Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Abstract

Background: Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage, and length of stay. In 2013, we made several changes to our perioperative approach to children undergoing complex craniofacial procedures. The goal of this study was to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis. Methods: A retrospective chart review was performed after IRB approval, for children who underwent fronto-orbital advancement for craniosynostosis from 2010 to 2018. The ERAS protocol, initiated in December 2013, involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific postoperative fluid titration, and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen, or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain. Results: Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, P < 0.0001) and volume of intraoperative transfusion (183.4 mL versus 339.8 mL, P = 0.05). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 P < 0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, P = 0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 versus 5.3, P = 0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, P < 0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic, or pulmonary concerns. Conclusions: Our ERAS protocol demonstrated a reduction in the overall and intraoperative allogenic blood transfusion rate, narcotic use, and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.

Geographic Financial Analysis of Craniosynostosis Surgery in the United States

“…Patients undergoing surgery at high-volume institutions were billed significantly less than other hospitals (P < 0.001), which may reflect increased efficiencies through economies of scale at highvolume centers and streamlined postoperative care pathways. As in other areas of surgery, high-volume centers may have intraoperative protocols and enhanced recovery after surgery protocols, [20][21][22][23] which might help decrease lengths of stay as demonstrated by single-institution experience. 13 This study reinforces this concept demonstrating that high-volume hospitals had significantly shorter lengths of ICU admission after surgery for craniosynostosis (P = 0.005).…”

The management of perioperative pain in craniosynostosis repair: a systematic literature review of the current practices and guidelines for the future

“…This study aimed to review and compare literature on perioperative pain management to provide the best evidence-based options for all children undergoing craniosynostosis repair. The proposal was registered to the International Prospective Register of Systematic Reviews (PROSPERO) guidelines (ID number: CRD42022339835) [ 21 ].…”

Enhanced Recovery after Surgery (ERAS) protocols in craniomaxillofacial surgery: an evidence-based review

“…In preparation for surgery, 20 mL/kg of packed red blood cells are prepared and divided into smaller aliquots (10 mL/kg per aliquot) to avoid over transfusion. This protocol illustrated a decreased rate and volume of intraoperative transfusion compared to controls, a lower required dose of postoperative morphine, and shorter overall hospital stay compared with controls [8 ]. Despite known reports of increased vascular thrombosis, risk of cancer progression, and cardiovascular complications with EPO use in the adult population, these adverse events have not been observed in pediatric patients [9].…”