The Impact of Nasal Intubation on Feeding Outcomes in Neonates Requiring Cardiac Surgery: A Randomized Control Trial.

Neonates who require surgery for congenital heart disease (CHD) frequently have difficulty with oral feeds post-operatively and may require a feeding tube at hospital discharge. The purpose of this study was to determine the effect of oral or nasal intubation route on feeding method at hospital discharge. This was a non-blinded randomized control trial of 62 neonates who underwent surgery for CHD between 2018 and 2021. Infants in the nasal (25 patients) and oral (37 patients) groups were similar in terms of pre-operative risk factors for feeding difficulties including completed weeks of gestational age at birth (39 vs 38 weeks), birthweight (3530 vs 3100 g), pre-operative PO intake (92% vs 81%), and rate of pre-operative intubation (22% vs 28%). Surgical risk factors were also similar including Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (3.9 vs 4.1), shunt placement (32% vs 41%), cardiopulmonary bypass time (181 vs 177 min), and cross-clamp time (111 vs 105 min). 96% of nasally intubated patients took full oral feeds by discharge as compared with 78% of orally intubated infants (p = 0.05). Nasally intubated infants reach full oral feeds an average of 3 days earlier than their orally intubated peers. In this cohort of patients, nasally intubated infants reach oral feeds more quickly and are less likely to require supplemental tube feeding in comparison to orally intubated peers. Intubation route is a potential modifiable risk factor for oral aversion and appears safe in neonates. The study was approved by the University of Virginia Institutional Review Board for Health Sciences Research and was retrospectively registered on clinicaltrials.gov (NCT05378685) on May 18, 2022.

The Use of Sequential Surveys to Shorten Implementation Time for Healthcare System-Level Enhanced Recovery After Surgery (ERAS) Pathways.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways improve healthcare quality, safety, and cost-effectiveness. We hypothesized that the RAND Method (a hybrid Delphi approach), involving anonymous sequential surveys and face-to-face meetings, would allow for more rapid agreement and initiation of new ERAS pathways. METHODS: Using the ERAS Society guidelines for cesarean section as a baseline, our institution's ERAS Leadership Team (ELT) compiled published literature and institutional practices to design a 32-component survey that was sent to obstetricians, nurse midwives, anesthesiologists, pharmacists, and nurses. Components that did not reach 90% consensus were included in a second survey the following week, and meetings were held to review results. At the conclusion of this process, time to agreement was retrospectively compared to the colorectal ERAS pathway process at this institution. RESULTS: ERAS pathway components were compiled and reviewed by 121 stakeholders at 7 hospitals using iterative surveys with review meetings over a 13-week period. Survey response rates were 61% and 50% in the initial and follow-up surveys, respectively. There was agreement on 28/32 and 32/32 items on the initial and follow-up surveys. Using the RAND Method, time to agreement decreased by 54.1% (24 vs 13 weeks) compared to prior system-wide efforts to standardize the colorectal surgery ERAS pathway. DISCUSSION: With rapidly expanding healthcare systems, effective methods to gain consensus and adopt ERAS pathways are critical to implementation of ERAS guidelines. We demonstrate that the RAND Method allows for a transparent and efficient means of agreement across a diverse group of clinicians practicing in several settings.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization.

BACKGROUND: Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care. METHODS: Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes. RESULTS: Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P = 0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant. CONCLUSIONS: At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review.

BACKGROUND: Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. METHODS: This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. RESULTS: A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6). CONCLUSION: Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

An enhanced recovery after surgery pathway in pediatric colorectal surgery improves patient outcomes.

