol in paediatrics.
 Describe the limited evidence for common ERAS interventions in paediatric practice.
 Propose future directions for multidisciplinary paediatric standardised care protocols.

Key points

 The concept of ERAS is that multiple, evidence- based best practice interventions combined into a protocol will contribute
synergistically to improved outcomes.
 The success of adult ERAS protocols has led to interest in creating paediatric ERAS pathways.
 Key ERAS principles include preoperative educa-

tion, reduced preoperative fasting, minimally invasive surgical techniques, multimodal opioid- sparing analgesia including
regional anaes- thesia, minimising the use of surgical drains and early postoperative feeding and mobilisation.

 Although robust, high-quality evidence is lacking, the available literature demonstrates reduced length of stay, use of opioids
and intraoperative fluids, and time to restarting a regular diet with paediatric ERAS protocols.

Background: history of enhanced recovery after surgery

In the era of modern surgery, it is vitally important to provide high-quality, resource-conscious, patient-centred care. Enhanced recovery
after surgery (ERAS) is a concept devel- oped to meet these goals. Enhanced recovery after surgery utilises a patient-centred,
multidisciplinary approach through the perioperative period. Key ERAS concepts include preop- erative education for patients and families,
reduction of pre- operative fasting, using minimally invasive surgical techniques, multimodal opioid-sparing analgesia and regional
anaesthesia, minimising tubes and drains and early postoperative feeding and mobilisation. 1 The concept of ERAS is that multiple, evidence-
based best practice interventions can be combined into a protocol; when applied together, the interventions contribute synergistically to
improved out- comes for patients.2 In adults, ERAS protocols reduce morbidity and increase patients’ satisfaction while reducing overall
costs. Clearly defined, standardised elements applied in a consistent manner can optimise care. The earliest uptake of ERAS Society
guidelines was for adults undergoing colo- rectal surgery. As growing evidence demonstrated benefits such as reduced length of stay (LOS)
and decreased costs, ERAS was expanded into other adult surgical specialties, including gynaecological, orthopaedic and cardiac surgery.
This was accompanied by increasing evidence that proto- colised care improves morbidity and mortality. 3

The term ‘fast-track surgery’ is often used interchangeably with ERAS. ‘Fast track’ was the term initially applied to the approach developed
by Kehlet in the 1990s that has subse- quently become ERAS. The early goal of fast-track surgery was earlier discharge from hospital after
surgery through a comprehensive programme to optimise perioperative care. Many of the original elements of fast-track surgery are similar
to current ERAS concepts, including early postoperative feeding and mobilisation, use of minimally invasive surgery and avoiding tubes and
catheters where possible. The term ‘enhanced recovery after surgery’ puts more emphasis on a holistic approach to recovery with a broader
focus on out- comes that are important for the patient.

An enhanced recovery protocol (ERP) is the implementation strategy used to institute an ERAS guideline. The goal of ERP is to ensure that
an evidence-based and standardised approach is applied to all patients undergoing surgery. ERPs involve all multidisciplinary team
members and engage the patient and their family in their care. An effective ERP uses an ERAS guideline to improve the quality and
efficiency of surgical care while reducing costs.

The success of adult enhanced recovery strategies has led to interest in creating ERAS pathways in children. Previous litera- ture reviews on
paediatric ERAS have identified a lack of pro- spective and randomised control trials in this area, and have acknowledged that the creation
and implementation of paedi- atric ERAS pathways (Table 1) has been slower than in adults.4

A recent review identified one retrospective and four pro- spective cohort studies evaluating children undergoing gastrointestinal (GI),
urological and thoracic surgery.1 The intervention bundles in the studies included six or fewer in- terventions, substantially less than the
more than 20 recom- mended interventions in most adult guidelines. Despite this, the studies did suggest that ERPs may be associated with
benefits such as decreased LOS and decreased use of opioids, without an increase in complications in appropriate groups of children
undergoing surgery.

In September 2016, a scoping review identified the extent to which ERAS has been used in paediatric surgery. 1 The au- thors identified nine
studies from 2003 to 2014 including 1269 patients. Interventions within these protocols were restricted in number and included early
postoperative feeding and mobilisation protocols, morphine-sparing analgesia and reduced use of nasogastric (NG) tubes and urinary
catheters. These relatively limited ‘fast-track’ programmes significantly reduced LOS, time to oral feeding and time to first stool.

