Journal of Pediatric Surgery 53 (2018) 592–598

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Original Articles

Appropriateness of a pediatric-specific enhanced recovery protocol using

a modified Delphi process and multidisciplinary expert panel☆,☆☆
Heather L. Short a, Natalie Taylor b, Kaitlin Piper b, Mehul V. Raval a,⁎
a
Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
b
Rollins School of Public Health, Emory University, Atlanta, GA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a
Received 23 March 2017 wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pe-
Received in revised form 11 August 2017 diatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing
Accepted 16 September 2017 elective intestinal procedures.
Methods: A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert
Key words:
panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member
Enhanced recovery after surgery (ERAS)
Modified Delphi process
multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/
Colorectal surgery family representatives.
Pediatric surgery Results: Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered ac-
Fast track surgery ceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi pro-
cess. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS
protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not
included in the final recommendations.
Conclusions: Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 el-
ements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS pro-
tocols in children are needed.
Level of evidence: Level V, Expert opinion.
© 2017 Published by Elsevier Inc.

Enhanced Recovery After Surgery (ERAS) protocols aim to optimize
perioperative care in patients undergoing major surgical procedures by
maintaining physiologic homeostasis and reducing surgical stress and
have been shown to reduce length of stay (LOS), reduce postoperative
morbidity, and decrease overall costs in a variety of adult surgical proce-
dures [1–7]. General tenets of ERAS include perioperative patient educa-
tion, shortened preoperative fasting durations, minimally invasive
surgical techniques, opioid-sparing analgesia, early postoperative oral
feeding and mobilization, and minimal use of surgical drains and cathe-
ters [8]. Evidence supporting the implementation of ERAS in pediatric
surgical populations is far less robust than in the adult literature. Two
Abbreviations: ERAS, Enhanced Recovery After Surgery; LOS, length of stay; RCT, ran-
domized, controlled trial; APSA, American Pediatric Surgical Association; MBP, mechanical
bowel preparation; VTE, venous thromboembolism; NGT, nasogastric tube; NPO, nil per
os; TAP, transversus abdominis.
☆ Disclosures: None.
☆☆ IRB Approval: Exempt.
⁎ Corresponding author at: Division of Pediatric Surgery, Department of Surgery, Emory
University School of Medicine, Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta,
GA 30322. Tel.: +1 404 785 0781 (Admin/Academic); fax: +1 404 785 0800 (Admin).
E-mail address: mehulvraval@emory.edu (M.V. Raval).
recent reviews of the pediatric literature demonstrated that the use of
ERAS protocols in children is limited, however both studies concluded
that the use of these protocols in children may be beneficial [9,10]. Cur-
rent ERAS protocols were designed specifically for use in adult surgical
populations. Accordingly, controversy exists regarding the adoption of
these protocols for use in children in their current form. Some elements
may require revision in order to meet the unique perioperative needs
of children.
Although there are no high-quality studies examining the use of
comprehensive ERAS protocols in children, there is existing literature
addressing the safety and efficacy of some individual elements
[11–18]. Additionally, none of the adult ERAS elements are novel, and
many are likely being implemented routinely by pediatric surgeons out-
side of an official ERAS protocol [19]. One approach to designing a
pediatric-specific ERAS protocol would be to conduct multiple random-
ized, controlled trials (RCTs) comparing individual ERAS elements to
traditional perioperative management techniques. However, this pro-
cess would require extensive resources and years to complete and
may delay potential benefits to patients by decades. An alternative ap-
proach is the adoption of specific elements for use in designated popu-
lations after consensus is reached through a process including review of

