ERAS is a multimodal, integrated perioperative pathway aiming to promote patient recovery by reducing stress and the incidence of postoperative complications; this is achieved through evidence-based interventions during the perioperative period . Various evidence-based optimization measures have achieved good results in the field of adult surgery ; however, their implementation among pediatric patients, especially in the field of neonatal surgery, is still in the exploratory stage .
The expert consensus proposed in the American Journal of Pediatric Surgery (2018) suggests 22 ERAS optimization measures that can be applied in the treatment of pediatric patients. The key points are as follows: (1) full pre-operative communication as well as seeking the patient’s understanding and cooperation; (2) no dwelling of the gastric tube and bowel preparation as usual; (3) no need for pre-operative fasting; (4) recommendation of minimally invasive surgery and controlled infusions; (5) conduction of reasonable anesthesia and postoperative analgesia; (6) intraoperative warming; and (7) encouraging of patients to ambulate early and eat early after surgery etc. .
Despite the lack of effective evidence-based medical support for these measures, certain data from relevant studies show the efficacy of ERAS in the perioperative management of congenital gastrointestinal anomalies, including jejunal atresia, congenital duodenal obstruction , neonatal intestinal malrotation, and congenital heart disease [8,9,10].
Due to the specificity of the age and disease spectrum in newborns diagnosed with CUGIO included in the present study, the following measures were selectively adopted in the implementation of the ERAS model.
(1) Preoperative publicity and education: compared with ERAS education for adults, ERAS education for newborns was primarily about gaining the understanding and cooperation of the parents. It has been shown that the cooperation and involvement of parents in the implementation of ERAS in children is important for speeding up the postoperative recovery of the pediatric patient [11, 12].
In the present study, an ERAS management team comprising three physicians and three NICU charge nurses (all nurses had at least three years of NICU experience) was established by the project team. Before the operation, members of the management team communicated fully with the parents of the patient in the ERAS group. They were informed about the implementation process and goals of the ERAS management model; they were also provided with training on basic non-medical care measures for newborns as well as knowledge of infection control (e.g., holding the child, changing diapers, feeding, patting the child’s back, monitoring vital signs, and adhering to standard hand hygiene).
The involvement of parents in the ERAS management model increased trust and satisfaction with health care providers compared with conventional preoperative health education.
(2) Intraoperative temperature management: In the ERAS group, various insulation measures (e.g., pre-warming, increasing the temperature in the operating room, and using a thermoregulator and a heated bed) were conducted, along with warming the intraoperative fluid infusion (36–37 °C) to ensure that the intraoperative core temperature of the pediatric patient was > 36 °C.
These measures helped ensure the function of vital organs and the stability of the internal environment; it also directly affected the surgical process and anesthesia resuscitation.
(3) Postoperative pain management: Ultrasound-guided nerve block anesthesia was conducted in both groups for postoperative analgesia. A soother was given to the patients in the ERAS group for non-nutritive sucking during the procedure; this relieved irritability and made the patients feel secure. Use of a soother can reduce the gastrointestinal distension and energy consumption caused by crying, which is conducive to promoting the recovery of gastrointestinal function and reducing the administration of analgesics.
(4) Early postoperative activity: Early postoperative activity facilitates gastrointestinal motility and neurotransmitter secretion, promoting the recovery of gastrointestinal function. Early postoperative ambulation is encouraged in both adult and pediatric patients; newborns are limited to passive early postoperative mobility.
Due to the requirements of ward management and infection control, NICUs in China are basically a closed management model at present. The conventional perioperative management model directs the pediatric patient to rest in bed, with the NICU nurses completing basic care (e.g., feeding, temperature measurement, and diaper changing).
According to the results of several domestic and international studies on family integrated care , the involvement of parents in pediatric patient care is important for the health and prognosis of pediatric patients in the NICU; it can promote the recovery of postoperative gastrointestinal function, build a harmonious doctor–patient relationship, and increase the ability of parents to care for their children after discharge.
Therefore, the parents of pediatric patients who participated in the ERAS management model were respectively included as one of the project team members. After training and guidance by the project management team members, the parents entered the NICU after the children were withdrawn from the ventilator with stable vital signs and participated in certain non-medical basic care measures (e.g., holding the child, changing diapers, feeding, and patting the child’s back), with a duration of 3–4 h each time until the pediatric patients were discharged.
The results of the present study revealed that the time to the first postoperative bowel movement, time to the first postoperative feeding, length of hospital stay, and days of parenteral nutrition were all shorter in the ERAS group than in the control group. Therefore, it was suggested that the involvement of parents had a positive effect on the postoperative recovery of pediatric patients with CUGIO.
There were some limitations in the present study. Due to the small sample size included in this study and the fact that only some of the measures in ERAS were implemented in the research process, there is still a lot of work to be done to safely and effectively apply the measures in the ERAS management model to the field of newborns, and more research data is needed to provide evidence-based medical support.