More extensive strategies to introduce ERAS in paediatrics have been undertaken. In 2017, at an American Academy of Paediatrics
symposium, paediatric surgeons assessed an existing ERAS Society guideline in adults for use in adoles- cents undergoing colorectal
surgery. The initial consensus agreement was to adopt 14 of the 21 key elements. After reviewing the evidence for the elements excluded,
group consensus resulted in the final inclusion of 19 of the 21 ele- ments. Experience with this paediatric-specific ERP was recently
published: outcomes from 43 patients undergoing surgery before the ERP were compared with those from 36 patients after introduction of
ERP. In the period before ERP, the median number of ERAS interventions per patient was five; in the period after ERP, the median number
of interventions was 11. Key results included a statistically significant difference in the median LOS from 5 to 3 days with the ERP. The
times to restarting a regular diet, use of opioids and volumes of fluids given during surgery were all reduced. 5

Paediatric evidence for common ERAS interventions

Children pose unique physical and psychosocial challenges to the anaesthetist. The surgical stress response is complicated by physiological
considerations based on a child’s develop- mental stage. Given the unique biopsychosocial factors in paediatrics, individual ERAS
principles may not be universally translatable to children, despite demonstrated evidence in adults. Adolescent ERAS guidelines may
resemble adult ERAS guidelines; however, neonates will require considerably different guidelines. The paediatric evidence supporting the
recommendations commonly used in adult ERAS protocols are described below. 4

Preoperative patient/family education

Engagement and education of patients is a major component of adult ERAS protocols. In paediatrics, information should be provided to
families to reduce the child’s and parents’ anxiety surrounding surgery. Education must be provided at an age- appropriate level before
surgery. Educating families has a substantial impact on overall satisfaction with the surgical process and reduces anxiety. Involving older
children and adolescents in the preoperative planning process can promote engagement and understanding and establish expectations, which
has been shown to improve the quality of their care and aid their postoperative recovery. 6

Minimisation of fasting and administration of a preoperative carbohydrate load

A recent joint consensus statement by the Association of Paediatric Anaesthetists of Great Britain and Ireland, the Eu- ropean Society for
Paediatric Anaesthesiology and L’Associa- tion Des Anesthesistes-Renamateurs Paediatriques d’Expression Francaise agreed that based on
the current literature and in the absence of a contraindication, children should be encouraged and allowed to consume clear liquids up to 1 h
before elective general anaesthesia, up to a recom- mended maximum volume of 3 ml kg e1.7 This is in contrast to other society guidelines,
such as the ASA, which continue to recommend 2 h fasting from clear liquids before surgery. 8 With a 2 h clear liquids fasting policy, the
literature suggests that patients actually fast for 6e7 h, with several studies demonstrating fasts of up to 15 h. The liberalised policy on clear
fluid fasting is based on evidence that water empties from the stomach within 30 min, and other clear fluids are almost gone within an hour.
There is evidence from rando- mised control studies demonstrating no significant difference in gastric volume or pH if children are fasted
for clear fluids for 1 compared with 2 h.9 Prolonged fasting primes metabolic and immune responses which induce a catabolic state, increase
insulin resistance and potentially reduce intravascular vol- ume. Giving an oral carbohydrate liquid drink 2e3 h before surgery in adults has
been shown to modify this response by reducing insulin resistance, maintaining glycogen reserves, minimising protein breakdown,
improving overall muscle strength and possibly contributing to earlier return of bowel function and decreased LOS, without increasing
complication rates.4