INTRODUCTION: Enhanced recovery after surgery (ERAS) pathways in adult colorectal surgery are known to reduce complications, readmissions, and length of stay (LOS). However, there is a paucity of ERAS data for pediatric colorectal surgery. METHODS: A 2014-2018 single-institution, retrospective cohort study was performed on pediatric colorectal surgery patients (2-18 years) pre- and post-ERAS pathway implementation. Bivariate analysis and linear regression were used to determine if ERAS pathway implementation reduced total morphine milligram equivalents per kilogram (MME/kg), LOS, and time to oral intake. RESULTS: 98 (70.5%) and 41 (29.5%) patients were managed with ERAS and non-ERAS pathways, respectively. There was no statistical difference in age, sex, diagnosis, or use of laparoscopic technique between cohorts. The ERAS cohort experienced a significant reduction in total MME/kg, Foley duration, time to oral intake, and LOS with no increase in complications. The presence of an ERAS pathway reduced the total MME/kg (-0.071, 95% CI -0.10, -0.043) when controlling for covariates. CONCLUSION: The use of an ERAS pathway reduces opioid utilization, which is associated with a reduction in LOS and expedites the initiation of oral intake, in colorectal pediatric surgery patients. Pediatric ERAS pathways should be incorporated into the care of pediatric patients undergoing colorectal surgery. LEVEL OF EVIDENCE: Level III evidence. TYPE OF STUDY: Retrospective cohort study.

Implementation of a pediatric enhanced recovery pathway decreases opioid utilization and shortens time to full feeding.

BACKGROUND: We hypothesized that an enhanced recovery after surgery (ERAS) pathway for pediatric patients undergoing surgery for inflammatory bowel disease (IBD) would be beneficial. METHODS: This is a single institution retrospective comparative study comparing patients treated with an ERAS pathway to consecutive patients in a Preimplementation Cohort (PIC) with similar open and laparoscopic surgeries for IBD. The pathway emphasized minimal preoperative fasting, multimodal and regional analgesia, and early enteral nutrition after surgery. Primary endpoints were time to 120 mL of PO intake (POI), length of stay (LOS), opioid utilization, and 30-day surgical outcomes. Continuous and categorical variables were compared (p < 0.05). RESULTS: There were 23 PIC and 28 ERAS patients with similar demographic data and surgical and anesthetic approaches. ERAS patients experienced a significant increase in the use of regional anesthesia, faster time to POI, and a nonsignificant decrease in mean LOS. ERAS patients had decreased total and daily opioid use with similar complication rates. CONCLUSION: This study demonstrates the effectiveness of a pediatric ERAS pathway for IBD patients requiring laparoscopic and (unique to this study) open surgery. The study demonstrates that opioid utilization and time to feeding can be positively impacted using ERAS pathways without negatively impacting outcomes. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Substantial postoperative pain is common among children undergoing laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common surgical procedures performed in children. However, to our knowledge, the postoperative pain experience of children undergoing laparoscopic appendectomy has never been described. In this study, we assessed the postoperative pain experience of children undergoing laparoscopic appendectomy. METHODS: A retrospective chart review of children aged 9-17 years undergoing laparoscopic appendectomy at a large academic medical center from 2004 to 2010 was performed. Demographic and clinical characteristics and self-reported pain scores (0-10 numeric rating scale) during hospitalization were abstracted from the medical record. Pain scores ≥4 were classified as moderate or severe. If ≥60% of pain ratings were moderate or severe during a specified time period (e.g., particular postoperative day), then the child was defined as experiencing substantial pain during that time. Pain outcomes were summarized using descriptive statistics. Secondary analyses assessed the predictors of substantial postoperative pain. RESULTS: Hundred and eighty-six children underwent laparoscopic appendectomy during the study period. One in three children experienced substantial postoperative pain on the day of surgery, and one in five children continued to have substantial pain the next day. Commonly available clinical and demographic characteristics were poor predictors of substantial postoperative pain. CONCLUSION: These preliminary data suggest that substantial postoperative pain is common in children undergoing laparoscopic appendectomy. More studies of postoperative pain outcomes among children undergoing laparoscopic appendectomy and other common pediatric surgical procedures are needed.