https://doi.org/10.1016/j.jpedsurg.2017.09.008
0022-3468/© 2017 Published by Elsevier Inc.
 H.L. Short et al. / Journal of Pediatric Surgery 53 (2018) 592–598
the current evidence, repetitive questioning, and expert vetting. This
method known as the modified Delphi process or the Rand/UCLA appro-
priateness method has been used in the surgical literature to develop
guidelines for the management of several controversial topics [20–22].
The purpose of this study was to determine which individual ERAS ele-
ments are appropriate for inclusion in a pediatric-specific protocol for
use in adolescents undergoing elective intestinal surgery for treatment
of inflammatory bowel disease through a modified Delphi process.
1. Methods
Fig. 1 depicts a timeline of the methodology used for the develop-
ment of our pediatric-specific ERAS protocol for use in adolescents un-
dergoing intestinal surgery. This process took place between June 3,
2016 and December 31, 2016. This study was submitted and deemed
exempt from review by the Children's Healthcare of Atlanta Institution-
al Review Board.
1.1. Round 1: national survey
A web-based survey of the American Pediatric Surgical Association
(APSA) membership was conducted in June 2016. Respondents were
asked to rate each of 21 adult colorectal ERAS elements on their willing-
ness to incorporate them into their own practice when considering a
14-year-old female with a long-standing history of Crohn's disease
scheduled to undergo an elective ileocecectomy. Willingness was mea-
sured using the following 5-point Likert scale: 1–“Unwilling”, 2–“Uncer-
tain”, 3–“Somewhat willing”, 4–“Definitely willing”, and 5–“Already
doing”. Elements that were ranked as “Definitely willing” or “Already
doing” (Likert score of 4 or 5) by more than 90% of respondents were
considered appropriate for inclusion in a pediatric-specific ERAS proto-
col without any further discussion. Elements that were ranked as “Un-
willing”, “Uncertain”, or “Somewhat willing” (Likert score of 3 or less)
by more than 10% of respondents were considered controversial and re-
quired further review prior to being included in a pediatric-specific
ERAS protocol [23].
Fig. 1. Timeline depicting rounds of modified Delphi process, which took place between June 2016 and December 2016.
593
1.2. Expert panel
In order to facilitate the Delphi process, an expert panel was assem-
bled. Potential panelists were identified by the authors (HLS and MVR)
and invited via email to voluntarily participate in the expert panel. The
final panel consisted of 16 individuals representing leaders in pediatric
care in multiple specialties related to pediatric abdominal/intestinal
surgery as well as patient/family representatives. Panel participants
represented 11 children's hospitals across the United States. The panel
included 8 pediatric surgeons, 3 pediatric anesthesiologists, 2 pediatric
gastroenterologists, 2 patient representatives, and 1 nurse practitioner.
1.3. Literature review
A compendium of the current literature surrounding ERAS protocol
implementation in pediatric surgery, as well as use of individual ERAS
elements, was compiled by the authors (HLS, NT, KP). This document
along with an “Executive Summary” was sent to all expert panel mem-
bers via email on October 10, 2016. The Executive Summary included a
short introduction to ERAS, a summary of our institutional experience
with ERAS in children, a short explanation of the Delphi process, and a
summary of the current scientific evidence for the controversial ERAS
elements identified in round 1 along with references (Executive Sum-
mary available upon request to the corresponding author). Panel mem-
bers were instructed to read this document in its entirety in preparation
for round 2 of the Delphi process.
1.4. Round 2: pre-meeting survey
After receiving the Executive Summary, expert panel members were
sent a web-based survey. In round 2, panelists were asked to rate the
appropriateness of inclusion of each of the controversial elements in a
pediatric-specific ERAS protocol for use in adolescents undergoing elec-
tive intestinal surgery. Specifically, respondents were asked to answer
each question as it pertained to a 14-year-old female with a long-
standing history of Crohn's disease scheduled to undergo an elective
ileocecectomy. Appropriateness was measured on a scale of 1 to 10
(1—“Extremely inappropriate”, 10—“Extremely appropriate”). Panelists
594 H.L. Short et al. / Journal of Pediatric Surgery 53 (2018) 592–598

were asked to identify themselves along with their answers. This pro- 2. Results
cess took place from October 11 through October 17, 2016.
2.1. Round 1: national survey