Avoidance of preoperative hyperosmotic mechanical bowel preparation

Mechanical bowel preparation (MBP) was once a mainstay in adult colorectal practice, but its utility and potential harms have recently been
questioned. The goal of MBP is to reduce complications associated with stool bacterial contamination

including anastomotic dehiscence, wound infection and sepsis. In adults, evidence suggests that hyperosmotic MBP may increase risk of
surgical site infection (SSI), increase bowel wall oedema and increase risks of bowel leak and anastomotic dehiscence; however, the data are
conflicting. In the largest study to date, 32,359 adult patients who underwent elective colorectal resections in the American College of Sur-
geons national surgery quality improvement programme database were analysed retrospectively. 10 MBP alone was ineffective at reducing
the risk of SSI when compared with no bowel preparation. However, oral antibiotics (OA) alone and OA plus MBP were associated with
decreased risk of SSI, anastomotic leak, postoperative ileus, readmission and shorter LOS. In a similar retrospective analysis of 27,804 adult
surgical patients undergoing elective colorectal resections, combined MBP/antibiotic bowel preparation (ABP) resulted in significantly
lower rates of SSI, organ space infection, wound dehiscence and anastomotic leak than no preparation; and a lower rate of SSI than ABP
alone.11 Thus, future adult ERAS recommendations may recommend that patients undergoing elective colorectal resection should have both
mechanical agents and OA when feasible.

In children, MBP carries increased morbidity, often requiring an additional hospital day, NG tube placement for administration of the
preparation and additional laboratory tests and i.v. fluids to ensure adequate fluid and electrolyte balance during the preparation. A small
randomised control pilot study identified no significant difference in rates of anastomotic leak, intra-abdominal infection or wound infec-
tion between children who received MBP and those who did not.12 A retrospective, multicentre review of 272 children who underwent
reversal of colostomy found that using MBP was associated with an increased risk of wound infection, increased LOS and no reduction in
any other complications. LOS in the MBP group was longer, primarily because these patients were admitted before their surgery for bowel
prepa- ration. These results suggest that omitting MBP in children is safe, and may reduce cost and discomfort. 13

Whether or not MBP is a beneficial element of paediatric ERAS protocols remains to be determined. Avoidance of MBP was one of only
two elements that the American Paediatric Surgical Association (APSA) ultimately excluded from their recommendations for an adolescent
colorectal ERAS protocol (the other excluded element being glucose monitoring). 14 Conflicting literature and lack of definitive evidence
were among the reasons for excluding avoiding MBP in the recommendation.

Judicious use of fluids

A major component of adult ERAS protocols is rational and judicious fluid therapy. However, there is less evidence that children are as
vulnerable to volume shifts as adults. Aggressive use of i.v. fluids has been associated with worse outcome in paediatric patients undergoing
cardiac surgery, but this trend has only recently been demonstrated in other specialties such as colorectal surgery. A recent retrospective
cohort study of paediatric patients undergoing colonic resec- tion identified an association between high volume intra- operative fluid
administration and worsened postoperative outcomes. Specifically, giving fluids greater than 90th percentile overall was associated with
LOS >6 days (odds ratio [OR], 8.14; 95% confidence interval [CI], 1.75e37.8; p1⁄40.007), time to first meal >4 days (OR, 5.91; 95% CI,
1.30e27.17; p1⁄40.02) and supplemental oxygen requirement >24 h (adjusted OR [AOR], 3.60; 95% CI, 1.25e10.39; p1⁄40.02), after
adjusting for ASA status, blood loss, transfusion and open surgery.15 The American Society for Enhanced Recovery makes several rec-
ommendations for adult colorectal surgery that may apply to paediatric patients, including avoidance of fluid administra- tion for
intraoperative oliguria (but not anuria), administering fluid to address specific clinical problems and avoiding fluid administration for
treatment of an isolated abnormal hae- modynamic value.16 ERAS principles such as reduced fasting and avoiding MBP have decreased the
intravascular volume deficits, and fluid needs and administration must be adjusted accordingly.

New technologies can help assess a patient’s fluid responsiveness (oesophageal Doppler, non-invasive cardiac output monitoring,
plethysmography variability index, aortic peak blood flow velocity). The goal of these technologies is to provide a metric to classify patients
in whom fluid adminis- tration will improve cardiac output and optimise tissue perfusion, and in whom preload therapy is unnecessary and
will result in fluid overload. In mechanically ventilated adults, dynamic indices of preload that rely on respiratory variation in stroke volume
are better able to predict fluid responsive- ness than static variables. Further investigations in children are required to guide fluid
administration, assessment and optimal maintenance of euvolaemia.

