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Medical Journal of Clinical Trials & Case Studies Research Article 11 min read

Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis

Kumba C*, Blanc T, De Cock A, Willems A, Harte C, Querciagrossa S, Orliaguet G and Melot C
* Corresponding author
ISSN: 2578-4838  10.23880/mjccs-16000211  Received: April 05, 2019  Published: April 29, 2019
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Keywords
Enhanced Recovery Pathways Children Outcome
Abstract

Introduction: In adult surgical patients rapid recovery pathways after surgery have shown improvement in postoperative complications and length of hospital stay. Enhanced recovery after surgery is a concept which includes patient management protocols beginning from the preoperative period, continues in the intraoperative period and the postoperative period. This concept aims to improve postoperative outcome. In pediatric patients rapid recovery pathways are beginning to develop. This study was undertaken to analyse whether enhanced recovery after surgery improved postoperative outcome in terms of postoperative complications and length of hospital stay in children. Methods: After registration of this study in Prospero under the number [CRD42018103518], a systematic review and meta-analysis of randomised and non randomised trials was realised in April 2019 using electronic databases in children less than 18 years old where enhanced rapid recovery pathways after surgery were applied and compared to standard care. Statistic analysis was realised with RevMan 5.3 software. Results: 6 studies with 1620 children

Introduction

In adult surgical patients rapid recovery pathways after surgery have shown improvement in postoperative complications and length of hospital stay [1]. Enhanced recovery after surgery (ERAS) is a concept which includes patient management protocols beginning from the preoperative period, continues in the intraoperative period and the postoperative period. For instance preoperatively anticipating blood transfusion in potential hemorraghic interventions by improving preoperative hemoglobin levels by administrating iron or erythropoeitin, anticipating the nutritional patient status, reducing preoperative fasting times [2, 3, 4].

Intraoperatively, ERAS includes titration of fluid therapy to avoid hypovolemia or fluid overload by using means or goals to improve end organ perfusion and oxygen delivery; includes protective invasive or noninvasive lung ventilation if necessary; includes optimal analgesia using non opioid medications (for instance loco-regional analgesia), prevention of postoperative nausea and vomitting, using minimal invasive surgical technics such as laparoscopy, robotic surgery, interventional radiology [5, 6]. Postoperatively ERAS includes rapid oral intake, preferring enteral alimentation, prevention of postoperative nausea and vomiting, rapid mobilisation, physiotherapy, avoiding naso-gastric tubes, urinary bladder catheters or tubes if not necessary, early intravenous access withdrawal if not necessary [7, 8, 9, 10]. The objective of this study was to analyse whether ERAS improved postoperative outcome in pediatric surgical patients.

Methods

This study was registered under the number CRD42018103518 in PROSPERO, the international registration database for systematic reviews and meta- analysis. Since this was a systematic review and meta- analysis ethical approval from the local ethic committee was not necessary. Types of studies included were randomised and non randomised. Types of Participants: Children aged 0-18 years (inclusion criteria) were included and patients above 18 years were excluded (exclusion criteria). Types of Interventions: Surgical pediatric patients in whom rapid recovery pathways after surgery were applied compared to interventions where these protocols were not applied. Primary outcome was morbidity defined as postoperative complications. Secondary outcome was length of hospital stay. Primary outcome measures were defined by the number of patients with postoperative complications defined as organ failure or dysfunction and infections. Secondary outcome measures determined by the number of days spent in hospital after surgery. Titles and abstracts were electronically searched using these keywords ’ Enhanced recovery pathways after surgery in children OR Rapid recovery pathways after surgery in children OR Fast-tracking after surgery in children OR Enhanced recovery pathways after surgery in children and Outcome OR Rapid recovery pathways after surgery in children and outcome OR Fast-tracking after surgery in children and outcome OR ERAS in children OR Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

Enhanced recovery pathways after surgery in children in randomised and non randomised trial OR Rapid recovery pathways after surgery in children in randomised and non randomised trials’. Electronic search was realised in medline, embase, central, Google Scholar, Clinicaltrials.Gov, Abstarct Conference And Dare see flow chart in figure 1.

Figure 1: Search flow chart according to the PRISMA statement [11].
Click to enlarge
Figure 1: Search flow chart according to the PRISMA statement [11].

