Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.
Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee.
J Surg Res. 2023 Aug;288:290-297. doi: 10.1016/j.jss.2023.03.025. Epub 2023 Apr 12.
There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation.
This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation.
The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14).
For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.
实施手术后加速康复（ERAS）方案存在许多障碍。本研究旨在比较外科医生和麻醉师对小儿结直肠患者 ERAS 方案实施前当前实践的看法，并利用这些信息来指导 ERAS 的实施。
这是一项在一家独立儿童医院进行的关于实施 ERAS 方案障碍的混合方法单机构研究。对一家独立儿童医院的麻醉师和外科医生进行了关于 ERAS 成分的现行做法的调查。对 2013 年至 2017 年间接受结直肠手术的 5 至 18 岁患者进行了回顾性图表审查，随后实施了 ERAS 方案，并前瞻性地对实施后 18 个月进行了图表审查。
外科医生的回复率为 100%（n=7），麻醉师的回复率为 60%（n=9）。术前非阿片类镇痛药和区域麻醉很少使用。术中，54.7%的患者液体平衡<10 cc/kg/h，仅 38.7%达到正常体温。机械肠道准备经常使用（48%）。无口服时间中位数明显长于 12 小时。术后，42.9%的外科医生报告说患者可以在术后第 0 天开始吃清淡食物，28.6%的患者可以在术后第 1 天开始吃清淡食物，28.6%的患者可以在放屁后开始吃清淡食物。实际上，53.3%的患者在放屁后开始吃清淡食物，中位数时间为 2 天。大多数外科医生（85.7%）希望患者在从麻醉中醒来后立即下床；然而，患者下床的中位时间是术后第 1 天。虽然大多数外科医生报告经常使用对乙酰氨基酚和/或酮咯酸，但只有 69.3%的患者术后接受任何非阿片类镇痛药治疗，只有 41.3%的患者接受两种或两种以上的非阿片类镇痛药治疗。非阿片类镇痛药从回顾性到前瞻性显示出最高的改善率：术前使用镇痛药从 5.3%增加到 41.2%（P<0.0001），术后使用对乙酰氨基酚增加了 27.4%（P=0.5），托烷司琼增加了 45.5%（P=0.11），加巴喷丁增加了 86.7%（P<0.0001）。术后使用>1 类止吐药预防恶心/呕吐的比例从 8%增加到 47.1%（P<0.001）。住院时间没有变化（5.7 天与 4.4 天，P=0.14）。
为了成功实施 ERAS 方案，必须评估观念与现实之间的差异，以确定当前的实践并确定实施的障碍。
