Table of Contents  
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 463-468

Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis

Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Abbasia, Cairo, Egypt

Date of Submission20-Sep-2015
Date of Acceptance01-Nov-2015
Date of Web Publication29-Dec-2015

Correspondence Address:
Mohamed Saleh
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Abbasia, Cairo 11566
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-7934.172664

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Enhanced recovery after surgery is a multimodal, multidisciplinary, evidence-based approach, aiming to control postoperative pathophysiology and rehabilitation. The aim of this article is to review current literature in pediatric cardiac practice, implementing the ERAS approach, to identify peri-operative strategies that are associated with enhanced recovery after pediatric cardiac surgery.

Keywords: Enhanced recovery, pediatric cardiac anesthesia, postoperative pathophysiology, postoperative rehabilitation

How to cite this article:
Saleh M. Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis. Ain-Shams J Anaesthesiol 2015;8:463-8

How to cite this URL:
Saleh M. Implementation of enhanced recovery after surgery in pediatric cardiac practice: a synopsis. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2023 Dec 2];8:463-8. Available from:

  Introduction Top

Enhanced recovery after surgery (ERAS) was introduced in 1997 by Henrik Kehlet, a gastrointestinal surgeon from Denmark. It is a multimodal, multidisciplinary, evidence-based approach, which aims to control postoperative pathophysiology and rehabilitation. It provides perioperative care that minimizes stress/surgical trauma reaction, aiming to reduce postoperative morbidity, and improves and accelerates recovery, leading to a shorter length of hospital stay. All of these factors have an economic advantage in terms of better utilization of resources and cost-benefit ratio. ERAS was originally described in colorectal surgery, but it has expanded to include other surgical specialties [1],[2] .

The aim of this article was to review current literature in pediatric cardiac practice, implement the ERAS approach, and identify perioperative strategies that are associated with enhanced recovery after pediatric cardiac surgery.

Enhanced recovery after surgery in pediatric cardiac practice

Early tracheal extubation after pediatric cardiac surgery is not a new concept, but has received renewed attention with the evolution of ERAS. Early extubation after pediatric cardiac surgery was first proposed by Barash et al. [3] in 1980. In 1984, Schuller et al. [4] reported that early extubation after pediatric cardiac surgery has minimal risk in carefully selected patients. However, early extubation and ERAS are not synonymous. Early extubation is an element component of ERAS program.

In 2010, a protocol was published from Great Ormond Street Hospital that describes a clinical perioperative pathway in which pediatric cardiac patients rapidly progress from preoperative preparation, through cardiac surgery and postoperative care. The protocol includes admission to hospital on the morning of surgery, reduced postoperative ventilation time, same-day discharge from ICU to high dependency unit in the ward, optimal analgesia, early liberalization from fluids and early mobilization, and earlier discharge from hospital. Greater experience with this type of protocol leads to reduction in the length of hospital stay [5] .

The benefit of implementation of ERAS in pediatric cardiac practice is decreased hospital stay, decreased overall medical costs, and better utilization of resources without affecting patient safety [6] . In the current era of limited resources and cost-benefit consideration, such protocol would be appreciated.

In this article, we have reviewed current literature in pediatric cardiac practice, implemented the ERAS approach, and identified the following perioperative strategies that are associated with enhanced recovery after pediatric cardiac surgery [Figure 1].
Figure 1: Implementation of enhanced recovery after surgery (ERAS) in pediatric cardiac practice

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Preoperative strategies

Patient selection

Appropriate patient selection is important for successful ERAS program [7],[8] . Patient selection criteria included the following:

  1. Age more than 6 months and weight more than 10 kg, as many studies demonstrated that there is an increased rate of reintubation in younger infants.
  2. Presence of simple cardiac lesion, including atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), and coarctation of the aorta, in addition to having undergone certain pediatric cardiac procedure, including Glenn and Fontan shunt. Children with cardiac lesions, including large left-to-right shunts and moderate-to-severe pulmonary hypertension, and those with complicated cardiac lesions, including atrioventricular canal, truncus arteriosus, D-transposition of the great vessels, total anomalous pulmonary venous return, and hypoplastic left heart syndrome, were excluded.
  3. Completely healthy preoperative condition: Patients with preoperative comorbidities, including preoperative respiratory compromise, preoperative congestive heart failure, and failure to thrive, were excluded.
Preadmission counseling

Adoption of specialized preanesthesia evaluation for pediatric patients scheduled for cardiac surgery allows admission to hospital on the day of surgery with significant reduction in surgical cancellation or delay from abnormal laboratory tests, upper respiratory infections, or other intervening events, as well as significant reduction in the length of admission [9],[10],[11] .