Copenhagen the Nordic Cochrane Centre, The Cochrane Collaboration 2014. Assessment of risk of bias in the included studies was realised using the tools proposed by the Cochrane Handbook for Systematic reviews of Interventions included with the software. Measures of treatment effect: Were dichotomous for morbidity (how many patients complicated) and was presented as odds ratio with 95%CI.

Results

6 retrospective studies with 1620 children were included (Table 1) in idiopathic scoliosis surgery (572 patients), in hypospadias (302 patients) and in appendicectomy (746 patients) [13, 14, 15, 16, 17, 18].

Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

Sanders 2016
Study IDWong 2018 [13]Fletcher 2017 [14]Gornitzky 2016 [15]Cundy 2017 [17]Skarda 2015 [18]
[16]
MethodsRetrospective
monocentric trial		Retrospective bicentric
study		Retrospective
monocentric trial		Retrospective
monocentric
trial		Retrospective/prospective
case control trial		Retrospective
monocentric trial
Participants302 children aged
between 22 months [15-
38] and 36 months [21-
50] hypospadias surgery		150 children aged
between 10-18 years in
adolescent idiopathic
scoliosis		138 children aged
between 14.8±2.3 and
15±2.3 years in
adolescent idiopathic
scoliosis surgery		284 children
aged between
10 and 18
years in
adolescent
idiopathic
scoliosis
surgery		166 children aged
between 12.0±3.0 and
12.2±2.9 years in
appendicitis surgery		580 children aged
between 9.7± 3.4 and
10.3±3.4 years in non
non ruptured
appendicitis surgery
by laparoscopy or open
surgery
Interventions176 children (control
group) treated with the
old service protocol
were compared to 126
children (experimental
group) treated with the
new service protocol
=enhanced recovery
pathway protocol		105 children from one
center using an
accelerated discharge
pathway (experimental
group) were compared
to 45 children from a
second center using a
traditional discharge
pathway (control
group)		80 children in the
conventional pathway
(control group) were
compared to 58
children in the rapid
recovery pathway		194 children
in the
traditional
pathway
(control
group) were
compared to
90 children in
the
accelerated
pathway
(experimental
group)		83 children treated before
the multidisciplinary
criteria-led protocol CLD =
preprotocol group or
control group, were
compared to 83 children
treated according to the
CLD protocol
(experimental group)		285 children treated
prior to the new
protocol= control
group were compared
to 295 children treated
according to the new
protocol
Definition of
the
interventions		old service protocol=
patients remained in the
hospital until removal of
the urethral catheter, IV
antibiotics, wound care
by medical staff, 6
pediatric surgeons took
care of the patients. The
new service protocol=		The traditional
discharge pathway was
defined as the
treatment on basis of
the surgeon's
preferences without a
formal pathway i.e
patient postoperative
surveilliance realised in		Conventional pathway
was characterised by
pain management with
intraoperative
methadone and
postoperative IV
morphine or
hydromorphone
patient controlled		The
Accelerated
protocol was
defined as
where effort
was
coordinated
by nursing,
physiotherapy,		The multidisciplinary
criteria-led discharge
(CLD) protocol consisted
of limiting postoperative
antibiotics to 2 IV doses,
avoidance of
postoperative intravenous
opioid analgesia,
administration of		The new protocol was
defined as a criteria-
based postoperative
treatment
management where
postoperative
antibiotics were
avoided and discharge
faciliated with bedside

Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

Copyright© Kumba C, et al.

enhanced recovery the surgical unit, transition to oral pain medications from PCA pump on postoperative analgesia (PCA); transition to oral medication (oxycodone pathway=patients discharged on day 2 or 3 postoperatively with the and acetaminophen ) as tolerated from day 3 urethral catheters, 3 day 3 after tolerating pediatric surgeons specialised in pediatric urology were in charge of the patients, parents oral intake, Foley removed on day 1-2, drain removed on day 2-3, mobilisation with to 4, diazepam for muscle spasme; bed rest on day 1 and physiotherapy and dietary progress on given instructions of wound care with saline instillation at home, oral physiotherapy once daily on day 1, transition to solid diet on day 2 after flatus and day 2; discharge criteria were oral antibiotics and patients oxycodone, acetaminophen, diazepam with bowel regimen (prevention of returned for catheter discharge home after removal a day after.

bowel movement on day 4-5. The accelerated pathway was defined as a highly narcotics side effects).

