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Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic cholecystectomy surgery
Goeto Dantes1, Olivia A Keane2, Matthew Margol3
1Department of Surgery, Emory University, Atlanta, GA, USA. gdantes@emory.edu.
Insights
Implementing enhanced recovery protocols (ERPs) in pediatric patients undergoing elective laparoscopic cholecystectomy significantly reduced opioid use without increasing complications. This approach offers effective pain management and improved surgical care for children.
Area of Science:
- Pediatric Surgery
- Anesthesiology
- Pain Management
Background:
- Enhanced recovery protocols (ERPs) standardize surgical care and improve outcomes in adults.
- Pediatric surgical centers aim to optimize care pathways for pediatric patients.
Purpose of the Study:
- To compare outcomes before and after implementing a pediatric-specific ERP for children undergoing elective laparoscopic cholecystectomy (ELC).
- To evaluate the impact of ERPs on peri-operative and post-discharge narcotic use, complications, and patient return rates.
Main Methods:
- Retrospective review of 606 pediatric patients undergoing ELC between July 2014 and December 2019.
- Comparison of 206 patients pre-ERP implementation with 400 patients post-ERP implementation (including 21 ERP-compliant cases).
- Primary outcomes assessed included peri-operative and discharge narcotic use (mean morphine equivalents [MME]), complications, nurse calls, and returns to system (RTS).
Main Results:
- ERP implementation led to a significant decrease in post-operative and discharge opioid use.
- ERP-compliant patients used significantly less MME post-operatively (0.85 vs. 6.40) and at discharge (86% required no narcotics).
- No significant changes were observed in RTS, nurse calls, or complication rates post-ERP implementation.
Conclusions:
- Pediatric-specific ERPs are safe and effective for children undergoing ELC.
- ERPs provide compassionate pain control, significantly reducing opioid requirements.
- The implementation of ERPs improved surgical care without adversely affecting patient safety or necessitating increased nursing interventions.
Purpose:
Enhanced recovery protocols [ERPs] standardize care and have been demonstrated to improve surgical quality in adults. We retrospectively compared outcomes before and after implementation of ERPs in children undergoing elective laparoscopic cholecystectomy [ELC] surgery.
Methods:
A pediatric-specific ERP was implemented for children undergoing ELC at one [C1] of the two Pediatric Surgical Centers in July 2016. We retrospectively reviewed 606 patients undergoing ELC between July 2014 and December 2019. Of these, 206 patients underwent ELC prior to ERP implementation [Pre-ERP] were compared to 400 patients undergoing ELC managed in the post-ERP implementation period (between January 2017 and December 2019), 21 of which were managed by enhanced recovery protocol. Primary Outcomes included immediate peri-operative and post-operative narcotic use in mean morphine equivalents [MME], narcotics at discharge, complications, nurse calls and returns to system [RTS].
Results:
There was a significant decrease in opioid use both post-operatively and at time of discharge in the ERP managed cohort. The MME use during the post-operative period was 0.85 in the in ERP-compliant patients compared to 6.40 in the non-compliant group (p < 0.027). Eighty-six percent of ERP-compliant patients in the study required no narcotics at discharge, which was statistically significant when compared to ERP non-compliant cohort (p < 0.0001). There was also no change in RTS, nurse calls or complications. In addition, in the post-ERP period (2017-2019), a dominant proportion of patients at C1 partially complied with the ERP, resulting in a statistically significantly decrease of opioid use between sites in the post-op period (6.54 vs 10.57 MME) post-ERP (p < 0.001). Similar effects were noted in discharge narcotics.
Conclusion:
The use of pediatric-specific ERP in children undergoing ELC is safe, effective, and provides compassionate pain control while leading to a reduction in opioid use peri-operatively and at discharge. This improvement occurred without changes in RTS, nursing calls or complications.
Level Of Evidence:
Level III; Retrospective study.