Regional anaesthesia
The adjunctive use of regional anaesthesia during procedures requiring general anaesthesia has many potential advantages. Although most
commonly thought of as an effective means of postoperative analgesia, regional anaesthesia may decrease intraoperative requirements for
intravenous and volatile anaesthetic agents, thereby providing a more rapid awak- ening and earlier extubation. Regional anaesthesia can
also attenuate or potentially ablate the harmful effects of the surgical stress response. Afferent neural blockade attenuates pro-inflammatory
and metabolic responses to stress and re- duces insulin resistance. High-quality evidence in adults suggests additional benefits of neuraxial
analgesia include accelerated return of GI transit (decreased time to first flatus and first stool) after abdominal surgery. In open surgeries, an
epidural infusion containing local anaesthetic may decrease the length of hospital stay (equivalent to 1 day). 17

In neonates major abdominal surgery includes intestinal resection surgery, congenital diaphragmatic hernia, gastro- schisis and omphalocele.
One means of reducing exposure to drugs that may cause neuronal apoptosis is to use neuraxial anaesthesia as an adjunct to general
anaesthesia.

Various researchers have also demonstrated several po- tential advantages of peripheral nerve block techniques in paediatric patients for
improving postoperative analgesia and reducing adverse effects related to opioids. Examples on these include transversus abdominal plane,
erector spinae plane, paravertebral, rectus sheath and quadratus lumborum blocks.

The paediatric regional anaesthesia network (PRAN) is a multi-institutional centralised database that collects pro- spective data on all
regional anaesthetics given at partici- pating centres, to study the incidence of complications of paediatric regional anaesthesia. Data on
14,917 regional blocks were gathered between 2007 and 2010, and all intra- and postoperative complications were tracked until resolution.
No deaths or complications with sequelae lasting more

than 3 months occurred.18 As such, regional anaesthesia, and specifically epidural or combined spinaleepidural (CSE), is safe and may have
physiological benefits in ERAS protocols.

Multimodal, opioid-sparing analgesia

Options for multimodal analgesia to reduce opioid re- quirements in children include paracetamol, midazolam, gabapentin, dexamethasone,
clonidine, dexmedetomidine and NSAIDs. Reduction in parenteral opioid requirements potentially contributes to faster return of gut
motility. Adjunct therapies can be administered i.v., orally, rectally or as com- ponents in regional blockade to prolong postoperative anal-
gesia. One study showed that addition of intravenous dexamethasone 0.1 mg kg1 in paediatric patients undergoing caudal analgesia with
ropivicaine reduced pain scores for up to 48 h and decreased the number of oral analgesics required after orchidopexy. 19 I.V. paracetamol
can significantly reduce postoperative care unit LOS, oversedation and total opioid consumption. 20

Avoidance or early removal of surgical drains and tubes

Nasogastric tube placement post laparotomy is intended to protect patients from abdominal distension and subsequent postoperative nausea
and vomiting, aspiration, anastomotic leaks and wound complications. This concept has been chal- lenged in adult patients, and robust level
1 evidence exists to support the avoidance of routine postoperative gastric drainage in adults after colorectal surgery. A systematic re- view
and meta-analysis of NG decompression from seven adult studies with a total of 1416 patients after elective colon and rectum surgery
revealed no difference in time to return of GI function and increased morbidity of pharyngolaryngitis and respiratory infection with NG
decompression. Routine NG tube decompression was therefore not recommended after elective colon and rectum surgery. 21 Nasogastric
tubes were assumed to be required as children swallow large amounts of air when distressed and crying, but evidence exists for avoidance of
routine NG tubes in paediatrics. One study found that there was no difference in postoperative complications after laparotomy for a variety
of upper and lower GI surgeries regardless of whether or not an NG tube was placed.22 A sig- nificant decrease in time to first feed, first
stool and discharge was found in patients without NG tubes. However, children who did not have postoperative NG decompression did have
a higher incidence of postoperative vomiting (22% vs 11%). Historically, the postoperative ileus that frequently accom- panies appendicitis
and other complicated surgeries was frequently cited as an indication for NG tube placement. Current literature challenges this concept. One
study suggests that children with perforated appendicitis have reduced time to first oral intake (3.8 vs 2.2 days), and reduced LOS (6.0 vs 5.6
days) if an NG tube is not inserted.23 As such, routine NG drainage in paediatric patients is not recommended.