1.5. Expert panel meeting
The expert panel meeting was held in conjunction with the
American Academy of Pediatrics conference in San Francisco, California
on October 23, 2016. Panelists were provided an individualized summa-
ry table depicting their own appropriateness rankings for each of the el-
ements from the pre-survey as well as blinded responses from the other
15 panelists. MVR served as the meeting moderator. At the beginning of
the meeting, a short introduction to ERAS and the expectations of the
meeting were presented. Approximately 10 min of open-ended discus-
sion time were allotted for each of the controversial ERAS elements. The
Executive Summary along with PubMed Central® access was available
during the meeting in order to facilitate evidence-based discussion for
and/or against the use of individual ERAS elements in children. Note-
takers along with a recorder were utilized to capture key quotes and dis-
cussion topics.
A 24% response rate was achieved with a total of 257 APSA members
completing the national survey, and full survey results have been sub-
mitted for publication [23]. Based on the results of this survey, 14 of
the 21 elements were ranked as “Definitely willing” or “Already
doing” by more than 90% of respondents (Table 1). These 14 elements
were considered appropriate for inclusion in a pediatric-specific ERAS
protocol without any further discussion. The remaining 7 elements
were more controversial and were ranked as “Unwilling”, “Uncertain”,
or “Somewhat willing” by more than 10% of respondents. The 7 conten-
tious elements that were subject to further review using the Delphi pro-
cess included: 1) avoidance of mechanical bowel preparation (MBP),
2) avoidance of prolonged perioperative fasting, 3) use of venous
thromboembolism (VTE) prophylaxis, 4) use of a standardized anes-
thetic protocol, 5) avoidance of routine nasogastric tube (NGT) use,
6) use of goal-directed fluid therapy, and 7) use of insulin to control se-
vere hyperglycemia (Table 2, Fig. 2).

2.2. Round 2: pre-meeting survey

1.6. Round 3: Post-meeting survey
In a final round, panelists were asked to complete a post-survey
where they once again ranked the appropriateness of each of the con-
troversial elements on a scale of 1 to 10. This survey was identical to
the survey in round 2 and was designed to gauge any changes in opinion
after the expert panel meeting. Respondents were instructed to base
their new rankings on discussion from the expert panel meeting. The
post-meeting survey was available from October 24, 2016 to November
7, 2016. Elements that achieved a mean appropriateness score of 9 or
higher were included in the final pediatric-specific ERAS protocol
along with the other elements that were previously accepted based on
the results of the national survey.
All 16 expert panel members completed the round 2 and 3 surveys
in their entirety. The pre-meeting survey results demonstrated a mean
appropriateness of N 7 for all elements. Despite all elements having a
high mean score, most elements received a wide range of rankings:
for instance, avoidance of fasting had a minimum score of 1 and a max-
imum score of 10 (Table 2, Fig. 2).
2.3. Round 3: post-meeting survey
In round 3, 6 of the 7 surveyed elements had a mean appropriateness
score of N 8 and demonstrated an increase in appropriateness scores be-
tween rounds 2 and 3. The only element that showed a decrease in

Table 1
Responses to the national survey.

ERAS Components Unwilling Uncertain Somewhat Willing Definitely Willing Already Doing

Preoperative
Provide preadmission/preoperative information, education, and counseling - - 11 (4.3%) 92 (35.8%) 154 (59.9%)
Preoperatively optimize any underlying medical conditions 2 (0.8%) - 10 (3.9%) 72 (28.2%) 171 (67.1%)
Minimize usage of mechanical bowel preparation 6 (2.3%) 11 (4.3%) 44 (17.2%) 53 (20.7%) 142 (55.5%)
Avoid prolonged perioperative fasting 1 (0.4%) 7 (2.7%) 21 (8.2%) 101 (39.5%) 126 (49.2%)
Administer non-opiate preoperative analgesic medications - 2 (0.8%) 19 (7.4%) 115 (44.7%) 121 (47.1%)

Intraoperative
Use prophylaxis against thromboembolism 9 (3.5%) 13 (5.1%) 45 (17.6%) 67 (26.2%) 122 (47.7%)
Use preoperative antibiotic prophylaxis and skin preparation - - 6 (2.4%) 37 (14.6%) 211 (83.1%)
Use a standard anesthetic protocol, including regional anesthesia when possible 3 (1.2%) 5 (2.0%) 21 (8.2%) 120 (46.9%) 107 (41.8%)
Apply a multi-modal approach to post-operative nausea and vomiting in - 2 (0.8%) 10 (3.9%) 170 (66.7%) 73 (28.6%)
patients with N 2 risk factors
Use laparoscopy as a modification to surgical access 2 (0.8%) 5 (2.0%) 16 (6.3%) 36 (14.1%) 197 (77.0%)
Avoid routine use of nasogastric tubes 5 (2.0%) 10 (3.9%) 26 (10.2%) 46 (18.0%) 169 (66.0%)
Use standardized protocol for hypothermia prevention - 3 (1.2%) 2 (0.8%) 122 (47.8%) 128 (50.2%)

