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Mini Review Volume 11 Issue 2
Protocol for rapid recovery pathways after surgery in children: a systematic review and meta-analysis
Kumba C,1 
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Blanc T,2 De Cock A,1 Willems A,3 Harte C,1 Querciagrossa S,1 Orliaguet G,4 Melot C5
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1Necker Enfants Malades University Hospital, Department of Pediatric Anesthesia and Critical Care, France
2Necker Enfants Malades University Hospital, Department of Pediatric Digestive and Urologic Surgery, France
3Leids Universitair Medisch Centrum, Pediatric Intensive Care Unit, Leids, The Netherlands
4Department of Pediatric and Obstetrical Anesthesia and Critical Care, Department of Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Necker University Hospital, Paris Descartes (Paris V) University, France
5Emergency Department, Erasme University Hospital, Brussels, Belgium
Correspondence: Kumba C, Necker Enfants Malades University Hospital, Department of Pediatric Anesthesia and Critical Care, 149 Rue De Sèvres, 75015, France, Tel 0033144494000
Received: February 18, 2019 | Published: March 11, 2019
Citation: Kumba C, Blanc T, Cock DA, et al. Protocol for rapid recovery pathways after surgery in children: a systematic review and meta-analysis. J of Anes & Cri Open Access. 2019;11(2):42?44. DOI: 10.15406/jaccoa.2019.11.00409
Abstract
Background: 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 is undertaken to analyse whether enhanced recovery after surgery improves postoperative outcome in children.
Methods: systematic review and meta-analysis of randomized and randomized trials starting in April 2019 until July 2019. Statistic analysis will be realised with RevMan 5.3 software. Results are expected by July 2019.
Conclusion: This protocol was realised to describe the systematic review and meta-analysis which will be undertaken to clarify the impact on postoperative outcome of rapid recovery pathways after surgery in children.
Keywords: Enhanced recovery after surgery, rapid recovery pathways, children, outcome
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 preoperatively, anticipating the nutritional patient status, 2 reducing preoperative fasting times. 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 ; 5 includes protective invasive or noninvasive lung ventilation if necessary; 6 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; and postoperatively ERAS includes rapid oral intake, preferring enteral alimentation, prevention of postoperative nausea and vomitting rapid mobilisation, physiotherapy, optimal analgesia using non opioid medication if possible, avoiding naso-gastric tubes, urinary bladder catheters or tubes if not necessary, early intravenous access withdrawal if not necessary. 7−10 This study is undertaken to analyse whether ERAS improves postoperative outcome in children.
Description of the condition
Surgical pediatric patients in whom rapid recovery pathways after surgery are applied compared to interventions where these protocols are not applied.
Description of the intervention
Surgical interventions where ERAS protocols as described in the background are applied and interventions where these protocols are not applied.
How the intervention might work
By optimizing preoperative, intraoperative and postoperative patient management, postoperative morbidity or complications are improved and thus length of hospital stay (LOS) can also be improved.
Objective
To demonstrate whether ERAS improves postoperative outcome in pediatric surgical patients.
Methods
To demonstrate whether ERAS improves postoperative outcome in pediatric surgical patients.
This study was registered under the number CRD42018103518 in PROSPERO, the international registration database for systematic reviews and meta-analysis. Since this is a systematic review and meta-analysis ethical approval from the local ethic committee was not necessary. Types of studies included will be randomized and non randomized.
Types of participants
Children aged 0-18 years (inclusion criteria) will be included and patients above 18 years will be excluded (exclusion criteria).
Types of interventions
Surgical pediatric patients in whom rapid recovery pathways after surgery are applied compared to interventions where these protocols are not applied.
Primary outcomes
Morbidity defined as postoperative complications.
Secondary outcomes
Length of postoperative (LOS).
Primary outcome measures
Number of patients with postoperative complications defined as organ failure or dysfunction and infections.
Secondary outcome measures
Number of days spent in hospital after surgery.
Search methods for identification of studies
One or more reviewers will search electronically for titles and abstracts including keywords defined here above. Once these are searched, abstracts with relevant content will be retained and complete articles searched and screened for further inclusion or exclusion.
Electronic searches
Electronic search will be done using MEDLINE, EMBASE, CENTRAL, GOOGLE SCHOLAR, CLINICALTRIALS.GOV, ABSTRACT CONFERENCE and DARE.
Searching other resources
Other sources will be searched like grey literature. Data collection and analysis : comparisons, outcomes and subgroups will be collected and analysed. Data collection and analysis will be done using RevMan 5.3 software.
Data extraction and management
Data selection and extraction will be realised by one or more researchers. A flow chart will illustrate the selection process as recommended by the PRISMA statement. Assessment of risk of bias in the included studies will be realised using the tools proposed by the Cochrane Handbook for Systematic reviews of Interventions.
Measures of treatment effect
- Will be dichotomous (how many patients complicated) and will be presented as relative risk or odds ratio with 95%CI. Forest plots will be used to provide visual summary of data included.
- Will be continuous for LOS with measurement of weighted mean and weighted mean difference.
Unit of analysis issues
- Morbidity in the postoperative period until discharge from hospital.
- LOS in the postoperative period.
Dealing with missing data
Missing data will not be included
Assessment of heterogeneity Forest plot will be used and I² statistics will be used to assess for heterogeneity.Assessment of reporting biases
Funnel plots will be used to assess for bias
Data synthesis
Data will be synthesized using RevMan 5.3 software.
Subgroup analysis and investigation of heterogeneity
See above.
Sensitivity analysis
Sensitivity analysis will be done by restricting the analysis to a defined intervention and or to a subgroup of patients.
Results
The study will begin 1/04/2019 and results are expected 31/07/2019.
Conclusion
This protocol was realised to describe the systematic review and meta-analysis which will be undertaken to clarify the impact on postoperative outcome of rapid recovery pathways after surgery in children.
Acknowledgments
Special thanks and acknowledgments to all the persons who will contribute in the accomplishement of this work.
Contributions of authors
Authors will contribute either by searching or selecting the articles or by reviewing the work.
Funding
None.
Conflicts of interest
Authors declare that there is no conflict of interest.
References
- Pearse R, Dawson D, Fawcett J, et al. Early goal directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care. 2005;9(6):R687−R693.
- Ross F, Latham G, Joffe D, et al. Preoperative malnutrition is associated with increased mortality and adverse outcomes after paediatric cardiac surgery. Cardiol Young. 2017;27(9):1716–1725.
- Thomas M, Morrisson C, Newton R, et al. Consensus statement on clear fluids fasting for elective pediatirc general anesthesia. Pediatr Anesth. 2018;28(5):411−414.
- Mesbah A, Thomas M. Preoperative fastening in children. BJA Education. 2017;17(10):346–350.
- Miller T, Roche A, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015;62:158–168.
- Thiele R, Raghunathan K, Brudney C, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med. 2016;5:24.
- Muhly W, Sankar W, Ryan K, et al. Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis. Pediatrics. 2016;137(4):e20151568.
- Rove K, Edney J, Brockel M. Enhanced Recovery after surgery in children : promising evidence-based multidisciplinary care. Pediatr Anesth. 2018;28(6):482−492.
- George J, Koka R, Gan T, et al. Review of the enhanced recovery pathway for children: perioperative anesthetic considerations. Can J Anesth. 2018;65(5):569–577.
- Leeds I, Boss E, George J, et al. Preparing Enhanced Recovery After Surgery for implementation in pediatric populations. J Pediatr Surg. 2016;51(12):2126–2129.
©2019 Kumba, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.