The utility of peritoneal drainage has also been challenged. Peritoneal drainage was routine for many surgeries with sig- nificant intra-
abdominal contamination, in addition to pancreatic and biliary surgeries. The rationale for drain placement after biliary surgery is to
facilitate early identifi- cation of biliary leaks or haemorrhage and potentially obviate the need for a radiologically placed drain.

There are few indications in the contemporary era for routine drain placement. There is no evidence supporting the placement of drains at
the time of removal of a perforated appendix. Even in complex biliary and pancreatic re- constructions, leaks are rare and interventional
drain place- ment, when required, is usually sufficient to manage these uncommon complications. Moreover, the drains themselves, aside
from being frequently unnecessary, can also be harmful. A surgical drain may be a source of infection and may oppose the goals of
minimally invasive surgery, such as reduction in postoperative pain. A randomised study of 100 children un- dergoing laparoscopic
choledochal cyst excision Roux-en-Y hepatojejunostomy (RYHJ) demonstrated that the group treated without drainage had shorter time to
resumption of normal activity, LOS and decreased pain scores. No patients in either group developed biliary, pancreatic or intestinal leaks in
the 12 month postoperative follow-up period.24 Drain placement is required to manage rare biliary and pancreatic leaks. With the increased
availability of interventional radi- ology support, the need to place these drains at the time of surgery has decreased substantially. A review
in 2018 assessed the benefits and harms of routine abdominal drainage after pancreatic surgery in adults, and concluded that it was unclear
whether routine abdominal drainage had an effect on mortality at 30 days or postoperative complica- tions after pancreatic surgery. Routine
abdominal drainage may slightly reduce mortality at 90 days. The evidence for this conclusion was moderate in quality. 21
In summary, the available literature on peritoneal drainage suggests that routine drainage is often unnecessary in chil- dren. However, the
quality of evidence is low and there are situations where operative drainage is warranted or even life- saving. In these cases, early drain
removal is recommended if feasible.

Prophylaxis for postoperative nausea and vomiting

ERPs best address postoperative nausea and vomiting (PONV) through a multimodal approach. This approach includes preoperative oral
hydration, minimal use of volatile anaes- thetics and opioids, prophylactic use of antiemetics and tailored PONV therapy. Prevention of
PONV begins in the preoperative period. Strategies to reduce baseline risk of PONV in children include avoidance of volatile anaesthetics
and nitrous oxide by utilisation of propofol for induction and maintenance, regional anaesthesia to avoid general anaes- thesia, multimodal
analgesia to minimise intra- and post- operative opioids, and adequate hydration. Risk scores for PONV, such as the paediatric specific
Eberhart risk score, should be used to help tailor antiemetic therapy to each spe- cific patient. The 4-point Eberhart scale assigns one point
for each of: surgery longer than 30 min, age older than 3 yr, strabismus surgery and history of PONV in relatives. When none, one, two,
three or four independent predictors are present, the risk for PONV is approximately 10%, 30%, 50% or 70%, respectively. 5-
Hydroxytrytamine type 3 (5-HT3) receptor antagonists, specifically ondansetron 0.1 mg kg1, are commonly used antiemetics for both
prophylaxis and rescue treatment of PONV. Other first-line prophylactic antiemetics include dexamethasone 0.15e0.3 mg kg1 and aprepitant
40 or 80 mg. Aprepitant is a neurokinin-1 receptor antagonist with a half-life of approximately 9 h. This potent antiemetic is optimally given
30e60 min before induction of anaesthesia. The safety and antiemetic efficacy of aprepitant has been well established in the paediatric
oncology population. There is evidence for antiemetic prophylaxis with aprepitant in high- risk adult surgical populations. 25