Optimization of patient's condition

All medications should be continued up to the time of surgery, except diuretics and digoxin, which should be stopped 24 h before surgery. Treatment of anemia and optimization of chest condition are of paramount importance [7],[8] .

Shortened preanesthetic fasting interval

Children scheduled for cardiac surgery may be allowed to drink clear liquids up to 2 h before induction of anesthesia without adversely affecting residual gastric fluid volume and gastric fluid pH. The aim of shortening preanesthetic fasting interval is to avoid preoperative dehydration and hypoglycemia, and to maximize patient and parent satisfaction. Avoiding preoperative dehydration and preserving intravascular volume improve hemodynamic response during inhalation induction of anesthesia and facilitate vascular access. Avoiding preoperative hypoglycemia through ingestion of dextrose-containing fluids maintain plasma glucose levels, especially in infants and young children with limited glycogen stores [12],[13] .


Clinically significant decrease in SpO 2 and rise in PaCO 2 were observed in children with congenital heart disease following standardized intramuscular premedication with morphine, scopolamine, and secobarbital. Hypoxia and hypercarbia are detrimental in these patients, as they cause acute increase in pulmonary artery pressure and pulmonary vascular resistance. Oral midazolam was demonstrated to be a safe alternative for such protocol [14],[15],[16] .

Intraoperative strategies

Short-acting anesthetic agents

For many years, a high-dose opioid technique was considered to be beneficial in improving outcome in complex surgery for congenital heart disease (CHD). It was shown that a high-opioid technique can blunt the stress response to surgery and cardiopulmonary bypass and was thought to provide superior hemodynamic stability [17],[18],[19] .

However, ERAS program requires an anesthetic technique that allows safe early extubation within a few hours in the ICU. Therefore, a high-dose opioid technique is typically not suitable for this approach [7],[8],[20] . It has been demonstrated that the use of moderate doses of short-acting or intermediate-acting opioid supplemented with inhalational anesthetic can reduce the duration of mechanical ventilation and intensive care stay [21],[22] .

Neuraxial blockade

Neuraxial blockade might be useful in minimizing intravenous opioid administration. Caudal or intrathecal opioid has been shown to blunt the stress response to surgery and cardiopulmonary bypass and improve postoperative analgesia in pediatric cardiac patients [23],[24],[25] .

Although there is no doubt that neuraxial blockade provides long-lasting analgesia with significant opioid-sparing effect, there is controversy as regards the safety and benefits of such technique [26],[27],[28] .

Minimally invasive surgical approach

Minimally invasive surgical approaches facilitate ERAS program. Limited skin incisions with median sternotomy, limited sternotomy, right anterior minithoracotomy, and video-assisted endoscopic technique have superior cosmetic results without affecting morbidity and offer more psychological and social satisfaction for the patients [29],[30],[31],[32],[33],[34],[35] .


The recent change to normothermic cardiopulmonary bypass and normothermic cardioplegia is gaining popularity in pediatric cardiac practice. Normothermic cardiopulmonary bypass and intermittent normothermic blood cardioplegia are associated with higher spontaneous resumption of sinus rhythm, smaller increase in troponin I, improved hemodynamic stability, allowing early extubation of patients, and shorter duration of ICU stay [36],[37],[38],[39] .


The systemic inflammatory response resulting from extracorporeal circulation, surgical trauma, protamine, and ischemia-reperfusion injury causes humoral and cellular responses, leading to increased interstitial fluid and generalized capillary leak, and has a potential for multiple organ dysfunction syndrome [40],[41],[42] .

