ERAS

IN
P AEDIATRIC A NAESTHESIA

Dr. Sudarsan Kasthuri

Head of Dept of Anaesthesiology President Elect
GEM Hospital & Research Centre ISA Tamilnadu
Coimbatore
 Dept. Of Anaesthesiology
GEM Hospital & Research Centre, COIMBATORE
 ERAS
“ To develop peri operative care
and to improve recovery
through research, education, audit
and implementation of
evidence-based practice”

Prof.Hendrik Kehlet
E R A S in Adults
• · ANAESTHESIA
• · BARIATRIC
• · NURSING
• · COLORECTAL
• · GYNAECOLOGY
• · PANCREAS
• · UROLOGY
• · LIVER
• · HEAD AND NECK
ERAS =Improved outcomes
 Can J Anesth/J Can Anesth (2018) 65:569–577
Review of the enhanced recovery pathway for children: Perioperative anesthetic considerations
Jessica A. George, MD, MEd . Rahul Koka, MD, MPH . Tong J. Gan

 Minimize surgical stress response

 Minimize Postoperative pain

ERAS  Reduce complications

Improve outcomes
GOALS


Decrease hospital length of stay

IN CHILDREN


 Expedite recovery following elective procedures

 It is unclear to what
extent these ERAS
principles are
applicable to
paediatric surgery
and whether similar
benefits could be
accomplished in
children.

What is the role of enhanced recovery after surgery in Children?

A scoping review. Pearson KL, Hall NJ. Pediatr Surg Int 2017;33:43-51.
Enhancing recovery in pediatric surgery: a review of the literature.
Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV. J Surg Res 2016; 202: 165-76.

What is the role of enhanced recovery after surgery in children?

A scoping review. Pearson KL, Hall NJ. Pediatr Surg Int 2017;33:43-51.
•

Leeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB.
Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg 2016; 51: 2126-9.
•

Can J Anesth/J Can Anesth (2018) 65:569–577

Review of the enhanced recovery pathway for children: Perioperative anesthetic considerations
Jessica A. George, MD, MEd . Rahul Koka, MD, MPH . Tong J. Gan
 •

Bevan JC, Johnston C, Haig MJ, et al. Preoperative parental anxiety predicts behavioural and emotional responses to induction of
anaesthesia in children. Can J Anaesth 1990; 37: 177-82.
•
•

•
•
•
NPO for Clear fluids – 1 hour
NPO for Breast Milk – 3 Hours

ORAL COMPLEX
CARBOHYDRATES

• Maintains glycogen
reserves

Minimizes protein
breakdown
Improves overall
muscle strength
Avoidance Of Hyperosmotic Bowel Preparation

• INCREASED BOWEL WALL EDEMA

• SURGICAL SITE INFECTION

• INCREASED RISK OF BOWEL LEAK & ANASTOMOTIC DEHISCENCE
• NO MAJOR DIFFERENCE IN BOWEL PREPARED & NOT PREPARED GROUPS FOR INFECTION
Children should not routinely receive long or short acting sedative
medication prior to surgery because it delays recovery

The place of premedication in pediatric practice

Abraham Rosenbaum MD Zeev N. Kain MD Peter Larsson Md Andrew R. Wolf MD FRCA
Paediatric Anesthesia 2009 - 19: 817–828
•

•
 AVOID NG TUBES
Goal
Quicker return of
bowel function,
decreased pulmonary
complication
anastomotic leak.
■ Discomfort, Postoperative fever & Airway
complications
■ 2007 cochrane review
Anastomotic bowel leak was no
different between NG & no NG groups.
■ Prophylactic use to be avoided but delayed
gastric emptying warrant NG insertion
■ Selective use permitted
 • THERE IS NO CLEAR ADVANTAGE TO
EARLY FEEDING KEEPING PATIENTS NPO AFTER
ELECTIVE GASTROINTESTINAL
SURGERY.

• NORMAL FOOD SHOULD BE TAKEN AS

SOON AS POSSIBLE AS THIS HAS BEEN
SHOWN TO BE SAFE AND REDUCE
LENGTH OF STAY

• CLEAR LIQUIDS EVENING OF

SURGERY, REGULAR DIET DAY AFTER
SURGERY
•
 Adult vs. Paeds

Preadmission counselling and education Included

Fluid and carbohydrate loading;

No prolonged fasting Gatorade®/Pedialyte® 2 hr before surgery

Standardized bowel prep, if needed Antibiotic + mechanical prep

Reduction of surgical site infection risk Antibiotic prophylaxis

Anxiolytic premedication Midazolam

Clonidine

Nonopioid pain adjuncts Gabapentin

Acetaminophen

Can J Anesth/J Can Anesth (2018) 65:569–577

Review of the enhanced recovery pathway for children: Perioperative anesthetic considerations
Jessica A. George, MD, MEd . Rahul Koka, MD, MPH . Tong J. Gan
Nonopioid pain adjuncts Low-dose ketamine

Neuraxial or peripheral nerve block Included, assuming no contraindication

Thromboembolism prophylaxis Age and surgery dependent

Avoidance of salt and water overload IVF selection on case-by-case basis

Balanced Salt solutions preferred

Maintenance of normothermia Included

Blood transfusion minimization Tranexamic acid infusion

BIS monitoring Excluded-controversial
Pain control from regional technique Included

Nasogastric tube avoidance Included

Prevention of nausea and vomiting Included

Early removal of urinary catheter Included, except if epidural catheter infusion is used

Early oral nutrition Included

Nonopioid analgesia IV acetaminophen

Early mobilization Included