Postoperative
Avoid routine peritoneal cavity drainage after colonic anastamosis 1 (0.4%) 1 (0.4%) 7 (2.7%) 26 (10.2%) 221 (86.3%)
Use goal directed fluid therapy model or zero fluid balance model to guide 2 (0.8%) 7 (2.7%) 23 (8.9%) 182 (70.8%) 43 (16.7%)
postoperative fluid management
Avoid urinary catheter placement or early removal on postoperative day 1 or 2 - 2 (0.8%) 4 (1.6%) 43 (16.8%) 207 (80.9%)
Employ interventions to minimize post-operative ileus - 4 (1.6%) 8 (3.1%) 152 (59.4%) 92 (35.9%)
Minimize use of opioids for postoperative pain control 2 (0.8%) 2 (0.8%) 16 (6.3%) 83 (32.7%) 151 (59.4%)
Use insulin to control severe hyperglycemia in the intensive care unit setting 3 (1.2%) 13 (5.1%) 33 (12.9%) 112 (43.9%) 94 (36.9%)
Provide perioperative nutritional care, including screening for nutritional status 1 (0.4%) - 12 (4.7%) 120 (46.9%) 123 (48.0%)
Begin early scheduled mobilization on post-operative day 0 to 1 - 1 (0.4%) 1 (0.4%) 38 (15.0%) 214 (84.3%)
Collect information on protocol compliance and outcomes 1 (0.4%) 4 (1.6%) 19 (7.4%) 184 (71.6%) 49 (19.1%)

Questions pertained to whether surgeons are willing to implement individual adult Enhanced Recovery After Surgery (ERAS) elements in an adolescent undergoing an elective colorectal
procedure for inflammatory bowel disease. Elements highlighted in gray had N90% of responses with a Likert score of 4 or 5.
 H.L. Short et al. / Journal of Pediatric Surgery 53 (2018) 592–598 595

Table 2
Results of round 1 (national survey), 2 (pre-meeting survey), and 3 (post-meeting survey) for the 7 controversial adult ERAS elements.

Round 1 Round 2 Round 3

Controversial ERAS Elements Percent of responses with Likert score ≤3⁎ Mean Appropriateness Score Mean Appropriateness Score
(min, max) (min, max)

Avoidance of mechanical bowel preparation 23.8 7.13 (3, 10) 8.69 (5, 10)
Avoidance of prolonged preoperative fasting 11.3 8.63 (1, 10) 9.94 (9, 10)
Use of venous thromboembolism prophylaxis 26.2 8.88 (4, 10) 9.13 (5, 10)
Use of standardized anesthetic protocol 11.4 9.00 (5, 10) 9.56 (8, 10)
Avoidance of nasogastric tubes 16.1 8.81 (6, 10) 9.88 (9, 10)
Use of goal-directed fluid therapy 12.4 9.19 (5, 10) 9.81 (9, 10)
Use of insulin to manage severe hyperglycemia 19.2 7.75 (5, 10) 5.94 (1, 10)
⁎ National survey results. Pediatric surgeons were surveyed on their willingness to implement individual ERAS elements in their individual practices. Likert score 1 = unwilling,
2 = uncertain, 3 = somewhat willing, 4 = definitely willing, 5 = already implementing.