During pediatric cardiac operations, using either conventional or modified ultrafiltration removes excess fluid and inflammatory mediators. Several studies demonstrated that ultrafiltration increased arterial oxygen tension and lowered carbon dioxide tension after bypass, shortened intubation and mechanical ventilation times, and improved postoperative pulmonary compliance [43],[44],[45],[46] .


Perioperative steroid administration is a common practice in pediatric cardiac surgery to modulate the inflammatory response associated with cardiopulmonary bypass [47] . Intraoperative steroid administration was associated with a significant decrease in postoperative cardiac troponin levels and shorter durations of stay in intensive care and hospital [48],[49],[50] . The use of an additional preoperative dose resulted in further modulation of inflammatory response, with improvement in oxygen delivery, and reduction in duration of mechanical ventilation [48],[51],[52] .

Postoperative strategies

Systemic nonopioid analgesic

Effective pain management and sedation without respiratory depression is a crucial issue during the postoperative period. Narcotic administration may cause respiratory depression as well as nausea, vomiting, and delayed alimentation [53],[54] . The use of nonopioid analgesic ketorolac in the postoperative period for pain control has been reported to be effective and safe in several studies [55],[56],[57],[58],[59] .

Parasternal intercostal nerve block

Parasternal intercostal block is a simple, safe, and effective technique for postoperative analgesia in pediatric patients undergoing cardiac surgery through median sternotomy. It resulted in less postoperative pain, reduced the requirement for postoperative opioids, and allowed early tracheal extubation [60] .

Continuous incisional infusion of local anesthetics

Continuous incisional infusion of local anesthetics is another simple, safe, and effective technique for postoperative analgesia in pediatric patients undergoing cardiac surgery through median sternotomy. It reduced postoperative analgesic requirement and sedative administration [61] .


Dexmedetomidine is a selective a-2 adrenergic receptor agonist with sedative, analgesic, and anxiolytic properties [62],[63] . The use of dexmedetomidine in pediatric patients after cardiac surgery has been demonstrated to be well tolerated in intubated and nonintubated children. Favorable effects of dexmedetomidine include blunting sympathetic stress response through reduction of endogenous catecholamine release and decrease in intraoperative anesthetic, as well as postoperative analgesic requirements [64],[65],[66],[67] . However, dexmedetomidine did not significantly affect the postoperative course of children as measured by success of early extubation, duration of mechanical ventilation, and length of ICU stay [68] .

Avoid fluid overload

Fluid overload in pediatric patients after cardiac surgery may lead to multiple organ dysfunction syndrome [69] . Moreover, pediatric patients undergoing cardiac surgery are at risk for acute kidney injury. Chan et al. [70] demonstrated that the risk was associated with long cardiopulmonary bypass duration, low cardiac output syndrome, and total circulatory arrest. The cause-effect relationship between acute kidney injury and fluid overload has been demonstrated in either directions [71] . Several studies showed that fluid overload was associated with impaired oxygenation and poor outcomes [72],[73],[74],[75] .

Blood transfusion

It has been demonstrated that greater intraoperative and early postoperative blood transfusion emerged as a risk factor for longer duration of mechanical ventilation and prolonged hospitalization and was associated with increased incidence of infections in children after cardiac surgery [76],[77],[78] .

Glycemic control

Hyperglycemia is common among pediatric patients after cardiac surgery. Severe hyperglycemia has been associated with increased morbidity and mortality rates [79],[80],[81],[82] . A conventional management (no insulin, no glucose) is satisfactory in most patients. However, insulin may be considered for small neonates with complex congenital heart surgery [83] .

Nutrition support

Several studies have demonstrated that early enteral feeding decreases postoperative complications, accelerates wound healing process, decreases the cost of hospitalization, and improves quality of life [84],[85],[86],[87] . However, feeding difficulties are common following pediatric cardiac surgery. Risk factors for feeding difficulties include increased risk adjustment for congenital heart surgery score (RACHS score) and prolonged postoperative intubation [88],[89] . The use of a standardized enteral feeding protocol reduced the incidence of necrotizing enterocolitis, enabled high-risk infants to achieve recommended daily calories earlier in their postoperative course, and also decreased the duration of total parenteral nutrition use [90],[91] .

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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