The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy

Abstract

Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children’s Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.

Special Issue: Advances in Healthcare for Neonates

“…Neonates with special conditions and genetic syndromes require a higher level of care and treatment strategies, and standardized tools to enhance their recovery. Vogt et al propose an enhanced recovery protocol for patients undergoing the Kasai procedure for biliary atresia [ 9 ]. The checklist includes, among other elements, parental education, preoperative dextrose-containing fluids, maintaining normothermia, adequate analgesia, and initiation of early feeds [ 9 ].…”

“…Vogt et al propose an enhanced recovery protocol for patients undergoing the Kasai procedure for biliary atresia [ 9 ]. The checklist includes, among other elements, parental education, preoperative dextrose-containing fluids, maintaining normothermia, adequate analgesia, and initiation of early feeds [ 9 ]. The checklists almost always provide a framework for clinicians to optimize outcomes in complex patients such as those requiring the Kasai procedure.…”

“…Vogt et al propose an enhanced recovery protocol for patients undergoing the Kasai procedure for biliary atresia [9]. The checklist includes, among other elements, parental education, preoperative dextrose-containing fluids, maintaining normothermia, adequate analgesia, and initiation of early feeds [9].…”