mean appropriateness was the use of insulin to control severe hypergly-
cemia (decreased from 7.75 to 5.94) (Table 2). Fig. 3 demonstrates indi-
vidual appropriateness score responses from each of the 16 panel
members for the pre- and post-surveys. Comments from the expert
panel meeting are summarized in the Discussion Section. At the end of
the process, elements that achieved a mean appropriateness score of 9
or higher in round 3 were included in the final pediatric-specific ERAS
protocol along with the 14 elements that were previously accepted
based on the results of the national survey (Table 2, Fig. 2). Two adult
ERAS elements were excluded from the final pediatric protocol: 1) no
routine use of preoperative MBP for elective colonic surgery 2) use of in-
sulin to control severe hyperglycemia postoperatively. In addition to not
meeting the minimum mean appropriateness score for inclusion, these
2 elements demonstrated more variance in the post-survey responses
than those that were ultimately included (Fig. 3).
3. Discussion
Despite reservations from the pediatric surgery community about
adopting adult ERAS principles for use in children, some surgeons are
beginning to introduce these protocols into their practice. Many adult
ERAS elements can be and already are being safely implemented in chil-
dren outside of an official ERAS protocol, while some elements remain
more controversial. In addition, a few institutions are beginning to de-
sign and execute comprehensive pediatric protocols [19,23]. On the
other hand, some groups are calling for RCTs to fill the void of evidence
pertaining to the use of certain elements in children [9,10]. RCTs for
each ERAS element may not represent a time or cost effective approach.
In order to move forward with examining outcomes associated with
ERAS in children, we must agree on which elements are appropriate
for use in children. This study employed a modified Delphi process to
develop a pediatric-specific ERAS protocol for use in adolescents under-
going elective colorectal surgery for treatment of inflammatory bowel
disease. This process resulted in the exclusion of 2 adult ERAS elements,
while 19 elements were deemed appropriate for use in children and in-
cluded in our pediatric ERAS protocol. Expert panel discussions sur-
rounding each of the 7 controversial elements are summarized in the
following paragraphs.
Two elements did not reach the minimum appropriateness score re-
quired to be included in the final pediatric ERAS protocol. Despite

Fig. 2. Flow diagram depicting individual Enhanced Recovery After Surgery (ERAS) elements up for review during each round of the modified Delphi process. Red indicates controversial
elements that require further review or were eliminated; green indicates elements accepted during each round, respectively.
596 H.L. Short et al. / Journal of Pediatric Surgery 53 (2018) 592–598

Avoidance of Mechanical Bowel Avoidance of Prolonged Use of Venous Use of Standardized Anesthetic
Preparation Perioperative Fasting Thromboembolism Prophylaxis Protocol
10 10 10 10
9 9 9 9
Appropriateness Score

Appropriateness Score

Appropriateness Score

Appropriateness Score
8 8 8 8
7
7 7 7
6
6 6 6
5
5 5 5
4
4 4 4
3
2 3 3 3
1 2 2 2
0 1 1 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Expert Panel Members Expert Panel Members Expert Panel Members Expert Panel Members

Avoidance of Routine Use of Goal-Directed Fluid Use of Insulin to Control Severe

Nasogastric Tube Insertion Therapy Hyperglycemia
10 10 10
9 9 9
Appropriateness Score

Appropriateness Score

Appropriateness Score
8 8 8
7 7 7
6 6 6
5 5 5
4 4 4
3 3 3
2 2 2
1 1 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Expert Panel Members Expert Panel Members Expert Panel Members

Fig. 3. Appropriateness scores for the 7 controversial adult Enhanced Recovery After Surgery (ERAS) elements by individual expert panel member. Pre-meeting survey scores are
represented by the red circles and post-meeting survey scores are represented by the blue diamonds.