Early feeding

The first ERAS protocols in adults challenged the initial dogma of delayed feeding after intestinal surgery to allow anasto- moses to heal
and reduce nausea and vomiting. Despite initial concerns, early feeding protocols in patients after GI surgery have consistently demonstrated
decreased length of hospital stay and decreased rates of infection. The same benefits of early feeding have been demonstrated in paediatric
patients although general practice has yet to catch up. There are ben- efits to early feeding that are of particular importance for the paediatric
patient. Nutrition in an infant must support growth and development in addition to anastomotic and wound healing. A prospective,
randomised trial published in 2013 of 150 infants randomised to ad libitum vs protocol feeds found that ad libitum feeding after
pyloromyotomy allowed infants to reach goal feeds sooner than the protocol group. 26 A meta- analysis of 14 studies published in 2015
comparing ad libitum feeding to structured feeding after pyloromyotomy demon- strated that ad libitum feeding is associated with shorter
LOS (mean difference, 4.66 days). Although emesis was more likely in infants on a rapid than a gradual feeding regime, emesis was not
found to have a negative effect on overall patient outcome.27 Even for neonatal patients after intestinal resec- tion, early feeding has been
associated with a shorter LOS and decreased time until first stool. Early postoperative feeding may not be appropriate for all patients; for
example infants who have undergone post bowel resection for volvulus or necrotising enterocolitis with ischaemic bowel may require a
different approach.

Strategies for implementation and future directions for paediatric ERAS

Few ERAS guidelines have been applied to children, and very few have been designed for children. Surrogate evidence from adults has been
used to guide paediatric ERAS in areas in which paediatric evidence is lacking. Many elements in adult ERAS protocols lack high-quality
RCT evidence for use in children (duration and timing of perioperative antibiotics, use of postoperative Foley catheters and use of MBP). 2
At the same time, there may be a lack of the equipoise required to perform paediatric RCTs, as strong but indirect data support the ben- efits
of individual ERAS elements (e.g. timing of perioperative antibiotics). 4

Implementation of ERAS protocols can be challenging as there are numerous barriers to their effective use. Many fea- tures of ERAS
protocols are not intuitive. Routine periopera- tive practices and the perception of best care can vary widely within an institution and often
lag behind latest evidence. Enhanced recovery after surgery implementation requires a team of motivated health professionals that catalyse
the ed- ucation of surgeons, anaesthetists, nurses, patients and their families in order to influence culture and advance the imple- mentation
of new, impactful protocols.

Complete adoption may not be required to achieve many of the benefits of ERAS. The application of even a few elements can increase
patients’ comfort and parental satisfaction and reduce LOS. For example in one study, minimally invasive techniques could not be applied in
48% of thoracic procedures, but these paediatric patients could still benefit from other ERAS elements, including early postoperative
mobilisation and nutrition.28 Exploring the relevance of adult ERAS pro- tocols for an expanded range of paediatric conditions and
developing new, paediatric-focused ERAS elements will in- crease the benefits of ERAS for children. It is notable that most elective
paediatric surgeries are performed on ASA 1 and 2 patients who are discharged on the same day as surgery. Simple ERAS initiatives, such
as encouraging clear fluids to be taken by mouth up until 1 h before surgery and administering regularly scheduled paracetamol and
ibuprofen after opera- tion, can have a significant impact on patient comfort and morbidity. These practices could be easily adopted across
large surgical systems that care for children.

The interest in ERAS in paediatric surgery is rapidly expanding. Teams of international perioperative experts have begun to implement
ERAS protocols in children based on available evidence and consensus recommendations. 14 Neonatal ERAS protocols will look
dramatically different than protocols in adults and adolescents. A neonatal guideline for intestinal resection surgery contains elements
specific to the needs of neonates including early introduction of breast milk, rational antibiotic administration, urinary sodium monitoring
and mucous fistula feeding for patients with stomas.6 Specific recommendations related to anaesthetic management include multimodal
analgesia and the use of anaesthetic protocols to maintain homeostasis. The first World Congress for Paediatric ERAS was held in
November 2018 in Virginia, USA, and an international working group for Paediatric ERAS Surgery within the ERAS Society has been
established.
ERAS requires education and engagement from numerous multidisciplinary teams throughout the perioperative periods. Paediatric ERAS
protocols will continue to develop in numerous surgical areas of relevance to children. Anaesthe- tists have an essential role in the creation
and dissemination of paediatric ERAS.