Advertisement

Development of a Five Point Enhanced Recovery Protocol for Pectus Excavatum Surgery

      Summary

      Purpose

      We implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation.

      Methods

      A 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test.

      Results

      A total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P=0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p=0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience.

      Conclusion

      Our results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics.

      Level of Evidence: III

      Retrospective comparative study.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Cobben JM, Oostra RJ, van Dijk FS. Pectus excavatum and carinatum. [Review]. 2014;1(8):414-417.

      2. Al-Qadi MO. Disorders of the Chest Wall: Clinical Manifestations. [Review]. 2018;1(2):361-375

        • Mao Y.Z.
        • Tang S.
        • Li S.
        Comparison of the Nuss versus Ravitch procedure for pectus excavatum repair: an updated meta-analysis.
        [Review]. 2017; 1: 1545-1552
        • Kanagaratnam A.
        • Phan S.
        • Tchantchaleishvili V.
        • Phan K.
        Ravitch versus Nuss procedure for pectus excavatum: systematic review and meta-analysis.
        [Review]. 2016; 1: 409-421
      3. Archer V, Robinson T, Kattail D, Fitzgerald P, Walton JM. Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review. 2020;1(5):805-810.

      4. Chan YY, Chu DI, Hirsch J, Kim S, Rosoklija I, Studer A, et al. Implementation and sustainability of an enhanced recovery pathway in pediatric bladder reconstruction: Flexibility, commitment, teamwork. 2021;1(6):782-789.

      5. George JA, Salazar AJG, Irfan A, Prichett L, Nasr IW, Garcia AV, et al. Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children. 2022;1(7):1349-1353.

      6. Keane OA, Dantes G, Emani S, Garza JM, Heiss KF, Clifton MS. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery. 2022;1(6):1132-1136.

      7. Loganathan AK, Joselyn AS, Babu M, Jehangir S. Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis. 2022;1(1):157-168.

      8. Pennington Z, Cottrill E, Lubelski D, Ehresman J, Lehner K, Groves ML, et al. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. 2020;1(2):225-238.

      9. Zhang Y, Liu D, Chen X, Ma J, Song X. An enhanced recovery programme improves the comfort and outcomes in children with obstructive sleep apnoea undergoing adenotonsillectomy: A retrospective historical control study. 2021;1(1):249-255.

      10. Mangat S, Hance L, Ricketts KJ, Phillips MR, McLean SE. The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair. 2020;1(9):1035-1045.

      11. Litz CN, Farach SM, Fernandez AM, Elliott R, Dolan J, Nelson W, et al. Enhancing recovery after minimally invasive repair of pectus excavatum. 2017;1(10):1123-1129.

      12. Wharton K, Chun Y, Hunsberger J, Jelin E, Garcia A, Stewart D. Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum. 2020;1(6):1065-1071.

      13. Holmes DM, Polites SF, Roskos PL, Moir CR. Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients - Benefits of an enhanced recovery pathway. 2019;1(10):1976-1983.

      14. DiFiore JW, Robertson JO, Chhabada S, DeRoss AL, Hossain MS, Rincon-Cruz L, et al. Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol. 2022;1(2):213-218.

      15. Nuss D, Obermeyer RJ, Kelly RE, Jr. Pectus excavatum from a pediatric surgeon's perspective. 2016;1(5):493-500.

      16. Naser B, Palozzi L, Crawford M, Pain management handbook. Toronto (ON): Acute pain service, The Hospital for Sick Children, 2010

        • Kelly Jr., R.E.
        • Mellins R.B.
        • Shamberger R.C.
        • Mitchell K.K.
        • Lawson M.L.
        • Oldham K.T.
        • et al.
        Multicenter study of pectus excavatum, final report: complications, static/exercise pulmonary function.
        and anatomic outcomes. 2013; 1: 1080-1089
        • Kelly Jr., R.E.
        • Daniel A.
        Outcomes, quality of life, and long-term results after pectus repair from around the globe.
        [Review]. 2018; 1: 170-174
      17. Daemen JHT, de Loos ER, Vissers YLJ, Bakens M, Maessen JG, Hulsewe KWE. Intercostal nerve cryoablation versus thoracic epidural for postoperative analgesia following pectus excavatum repair: a systematic review and meta-analysis. 2020;1(4):486-498.

      18. Parrado R, Lee J, McMahon LE, Clay C, Powell J, Kang P, et al. The Use of Cryoanalgesia in Minimally Invasive Repair of Pectus Excavatum: Lessons Learned. 2019;1(10):1244-1251.

      19. Moorjani N, Zhao F, Tian Y, Liang C, Kaluba J, Maiwand MO. Effects of cryoanalgesia on post-thoracotomy pain and on the structure of intercostal nerves: a human prospective randomized trial and a histological study. 2001;1(3):502-507.

      20. Sun RC, Mehl SC, Anbarasu CR, Portuondo JI, Espinoza AF, Whitlock R, et al. Intercostal cryoablation during Nuss procedure: A large volume single surgeon's experience and outcomes. 2021;1(12):2229-2234.

      21. Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. 2015;1:695-702.

        • Mikhaeil J.
        • Ayoo K.
        • Clarke H.
        • Wasowicz M.
        • Huang A.
        Review of the Transitional Pain Service as a method of postoperative opioid weaning and a service aimed at minimizing the risk of chronic post-surgical pain.
        [Review]. 2020; 1: 148-153
      22. Criscitelli T. Improving Efficiency and Patient Experiences: The Perioperative Surgical Home Model. 2017;1(3):249-253.

        • Kain Z.N.
        • Vakharia S.
        • Garson L.
        • Engwall S.
        • Schwarzkopf R.
        • Gupta R.
        • et al.
        The perioperative surgical home as a future perioperative practice model.
        [Review]. 2014; 1: 1126-1130
        • Connelly M.
        • Fulmer R.D.
        • Prohaska J.
        • Anson L.
        • Dryer L.
        • Thomas V.
        • Ariagno J.E.
        • Price N.
        • Schwend R.
        Predictors of postoperative pain trajectories in adolescent idiopathic scoliosis.
        Spine (Phila Pa 1976). 2014 Feb 1; 39 (PMID: 24173016): E174-E181https://doi.org/10.1097/BRS.0000000000000099