Perioperative analgesia strategies in fast-track pediatric surgery of the kidney and renal pelvis: lessons learned.

PURPOSE: Effective analgesia is essential for the success of fast-track (FT) pediatric surgery. Aim of the study was to achieve an optimal analgesia protocol for a comfortable postoperative course and early mobilization in children undergoing urological procedures. METHODS: A prospective study of two analgesia concepts in a series of children undergoing laparoscopic pyeloplasty (LP) and nephrectomy (LN) was performed. Thirty-six consecutive patients received analgesia according to the protocol "Fast Track I" (FT I), 23 patients according to the modified analgesia protocol "Fast Track II" (FT II). Differences between the protocols were frequency of pain measurement, more frequent use of local anesthesia and higher dosage of Acetaminophen. End points were pain intensity, use of opioids and side effects. Data derived from the German reimbursement system (G-DRG) regarding lengths of hospital stay were compared. RESULTS: On the day of operation (6:00 p.m.), pain scores of patients using FT II were significantly lower than those using the FT I protocol (1.51 + or - 0.4 FT II versus 3.8 + or - 0.4 FT I, p = 0.001). Pain scores still tended to be lower in the FT II group on the first postoperative day (8:00 a.m.), but from that point on, the difference was not significant (1.52 + or - 0.5 FT II versus 2.3 + or - 0.4 FT I, p = 0.186). Hospital stay was short, compared to the German average, in both groups. CONCLUSION: The modified analgesia protocol FT II leads to earlier and more effective pain reduction, lower use of opioids and fewer side effects than the previously used protocol FT I. Hence, modification of analgesia in pediatric urology is essential.

Fast-track surgery in infants and children.

BACKGROUND/PURPOSE: Fast-track surgery is not well established for infants and children. The aim of our prospective study was to investigate the feasibility of fast-track concepts for pediatric surgical procedures including laparoscopic techniques. METHODS: Fast-track concepts, including immediate postoperative feeding, immediate mobilization, and morphine sparing pain treatment, were established for pyeloplasty, appendectomy, bowel anastomosis, fundoplication, hypospadia repair, and full/partial nephrectomy. All consecutive patients undergoing these procedures were prospectively investigated from June 2004 to June 2005. Patients with additional relevant diseases, reoperation, and perforated appendicitis were excluded from fast-track treatment. The length of hospital stay was compared with data derived from the German reimbursement system with German diagnosis-related groups for patients with a similar case mix index and hospitals with a similar structure. RESULTS: Of a total of 159 patients (mean age, 5.8 +/- 5.3 years), 113 (71%) were finally treated according to the fast-track protocols. There were no complications associated with fast-track surgery. The intensity of pain during the immediate postoperative period was higher than 5 on a 10-point scale in children older than 4 years. Analgesia was excellent at all other time points. The mean hospital stay of fast-track patients was 2.3 +/- 1 days and was significantly shorter (P < .01) compared with German diagnosis-related group data for all procedures (pyeloplasty, 1.9 +/- 0.9 vs 12.2 +/- 0.2; nephrectomy, 1.9 +/- 1.0 vs 14.4 +/- 2.8; bowel anastomosis, 3.2 +/- 0.6 vs 12.9 +/- 2.4; fundoplication, 3.2 +/- 0.8 vs 15.2 +/- 4.2; appendectomy, 3.7 +/- 2.4 vs 6.3 +/- 1.8; hypospadia repair, 2.1 +/- 1 vs 8.4 +/- 1.4). Two readmissions were recorded. Ninety-six percent of patients and parents scored the fast-track concepts as excellent. CONCLUSION: The feasibility of fast-track concepts in children is excellent, with short duration of hospitalization and high comfort.