Bringing Enhanced Recovery After Surgery to the NICU: An Implementation Trial

Mercedes Pilkington; Brandon Pentz; Jennifer Yk Lam; Lori Stephen; Alexandra Howlett; Michelle Theam; Jennifer Unrau; Duncan McLuckie; Scott Else; Mary E Brindle

doi:10.1016/j.jpedsurg.2023.11.025

Bringing Enhanced Recovery After Surgery to the NICU: An Implementation Trial

J Pediatr Surg. 2024 Apr;59(4):557-565. doi: 10.1016/j.jpedsurg.2023.11.025. Epub 2023 Dec 19.

Authors

Affiliations

¹ Division of Pediatric General and Thoracic Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, USA. Electronic address: mpilkington@ariadnelabs.org.
² Department of Surgery, University of Calgary, Calgary, Canada.
³ Division of Pediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, Canada.
⁴ Alberta Children's Hospital, Calgary, Canada.
⁵ Department of Pediatrics- Neonatology, Cumming School of Medicine, University of Calgary, Calgary, Canada.
⁶ Department of Anesthesia, Cumming School of Medicine, University of Calgary, Canada, Canada.
⁷ Department of Anesthesia, Victoria General Hospital, Victoria, Canada.
⁸ Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, USA; Division of Pediatric Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.

PMID: 38185540
DOI: 10.1016/j.jpedsurg.2023.11.025

Abstract

Introduction: Enhanced Recovery After Surgery (ERAS) guidelines are bundled evidence-informed recommendations implemented to improve quality and safety of perioperative care. This study aims to determine feasibility of NICU implementation of an ERAS Guideline for Intestinal Resection, describing clinical outcomes and adherence to recommendations following light-touch implementation.

Methods: Infants <28 days undergoing laparotomy for intestinal resection in a closed-NICU were prospectively enrolled. Exclusion criteria included prematurity (<32wks), instability, or major comorbidity. Clinical data reflecting 13 ERAS recommendations were collected through chart review. Descriptive statistics are presented as median [interquartile range]. Thirty-day post-discharge outcomes include NICU and hospital length of stay (LOS), ventilator days, surgical site infection (SSI), re-intubation, readmission, reoperation, and mortality. Adherence was calculated as the percentage of patients eligible for each recommendation whose care was adherent.

Results: Ten infant-parent dyads were enrolled (five females; GA 37 weeks [35, 38.8]; birthweight 2.97 kg [2.02, 3.69]). Surgical diagnoses included intestinal atresia/web (n = 6), anorectal malformation (n = 3), and segmental volvulus (n = 1). NICU LOS was 16 days [11, 21], hospital LOS 20 days [18, 30], and 2.5 ventilator days/patient [2, 3]. There was reduced opioid use, no SSIs, one re-intubation, three readmissions, three reoperations, and no mortalities. Adherence to ERAS recommendations ranged 0-100 % with a pooled adherence rate of 73 %.

Conclusion: It is feasible to introduce ERAS to the NICU with acceptable overall adherence. Assessing adherence was challenging for some measures. There were promising early clinical findings including a reduction in opioid use. This implementation trial will inform development of an ERAS protocol for surgical NICUs.

Level of evidence: IV (Cohort Study).

Keywords: ERAS; Enhanced Recovery After Surgery; Neonatal; Quality.

MeSH terms

Aftercare
Analgesics, Opioid
Cohort Studies
Enhanced Recovery After Surgery*
Female
Humans
Infant
Infant, Newborn
Intensive Care Units, Neonatal
Length of Stay
Patient Discharge
Postoperative Complications
Retrospective Studies

Substances

Analgesics, Opioid