Rapid recovery pathway included

standardised pathway including patient preoperative gabapentin and acetaminophen; intraoperative IV postoperative surveillance on the surgical floor, transition to oral pain medications from PCA methadone and acetaminophen;

pump from postoperative day 1, postoperative hydromorphine PCA

Foley removed on postoperative day 1,

and diazepam, IV

acetaminophen, drains removed on postoperative day 1-2,

gabapentin and ketorolac on day 1 ; ambulation and full mobilisation with physiotherapy on from diet on day 1;

day 1 twice a day, transistion to solid diet accelerated physiotherapy on day Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

pain management intraoperative non- nurses to evaluate readiness to leave the steroidal anti- inflammatory drugs, early and orthopedic hospital oral intake and surgery to facilitate early ambulation ambulation and standardised pain management Copyright© Kumba C, et al.

on postoperative day 1 and discharge home on

0, 3 times a day bed to chair and walking on day 1; discharge home criteria included drain postoperative day 2-3 removal, same medication as in the conventional pathway Early morbidity [urine/wound swab culture) and/or documentations of urethral catheter dislodgement, wound bleeding, or wound Pain scores, LOS, gaping in the early postoperative period], Length of hospital stay, unplanned hospital stay, long-term complications Lenth of hospital stay, LOS and postoperative remaining postoperative pathway Outcomes complications (removal of PCA and urinary catheter) (=meatal stenosis, neo- urethra dehiscence, urethral fistula, urethral stricture or diverticulum) Early morbidity 28 [3 urinary tract infections, Number of patients with postoperative

2 catheter dislodgements, 24

9 (4 conservative wound, 1 operative wound, 3 revisons, 1

morbidity wound related (infection, bleeding, gaping)] /Long-term

NA (non applicable)

(organ dysfunction or medical) infection) Control group complications 61 [=Overall operative failure]

Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

LOS, complications, total

LOS, complications,

number of antibiotics dosages, postoperative opioid analgesia usage, postoperative anti-emetic requirement and direct in- LOS, costs of care, readmissions and postoperative pain management complications hospital costs

5 (inpatient readmission,

6 ( 1 re-presentation with

25 (return to nausea and vomiting, 1

observation readmission, post discharge emergency, the OR, postoperative re-admission for abdominal pain, 2 wound medical problems, site infections, 1 re- admission for intra- abdominal collection treated with IV antibiotics, abdominal abscess, reoperation, interventional radiology drainage, subcutaneous abscess, wound complications)

1 clostridium difficile ) clostridium difficile Copyright© Kumba C, et al.

colitis, postoperative CT imaging)

9 (inpatient readmission,

  • Early morbidity 7 [0 urinary tract infections,
  • Number of patients with postoperative
  • 4 catheter dislodgements, 3 wound morbidity
  • 8 (6 conservative wound, 1 operative related (infection, bleeding, gaping)]
  • (organ dysfunction or wound, 1 medical)
  • /Long-term complications 22
  • [=Overall operative infection)
  • Experimental group failure]
  • CT imaging)
  • Length of hospital stay in days median
  • IQR or mean
  • 10 [8-12]
  • 4.2 [4.04-4.92]
  • 5.0±0.8
  • 5.0±1.26
  • 27.7 [19.6] hours
  • 40.1±27.5 hours
  • ± SD Control group
  • Length of hospital stay in days median
  • IQR or mean
  • 2 [2-2]
  • 2.17 [2.11-2.23]
  • 3.5±0.8
  • 3.7±0.93
  • 19.6 [6.3] hours
  • 23.5 ± 20.8
  • ± SD
  • Experimental group
  • Risk of Bias
  • High
  • High
  • High
  • High
  • High
  • High

Table 2: characteristics of the included studies

Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

Copyright© Kumba C, et al.

