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Author Spotlight: Simulating Pediatric Cardiac Surgery Using a Neonatal Piglet Model
Published on: May 26, 2023
Initial results from an enhanced recovery program for pediatric cardiac surgical patients
Tim Murphy1, Steven M Sale1, Francisco Gonzalez Barlatay2
1Pediatric Cardiac Anesthesia, Bristol Royal Hospital for Children, Bristol, UK.
Insights
Implementing an enhanced recovery pathway for pediatric cardiac surgery is feasible and shows promising outcomes, including reduced intensive care unit stays. This approach optimizes patient recovery and timely discharge.
Area of Science:
- Pediatric Cardiac Surgery
- Perioperative Management
- Enhanced Recovery Programs
Background:
- Enhanced recovery programs (ERPs) are increasingly adopted in adult surgery.
- Interest in pediatric ERPs led to the development of a pathway for pediatric intestinal surgery.
- A specific focus on "fast track" management for pediatric cardiac surgery emerged, often emphasizing ventilation duration.
Purpose of the Study:
- To design and implement a comprehensive enhanced recovery pathway for selected pediatric cardiac surgical patients.
- To base the pathway on Enhanced Recovery after Surgery (ERAS®) methodology.
- To evaluate the perioperative management and outcomes of patients undergoing this new pathway.
Main Methods:
- A prospective audit was conducted over 25 months.
- The study included 88 pediatric cardiac surgical patients.
- Data collected included perioperative interventions and patient outcomes.
Main Results:
- The mean patient age was 5.8 years; 68 patients underwent cardiopulmonary bypass.
- 89% of patients met the target extubation time of 6 hours.
- A 22% reduction in median intensive care unit stay was observed compared to a historic control group.
Conclusions:
- Implementation of this enhanced recovery pathway for pediatric cardiac surgery is feasible.
- The pathway demonstrated acceptable outcomes, including reduced ICU length of stay.
- Results suggest potential for further development and wider application of the pathway.
Background:
Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019.
Methods:
We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution.
Results:
The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day.
Conclusions:
These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.
