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Published on: March 12, 2019
The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy
Peggy Vogt1,2, Renee Tolly1,2, Matt Clifton3
1Department of Pediatric Anesthesia and Pain Medicine, Egleston Hospital, Children's Healthcare of Atlanta, 1405 Clifton Rd, Atlanta, GA 30322, USA.
Insights
Optimizing pain control and bowel function after the Kasai procedure (hepatoportoenterostomy) in infants is achievable. This study suggests an enhanced recovery protocol can improve outcomes for these young patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Anesthesiology
Background:
- The Kasai procedure (hepatoportoenterostomy) presents challenges in balancing post-operative pain control, respiratory depression, and bowel function in infants.
- Optimizing these factors is crucial for successful patient recovery.
Observation:
- A retrospective review of 12 infants undergoing the Kasai procedure was conducted.
- Patients received multimodal pain management, balanced fluid resuscitation, and blood products as needed.
- All infants were extubated in the operating room and transferred to the surgical floor without immediate complications.
Findings:
- Return of bowel function occurred by post-operative day 2, with enteral feeds initiated by post-operative day 3 for all patients.
- One patient experienced a presumed opioid overdose requiring brief oxygen supplementation.
- Multimodal pain management and fluid strategies appear effective in this cohort.
Implications:
- Simultaneous optimization of pain, respiratory, and bowel function is feasible in infants undergoing the Kasai procedure.
- An enhanced recovery protocol is proposed to further improve outcomes in this fragile population.
- Larger, prospective studies are needed to validate these findings and establish robust recommendations.
Abstract:
Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children's Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.