mostly positive discussion from expert panelists surrounding avoiding highlighted many of the benefits of limited perioperative fasting includ-
the use of preoperative MBP, the lack of evidence and conflicting litera- ing decreased perioperative dehydration, hypotension, hypoglycemia,
ture surrounding MBP in children was brought up repetitively. While and patient discomfort associated with hunger.
there is strong evidence in the adult literature demonstrating no differ- While the use of VTE prophylaxis did reach an appropriateness score
ence in infectious complications with or without the use of MBP, the pe- of N9, there were differing opinions from expert panels regarding this
diatric literature on this topic is far less robust [13,14,24,25]. Bowel element with some panelists expressing concerns. While there is evi-
preparation options including MBP alone, MBP plus enteral antibiotics, dence for the use of thromboprophylaxis in high-risk pediatric patients
and enteral antibiotics alone were all discussed and the literature for including those with trauma, systemic infection, mechanical ventilation,
each reviewed. The expert panel discussion highlighted that the deci- LOS N 5 days, age N 15, obesity and inflammatory bowel disease, use in
sion to use MBP is largely based on provider preference. While this ele- all children undergoing surgery is not common practice [29,30]. In addi-
ment did not meet the criteria for inclusion in our final protocol, it did tion, expert panelists unanimously expressed a preference for mechan-
receive a high mean score of 8.69, However the range of appropriate- ical over chemical prophylaxis in children's surgery. One surgeon
ness rankings was large (minimum: 5, maximum: 10), suggesting that commented that he uses lower extremity sequential compression de-
there was disagreement regarding the appropriateness of this element vices in all patients age N 13 years, but explained that he chose this
for use in children, and further research in the form of a prospective criteria arbitrarily and that there is little evidence supporting this prac-
RCT may be warranted. tice. Other panelists suggested that it is less age-related and more about
The use of insulin to control severe hyperglycemia was the most the patient's risk profile, which is in line with current literature.
contentious element. Although adult studies support the routine moni- The use of a standardized anesthetic protocol in the context of ERAS
toring of blood glucose in all perioperative patients in order to prevent focuses on limiting narcotics and promoting rapid awakening in the op-
complications associated with hyperglycemia, there is a lack of data to erating room [31]. There are no RCTs comparing general anesthetic
support a similar practice in children [26,27]. Experts questioned techniques in gastrointestinal surgery in adults or children. Despite
whether perioperative hyperglycemia was a common enough problem this, there was an overall consensus among the experts that use of a
in children to warrant routine monitoring in all patients and raised the standardized anesthetic protocol is appropriate in children. Anesthesi-
concern than multiple unnecessary finger sticks would cause needless ologist panelists endorsed the use of a multimodal pain management
discomfort in children. Panelists were concerned that implementation approach including preoperative loading with non-opioid analgesics,
of this element would require a sweeping change in practice on pediat- the use of transversus abdominis plane (TAP) blocks and epidurals, as
ric surgical floors, likely incur a huge cost, and may not result in an im- well as non-opioid medications such as gabapentin, acetaminophen,
provement in outcomes. and ketorolac postoperatively. Many potential interventions such as
The remaining 5 elements received adequate appropriateness scores these were suggested for inclusion, however the panel did not attempt
to be included in the final protocol. Avoidance of prolonged periopera- to formalize an anesthesia protocol. Instead, it was discussed that indi-
tive fasting received the highest score. Although the American Society vidual institutions should develop their own protocols based on collab-
of Anesthesiologists currently recommends fasting from clear fluids orations between the operating surgeon and anesthesiologist and the
for only 2 h preoperatively and solid foods for 6 h preoperatively, panel- availability of certain interventions.
ists noted that this recommendation is not followed consistently across When discussing the elimination of NGTs postoperatively, expert
institutions with most anesthesiologists requiring nil per os (NPO) sta- panelists were surprised that there was any debate surrounding this,
tus after midnight the night before surgery [28]. Further discussion and commented that they felt that most surgeons recognized that
 H.L. Short et al. / Journal of Pediatric Surgery 53 (2018) 592–598
NGTs were not necessary in the majority of cases, especially elective
cases. Both the adult and pediatric literature supports this practice
[32,33]. Surgeon panelists felt that there may be some more traditional
surgeons who were unwilling to change their practice of always leaving