Figure 2: Forest plot of enhanced recovery after surgery compared to standard care, for number of patients with postoperative complications.
Click to enlarge
Figure 2: Forest plot of enhanced recovery after surgery compared to standard care, for number of patients with postoperative complications.
Figure 3: Funnel plot of comparison enhanced recovery after surgery compared to standard care, for outcome number of patients with postoperative complications.
Click to enlarge
Figure 3: Funnel plot of comparison enhanced recovery after surgery compared to standard care, for outcome number of patients with postoperative complications.

Postoperative Morbidity Defined as Organ Dysfunction or Infections

Five studies with 1482 patients analysed this outcome (Figures 2 & 3) [13, 14, 16, 17, 18]. Organ dysfunction or infections (see table 1 for details) were lower in the enhanced rapid recovery group, odds ratio (OR), 0.49 [0.26, 0.91], p=0.02. Heterogeneity was low, the risk of bias was high in all the studies (Figure 2). Publication bias was present see figure 3. The level of evidence (GRADE) was low (bias) to moderate (low heterogeneity and great number of patients) Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

Length of Hospital Stay, LOS

Four studies were included in this analysis with 1168 children (Figure 4) [15, 16, 17, 18]. LOS was lower in the enhanced recovery group, p=0.0002. Heterogeneity was high and all studies had bias. Publication bias was also present (Figure 5). The level of evidence (GRADE) was low.

Figure 4: Forest plot of enhanced recovery after surgery compared to standard care for outcome length of hospital stay LOS.
Click to enlarge
Figure 4: Forest plot of enhanced recovery after surgery compared to standard care for outcome length of hospital stay LOS.
Figure 5: Funnel plot of enhanced recovery after surgery compared to standard care for outcome length of hospital stay LOS.
Click to enlarge
Figure 5: Funnel plot of enhanced recovery after surgery compared to standard care for outcome length of hospital stay LOS.

Discussion

This meta-analysis showed that in hypospadias, idiopathic scoliosis and appendicectomy surgery, the number of patients with postoperative complications in terms of infections, reoperations and bleeding and length of hospital stay were reduced when enhanced recovery pathways were applied. In adult surgery these protocols begun to develop since 20 years and have proven improved postoperative morbidity and length of hospital stay in certain surgical populations [8, 9]. In children rapid recovery protocols after surgery are just beginning to develop [8, 9]. This systematic review and meta-analysis of retrospective trials has brought some evidence that Kumba C, et al. Rapid Recovery Pathways after Surgery in Children: A Systematic Review and Meta-Analysis. Med J Clin Trials Case Stud 2019, 3(2): 000211.

these protocols reduce LOS and complications. It has been shown previously that LOS was a predictive factor of postoperative complications in surgery like scoliosis [19]. Effort must be done to continue to develop this clinical practice to improve patient outcome in children. Future prospective randomised controlled trials will definitely confirm this evidence in the pediatric population. Limits: Only retrospective studies were included. The strength of this study was the great number of patients included.

Conclusion

This study demonstrated that when enhanced recovery protocols were applied in hypospadias, idiopathic scoliosis and appendicitis surgery the number of patients with postoperative complications and length of hospital stay were reduced.

References

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@article{kumba2019,
  title   = {Rapid Recovery Pathways after Surgery in Children: A
Systematic Review and Meta-Analysis},
  author  = {Kumba C, Blanc T, De Cock A, Willems A, Harte C, Querciagrossa S, Orliaguet G and Melot C},
  journal = {Medical Journal of Clinical Trials & Case Studies},
  year    = {2019},
  volume  = {3},
  number  = {2},
  doi     = {10.23880/mjccs-16000211}
}
Kumba C, Blanc T, De Cock A, Willems A, Harte C, Querciagrossa S, Orliaguet G and Melot C (2019). Rapid Recovery Pathways after Surgery in Children: A
Systematic Review and Meta-Analysis. Medical Journal of Clinical Trials & Case Studies, 3(2). https://doi.org/10.23880/mjccs-16000211
TY  - JOUR
TI  - Rapid Recovery Pathways after Surgery in Children: A
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AU  - Kumba C, Blanc T, De Cock A, Willems A, Harte C, Querciagrossa S, Orliaguet G and Melot C
JO  - Medical Journal of Clinical Trials & Case Studies
PY  - 2019
VL  - 3
IS  - 2
DO  - 10.23880/mjccs-16000211
ER  -