Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

Table 1 Modified enhanced recovery after surgery pathway in pediatric surgical patients[13]

Preoperative	Intraoperative	Postoperative
Counsel about ERAS, obtained from caregiver	Regional anesthesia with catheter-based block	Prevention of nausea and vomiting
Clear-liquid carbohydrate load (10 mL/kg up to 350 mL)	Avoiding excess drains, intraperitoneal or subcutaneous	Early feeding, clear fluids in post-operative day zero, regular diet on post-operative day one
Avoid prolonged fasting, eat regular diet, clears-only diet is given in the day prior to surgery	Ensure euvolaemia, parenteral fluids are crystalloid administered 4–7 mL/kg/h	Early mobilization, out-of-bed in the post-operative day one
No bowel preparation	Normothermia (36 °C–38 °C during the surgical procedure. (skin-to-skin time/ endoscopy/ laparoscopy)	Adjunctive pain medication (acetaminophen and non-steroidal anti-inflammatory drugs)
Antibiotic prophylaxis	Minimizing opioids (< 0.15 mg/kg intravenous morphine equivalents)	Early stoppage of intravenous fluids (either discontinue or lower rate to keep vein open. Post-operative day two)
Prophylaxis against deep vein thrombosis (age ≥ 14, or presence of risk factors)	Minimally invasive surgical procedures	Early removal of extra drains/catheters. Non-urinary drain is removal by post-operative day four

ERAS: Enhanced recovery after surgery.

Table 2 Anesthetic task in enhanced recovery after surgery

Preoperative	Intraoperative	Postoperative
Preoperative counseling & patient evaluation with requires investigators including laboratory work	Shot acting anesthetics and analgesics. Multimodal opioid sparing and pain management plan should be used and implemented before the induction of anesthesia. Narcotic alternatives that decreases opioid needs are: acetaminophen, non-steroidal anti-inflammatory drugs, 2-agonists as clonidine and gabapentin, and IV Xylocaine infusion	Shifting of the patient to the surgical ICU. On arrival of the patient in the ICU, all laboratory tests should be done: Chest X-ray, arterial blood gases, checking hemodynamic stability, verification of the lines, body temperature, making sure that the patient is warm enough and pain-free, as well as baseline monitoring
Patient education and information in collaboration with the surgeon, and nursing staff	Restricted sodium and fluid infusion. Goal directed fluid therapy. Prevent hyponatremia, and optimization of intravascular volume avoiding hypo or hypervolemia. The use of electrical cardiometry device could be a guide to goal-directed fluid therapy, noninvasive determination of stroke volume and cardiac output	No nasogastric tube
Scheduling period of fasting or no fasting	Regional anesthesia (when indicated): (1) Epidural anesthesia (mid-thoracic, lumbar, epidural catheter should be inserted between T5 and T8 roots levels); (2) Lumbar nerve block; (3) regional nerve block; and (4) local anesthesia	Post-operative pain relief is either through an epidural catheter that should be removed 12 h before application of anticoagulant or the use of patient-controlled analgesia
Preoperative carbohydrate drinks are recommended for patients without diabetes. In adults, clear fluid is given 5–6 h before the procedure, and in pediatrics, 2 h	Prevent hypothermia: Body& limbs warming. Maintaining intraoperative normothermia with either passive (surgical draping, sheets, and blanket), or active with electric heating blanket, space heater, or the burr hugger	Encourage early and progressive patient mobilization
Nutritional status should be assessed using a systemic screening tool, and malnourished patients should be optimized with oral Supplements, or parental nutrition	Prevention of PONV. Preemptive multimodal antiemetic prophylaxis should be used in all at-risk patients to reduce PONV. An intervention for patients determined to be high-risk for PONV is the administration of dexamethasone (8 mg) at the induction of anesthesia and ondansetron (Zofran) (4 mg) at emergence from anesthesia. The combination of ondansetron with dexamethasone is superior to single-agent therapy in the prevention of PONV in moderate- to high-risk patients undergoing abdominal surgery	Non-opioid analgesia
Prophylactics for thromboembolic events	Patients at high risk, it is recommended to use low-molecular-weight heparin	Early removing of urinary catheter
Antibiotic prophylactic		Evaluation of outcome

PONV: Post-operative nausea and vomiting; ICU: Intensive care unit.