October 25, 2016

A new anesthesia pathway for pediatric patients at the Johns Hopkins Children’s Center is designed to decrease infection rates and length of stays and improve pain scores and patient satisfaction.

Kendra Penn, a 20-year-old junior at Ohio State University, was anxious about her upcoming surgery to remove part of her intestines due to Crohn’s disease. She had two options—an open surgery with general anesthesia or a minimally invasive laparoscopic procedure with regional anesthesia. While she was relieved that she could avoid an open operation and the post-operative nausea that often comes with it, she still had concerns about a regional nerve block.

“I was really freaked out and called my mom and asked her to please not let them accidently paralyze me,” says Penn. “Then, Dr. George called me.”

“Dr. George” is pediatric anesthesiologist Jessica George, who under a new pathway for pediatric patients called Penn at home prior to admission to discuss her anesthesia plan. Rather than injecting a block into her spine, George explained to Penn that she would be asleep and then administered a transabdominal plane block, numbing the nerves that innervate the abdominal wall. Penn was reassured.

“It was sweet of her to reach out to me,” says Penn. “She walked me through the two options and the plan we decided on. Then, when I got to the hospital, people from anesthesia came to see me and walked me through it again, which was nice.”

This pre-surgery anesthesia consultation is one piece of the new pathway called enhanced recovery after surgery, or ERAS, which is designed to improve surgical outcomes and the patient experience before, during and after surgery. Along with George, the pathway’s director, ERAS comprises a multidisciplinary team of surgeons, anesthesiologists and nurses working collaboratively to implement evidenced-based interventions for pediatric patients that have been shown to accelerate recovery in adult patients. At The Johns Hopkins Hospital, for example, the average length of stay for adult colorectal surgery patients on the ERAS pathway decreased by 50 to 60 percent. George and her colleagues are aiming to achieve similar results for pediatric patients.

“Enhanced recovery protocols have been successful on the adult side but have not really been implemented in pediatrics,” says George. “This is an area in which the Johns Hopkins Children’s Center is trying to gain some traction.”

In the pathway, modalities like regional anesthesia and propofol infusion are encouraged to avoid anesthetic gases, reducing postoperative nausea and vomiting. Nonopioid and other nonnarcotic painkillers are utilized. Print and electronic educational materials to prepare patients for surgery and anesthesia are also provided. Postoperatively, nurses encourage patients to drink the proper amount of fluids, get out of bed more quickly, get moving and eat. In all aspects of the pathway, says George, standardization is key: “The goal overall of ERAS is to minimize variations in standards of care, with an emphasis on their preoperative evaluation and patient education.”

Although the pathway was just recently launched and limited to a few procedures, including colorectal surgery and adolescent idiopathic posterior spinal fusion surgery, George and her colleagues are already seeing some positive results. For example, through standardization of patient care and eliminating the use of drains, tubes and catheters in some patients under the pathway, infection rates are down. In 2015, the infection rate for pediatric patients after colorectal surgery was 14 percent. “So far under the protocol,” says George, “the infection rate is zero.”