Utility of the Enhanced Recovery after Surgery Protocol (ERAS Protocol) in Anesthetic Management for Pediatric Surgery in Patients with Down Syndrome: Case Report

Abstract

Introduction: Down syndrome is a common genetic condition affecting approximately 1 in every 1,000 births, caused by a trisomy on chromosome 21. This condition leads to several abnormalities, including cardiac, respiratory, musculoskeletal, and digestive problems such as atresia and duodenal stenosis. The latter may require surgery in childhood, with general or regional anesthesia. The Enhance recovery after surgery (ERAS) Protocol is a set of scientifically supported strategies to reduce surgical stress and improve patient recovery. Although it has been used in adult surgeries for more than 20 years, its implementation in pediatric surgeries is more recent, demonstrating promising results in reducing complications and hospital stays.

Case presentation: 3-year-old female, diagnosed with Down syndrome and duodenal stenosis, with a history of closure of the ductus arteriosus at 2 years of age, electively scheduled for diagnostic laparoscopy. Fasting for 6 hours was indicated prior to surgery. Upon her arrival to the operating room, Midazolam and Paracetamol were administered as anxiolysis. Non-invasive continuous cardiac monitoring was initiated in the operating room, anesthetic induction was performed with Fentanyl, Lidocaine, Propofol and Cisatracurium. Orotracheal intubation with videolaryngoscopy was performed. Anesthetic maintenance was using Sevoflurane, as well as Fentanyl infusion. During the surgical procedure, multiple intra-abdominal adhesions were evident, so it was modified to open surgery, performing duodenal-duodenal anastomosis. Bispectral index (BIS) monitoring was performed throughout the procedure with values of 40-60. The fluid balance remained neutral. For analgesia, caudal block with Ropivacaine was used at the end of the surgery. For the prevention of postoperative nausea and vomiting, Ondansetron was administered. Emersion and extubation were performed without complications. Anesthesiology follow-up was carried out in the first 24 hours, with adequate pain control. Enteral feeding was started after 48 hours and progressively. Hospital discharge took place 72 hours after surgery. Clinical discussion: The ERAS protocol was implemented for the first time in adult patients undergoing open colectomy; prolonged fasting, prolonged rest, excessive fluid resuscitation, and opioid analgesia were found to favor hospital stay and complications. For anesthetic management, the main points to take into account are: suspend the consumption of clear liquids up to two hours before surgery; in the perioperative phase, a multimodal approach should be focused on reducing postoperative nausea and vomiting. Regarding Regional anesthesia for abdominal surgery, options such as ultrasound-guided transversus abdominis plane (TAP) block or rectus abdominis sheath block can be used safely; when ultrasound is not available, caudal epidural block is the ideal technique in pediatric patients. The administration of fluids in the perioperative period at an average rate of 2-5 ml/kg/h achieves a neutral balance to reduce complications such as pulmonary edema. Monitoring and maintaining temperature reduces surgical site infections, cardiac complications, as well as bleeding. In the postoperative phase, the multimodal analgesia regimen continues based on Paracetamol, Ketorolac, regional anesthesia, Gabapentin; in addition to implementing the start of enteral feeding and early ambulation in order to reduce postoperative ileus and favor conditions for hospital discharge.

Conclusion: The ERAS protocol is a tool that has recently been implemented in pediatric surgery with good results. The reduction in fasting time prior to elective surgery, fluid control, the initiation of multimodal analgesia through the use of paracetamol, non-steroidal anti-inflammatory drugs as well as regional anesthesia techniques have a positive impact on the patient and with better results in the postoperative period.