Murphy Tim, Sale Steven M, Gonzalez Barlatay Francisco, Armstrong Catherine, Parry Andrew, Houghton Ella, Jerrom Tom, Schadenberg Alvin
Pediatric Cardiac Anesthesia, Bristol Royal Hospital for Children, Bristol, UK.
Pediatric Cardiology, Bristol Royal Hospital for Children, Bristol, UK.
Paediatr Anaesth. 2022 May;32(5):647-653. doi: 10.1111/pan.14418. Epub 2022 Mar 1.
Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019.
We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution.
The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day.
These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.
近年来，一些强化康复计划首先出现在成人结直肠手术中，随后在许多其他成人外科专科中也相继出现。对这种儿童围手术期管理方法的兴趣日益浓厚，最终促成了首个由手术加速康复协会（ERAS®）认可的小儿肠道手术强化康复路径的制定。与此同时，对于特定小儿心脏手术患者围手术期管理的优化也越来越受到关注，这一管理方式通常被称为“快速通道”管理。相关举措主要集中在术后通气时间上，而非更广泛的围手术期干预措施，以优化康复并确保术后及时出院。在我们机构，一家“一级”小儿心脏外科中心，我们组建了一个多学科团队，基于ERAS®方法，为特定心脏手术患者设计了一条全面的强化康复路径。经过长时间的规划、员工培训和准备，我们于2019年11月底实施了该路径。
我们对在我们机构25个月期间按照这一强化康复路径管理的前88例患者的围手术期管理和结果进行了前瞻性审计。
患者的平均年龄为5.8岁（范围0.5 - 17.9岁），平均体重为22.4千克（范围6.6 - 57.2千克）。88例患者中有68例接受了体外循环手术。共有54%的患者接受了所有四项明确的术中麻醉干预措施（静脉注射对乙酰氨基酚、非甾体类抗炎药、4岁以上患者使用止吐药以及采用局部麻醉技术）。共有89%的患者在注射鱼精蛋白后6小时达到目标拔管时间。术后重症监护病房的中位住院时间为23.5小时（范围15.2 - 89.5小时）。与历史对照组相比，这意味着重症监护病房中位住院时间减少了22%，尽管总住院时间保持不变。共有83%的患者在术后第五天达到目标出院标准。
这些初步结果表明，为特定小儿心脏手术患者实施强化康复路径是可行的，且结果可接受。它们指出了进一步发展的领域以及更广泛实施的潜力。
