Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children. OBJECTIVE: The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls. STUDY DESIGN: Institutional Review Board approval was obtained to prospectively enroll patients agedpreparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery. RESULTS: A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P \u3c 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P \u3c 0.001), and early feeding (P \u3c 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations. DISCUSSION: Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding. CONCLUSION: ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS

Environmental enrichment for neotropical primates in captivity Enriquecimento ambiental para primatas neotropicais em cativeiro

Captivity is an extreme non-natural environment for primates. The success of a breeding colony depends of management and veterinarian procedures which must rely on the knowledge of primates' behavioral needs. Environmental enrichment consists of a series of procedures that improve the quality of life of captive animals by meeting their ethological needs. Enrichment can reduce stress, while increasing animal well being in captivity. Suitable ethical conditions, incidences of behavioral disorders, minimal clinical interventions, low mortality, higher reproduction rates and cost/benefit relationship, reflect directly on the quality of captive breeding colonies. Anthropoids like Neotropical primates possess complex neural structures and relate, in a sophisticated manner, to the environment. This review reports important experiences on enrichment procedures for Neotropical primates and the physiological events which could explain improvement of animal well-being.<br>Cativeiro é um ambiente de extremos não naturais para primatas. O sucesso de uma criação de primatas depende do manejo e de procedimentos veterinários que devem considerar as necessidades etológicas dos animais cativos. Enriquecimento ambiental é um conjunto de técnicas que modificam o ambiente, resultando em uma melhora na qualidade de vida dos animais, ao satisfazer as suas necessidades comportamentais. O enriquecimento pode diminuir o estresse e melhorar o bem-estar. Primatas neotropicais se caracterizam por complexas estruturas neurais e se relacionam de maneira sofisticada com o ambiente. O enriquecimento ambiental pode aumentar a qualidade de uma criação ao adequar o manejo a padrões éticos aceitáveis, estimular o repertório normal do comportamento, diminuir a casuística clínica, diminuir a mortalidade, incrementar a taxa reprodutiva e maximizar a relação custo/benefício em uma criação. Esta revisão relata experiências relevantes nos procedimentos de enriquecimento para primatas neotropicais, além de comentar as bases fisiológicas em que essas intervenções melhoram o bem-estar dos animais cativos