ERAS protocol has been widely applied in many surgical fields, especially in abdominal surgery. In the past few years, there were reports on its application in orthopedic surgery such as joint replacement, trauma and spine surgery[17,18,19]. However, the literature on pediatric orthopedic surgery was quite rare. Pediatric population is a group that requires special attention and discretion.
Preoperative evaluation of malnutrition and anemia are critical as they are associated with a higher rate of postoperative complications such as delayed wound healing, infection, and prolonged duration of hospital stay[20, 21]. A recent history of common cold, cough, diarrhea should be taken carefully before admission; if one had such symptoms, surgery should be postponed. A preoperative hemoglobin level of less than 12g/dL should be investigated to rule out other pathological causes. If the body weight is 2 standard deviation lighter than the standard weight in peers, more attention should be paid to the patients.
Preoperative counseling and education are crucial components of the ERAS protocol. Patients and patient's legal guardians should be counseled and educated for the expectation adjustment, pain coping mechanism, and the rehabilitation plan preoperatively. A team consisting of surgeons, nurses, physical therapists should discuss the treatment strategy with the legal guardians thoroughly. Although preoperative education reduces the level of anxiety in parents, it does not reduce the duration of hospital stay significantly, lower the VAS score and the incidence of complications[22].
Multi-mode analgesia is advocated to boost the effect of pain alleviation and reduce the incidence and severity of adverse effects. One of the key aspects of ERAS program is to reduce the dose of opiates and even eliminate the application of opiates postoperatively [23]. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the cornerstone for postoperative pain alleviation, but the possible sides effects to the digestive and cardiovascular system should not be overlooked. Dexibuprofen, a non-selective NSAID, has been widely used in pediatric orthopedics to cope with mild to moderate pain, but the long-term effects remain to be investigated. Unlike adults, most children are not able to endure pain. Novel drug such as bupivacaine liposome with longer half-life has been used in developed and used in clinical practice[24]. However, its application in children has not been thoroughly investigated. Dexamethasone is a strong anti-inflammatory drug, high dosage (>0.1 mg/kg) is able to alleviate all kinds of postoperative pain[25] De Oliveira GS et al. performed a meta-analysis of randomized controlled trials to evaluate the dose-dependent analgesic effects of perioperative dexamethasone. They reported that an intraoperative infusion of 10mg mg dexamethasone could reduce the duration of hospital stay significantly, and it is not associated with delayed healing and infection [26]. However, the safety and validity of application of glucocorticoids in children remains to be investigated.
Peripheral nerve block is routinely performed in patients with long bone fracture surgeries; however, it is not commonly performed in DDH patients. Local anesthetic agents such as lidocaine and ropivacaine have also been reported to use around the incision site for postoperative pain management. As for joint replacement surgeries, surgeons advocate the injection of a cocktail consisting of opiates, NSAIDs, and steroids periarticularly [27]. However, this technique has not been used and validated in our institute for the pediatric population.
American Society of Anesthesiology has recommended that the preoperative fasting for children should be at least 2 hours for clear water, 4 hours for breast milk, 6 hours for non-human or cow milk, 8 hours for meat or oily food. It has been validated that 2 hours fasting for clear water intake is safe in children, and it significantly reduces the thirst and hunger of sick children while waiting for the surgery [28]. In our institute, we try to calculate the precise timing of surgery and minimize the fasting time for children.
Most of the orthopaedic procedure does not need the drainage tub[29]; however, it is recommended in the DDH patients as the wounds are covered in Spica cast, and there is always the possibility of blood loss from the osteotomy sites causing postoperative hematoma and infection. In routine ERAS program, all kinds of catheters and drainage tubes are encouraged to remove early to promote early rehabilitation.
Early diet is recommended for DDH patients after anesthesia awareness. However, most young children are not able to eat regular diet immediately after surgery. Noodles or thin soup was recommended for young children on the first meal postoperatively. Food rich in dietary fiber is recommended for patient to lower the incidence of constipation. Walking is not possible postoperatively as the hips are immobilized in Spica cast. But early ambulation is always encouraged.
So far, there are limited reports of ERAS program in the field of pediatric orthopedics, most of our core components in the ERAS protocol were derivatives from research in adults. In clinical practice, the application of multi-mode analgesia alleviates the postoperative pain response that increases the surgical cost. The predictive increase of medication cost might be compensated by the reduction of hospital stay, however, that requires multi-center study.