ABSTRACT
Importance: Neonates requiring surgery are often cared for in neonatal intensive care units (NICUs). Despite a breadth of surgical pathology, neonates share many perioperative priorities that allow for the development of unit-wide evidence-based Enhanced Recovery After Surgery (ERAS) recommendations. Observations: The guideline development committee included pediatric surgeons, anesthesiologists, neonatal nurses, and neonatologists in addition to ERAS content and methodology experts. The patient population was defined as neonates (first 28 days of life) undergoing a major noncardiac surgical intervention while admitted to a NICU. After the first round of a modified Delphi technique, 42 topics for potential inclusion were developed. There was consensus to develop a search strategy and working group for 21 topic areas. A total of 5763 abstracts were screened, of which 98 full-text articles, ranging from low to high quality, were included. A total of 16 recommendations in 11 topic areas were developed with a separate working group commissioned for analgesia-related recommendations. Topics included team communication, preoperative fasting, temperature regulation, antibiotic prophylaxis, surgical site skin preparation, perioperative ventilation, fluid management, perioperative glucose control, transfusion thresholds, enteral feeds, and parental care encouragement. Although clinically relevant, there were insufficient data to develop recommendations concerning the use of nasogastric tubes, Foley catheters, and central lines. Conclusions and Relevance: Despite varied pathology, neonatal perioperative care within NICUs allows for unit-based ERAS recommendations independent of the planned surgical procedure. The 16 recommendations within this ERAS guideline are intended to be implemented within NICUs to benefit all surgical neonates.
ABSTRACT
Whose preferences influence the design of international institutions? Scholarship on the legalization of international politics and creation of international legal institutions largely adopts a state-centric perspective. Existing accounts, however, fail to recognize how states often delegate authority over institutional design tasks to independent legal experts whose preferences may diverge from those of states. We develop a principal-agent (PA) framework for theorizing relations between states (collective principals) and legal actors (agents) in the design process, and for explaining how legal actors influence the design of international institutions. The legal dimensions of the PA relationship increase the likelihood of preference divergence between the collective principal and the agent, but also create conditions that enable the agent to opportunistically advance its own design preferences. We argue that the more information on states' preferences the agent has, the more effectively it can exploit its legal expertise to strategically select and justify design choices that maximize its own preferences and the likelihood of states' acceptance. Our analysis of two cases of delegated institutional design concerning international criminal law at the United Nations and the African Union supports our theoretical expectations. Extensive archival and interview data elucidate how agents' variable information on states' preferences affects their ability to effectively advance their design preferences. Our theory reveals how independent legal experts with delegated authority over design tasks influence institutional design processes and outcomes, which has practical and normative implications for the legalization of international politics.