an NGT after gastrointestinal surgery, and this may be the source of re-
sistance to this element seen in round 1. Patient representatives advo-
cated for not using NGTs unless absolutely necessary, because they are
uncomfortable to patients. All panelists agreed that there is a time and
a place for NGT use, but it is generally not necessary for elective, uncom-
plicated cases.
The final element accepted into the protocol was the use of goal di-
rected fluid therapy. While adult studies support this practice [34,35],
evidence in the pediatric literature is lacking. However, panelists agreed
that it would be appropriate to extrapolate the adult data to children.
The anesthesia representatives on the panel made the point that much
of the adult data relies on the use intraoperative monitoring with esoph-
ageal Doppler to assess fluid status; however, this is difficult in children,
and the practice of titrating fluids to vital signs (i.e. heart rate and non-
invasive blood pressure monitoring) and urine output in order to
achieve near-zero fluid balance has the same effect. Postoperatively, ex-
pert opinion suggested that intravenous fluids should be stopped as
soon as the patient is tolerating liquids in order to avoid positive fluid
balance. Daily weights and urine output should be monitored in order
to guide fluid administration.
While this study was directed by the best available evidence and ex-
pert opinion, there are limitations to the Delphi technique. When con-
sensus is reached, it is based on opinion only. We acknowledge that
this methodology does not provide Level 1 evidence in the way that
RCTs would, however the pragmatic application of ERAS in children is
already happening. Waiting for the completion of multiple RCTs to jus-
tify the use of ERAS in pediatric surgery would delay potential improve-
ment in outcomes by decades. Additionally, we were limited by the low
response rate on the national survey in round 1, however we had 100%
response rates in round 2 and 3 from expert panel members. We desig-
nated this protocol for use in adolescents undergoing elective abdomi-
nal/intestinal surgery. We realize that this particular protocol may not
be appropriate for use in children of all ages or other procedures, and
further research is warranted in order to ensure that the use of ERAS
protocols in these populations is appropriate.
4. Conclusions
While ERAS is being used widely in adult surgical populations, pedi-
atric surgeons have been more hesitant to implement these protocols in
children. Controversy exists over exactly what a pediatric-specific ERAS
protocol should entail, and this stems from the paucity of evidence
supporting the use of some elements in children. Using a modified Del-
phi process, we developed a pediatric ERAS protocol for use in adoles-
cents undergoing elective colorectal surgery for treatment of
inflammatory bowel disease to include 19 distinct interventions.
Acknowledgements
We acknowledge the contribution of the survey respondents and of
the members of the expert panel including the following: Mary Austin,
MD, MPH (Department of Pediatric Surgery, University of Texas Medical
School at Houston); Martin Blakely, MD, MS (Department of Pediatric
Surgery, Vanderbilt University Medical School); Megan Brockel, MD
(Department of Anesthesiology, University of Colorado School of Medi-
cine); Katelyn Burch, MSN, CNP (Division of Pediatric Surgery,
Children's Healthcare of Atlanta); Mr. Laurence Diamond (Patient Rep-
resentative, Crohn's & Colitis Foundation of America); John Edney, MD
(Division of Pediatric Anesthesiology, Department of Anesthesiology,
Emory University School of Medicine); Kurt Heiss, MD (Division of Pedi-
atric Surgery, Department of General Surgery, Emory University School
of Medicine); Shinjiro Hirose, MD (Division of Pediatric General,
597
Thoracic and Fetal Surgery, UC Davis School of Medicine); Eunice
Huang, MD, MS (Division of Pediatric Surgery, Department of General
Surgery, University of Tennessee Health Science Center); Eric Jelin, MD
(Division of Pediatric Surgery, Department of General Surgery, Johns
Hopkins Hospital); Jenifer Lightdale, MD (Division of Gastroenterology,
Hepatology & Nutrition, Department of Pediatrics, University of Massa-
chusetts Medical School); Ms. Liz Pavlov (Department of Family Cen-
tered Care, Stanford Children's Hospital); Steven Shew, MD (Division
of Pediatric Surgery, Department of Surgery, University of California
Los Angeles School of Medicine); Sohail Shah, MD, MSHA (Division of
Pediatric Surgery, Department of General Surgery, Baylor College of
Medicine); Claudia Venable, MD (Division of Pediatric Anesthesiology,
Department of Anesthesiology, Emory University School of Medicine);
and Sofia Verstraete, MD (Division of Gastroenterology, Hepatology, &
Nutrition, Department of Pediatrics, University of California San
Francisco School of Medicine).
This study was funded, in part, by the Emory + Children's
Healthcare of Atlanta Pediatric Research Alliance (MVR). This study
was conducted under guidance from the PedSRC (Pediatric Surgical Re-
search Collaborative).
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