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Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study
  1. John C Edney1,
  2. Humphrey Lam1,
  3. Mehul V Raval2,
  4. Kurt F Heiss2 and
  5. Thomas M Austin1
  1. 1 Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
  2. 2 Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
  1. Correspondence to John C Edney, Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA 30032, USA; john.edney{at}emory.edu

Abstract

Background and objectives Enhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.

Methods Patients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.

Results After matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (−1.19, 0) points, 95% CI −0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference −0.3±1.9 points, 95% CI −0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference −0.15 [−0.21, –0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference −1.5 [−4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).

Conclusions Implementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.

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Footnotes

  • Contributors JCE helped create the enhanced recovery protocol, edit the manuscript, implement the study, and collect the data. HL helped edit the manuscript and collect the data. MVR helped edit the manuscript. KFH helped create the enhanced recovery protocol and helped edit the manuscript. TMA helped edit the manuscript, implement the study, and analyzed the data.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required

  • Ethics approval This study was approved by the Children's Healthcare of Atlanta Institutional Review Board (#17–191), and as this is a retrospective chart review written informed consent was waived by the Institutional Review Board.

  • Provenance and peer review Not commissioned; Externally peer reviewed.

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