Enhanced recovery after surgery (ERAS) protocols in neonates should focus on the respiratory tract

  • Yuji Wakimoto
  • Sathyaprasad BurjonrappaEmail author
Original Article



Enhanced recovery after surgery (ERAS) protocols have shown significant benefits in terms of patient outcomes and institutional cost savings in colorectal and bariatric surgery. This has not, however, been tried in the neonatal setting. One of the major barriers to developing ERAS protocols in the neonatal intensive care unit (NICU) is the often-prolonged intubation of neonates after surgery. To this end, we evaluated our institutional data to determine if prolonged intubation post-operatively is associated with adverse events.


This is a retrospective cohort study of neonates who were intubated for a surgical procedure from January 2012 to December 2016. Documented data included pre-operative intubation status, timing of post-operative extubation: immediate (< 24 h) or delayed (> 24 h), and adverse respiratory events. The Fisher exact test and Student’s t test were used to study differences amongst categorical and continuous variables, respectively.


58 surgical procedures were identified, where the patient was intubated specifically for the surgical intervention, of which 28 were extubated immediately and 30 were extubated in a delayed fashion. The overall incidence of adverse respiratory events was increased in the delayed extubation group (P = 0.03).


Healthcare providers should encourage early extubation after neonatal surgery. Consideration should be given to implementing ERAS protocols in NICUs.

Level of evidence

Prognosis study—level II.


Enhanced recovery after surgery Neonates Post-operative extubation Intubation NICU 




Compliance with ethical standards

Conflict of interest

Neither author has a conflict of interest.

Ethical approval

The study is retrospective. Study was performed after institutional review board approval and in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


  1. 1.
    Harris KC, Holowachuk S, Pitfield S, Sanatani S, Froese N, Potts JE et al (2014) Should early extubation be the goal for children after congenital cardiac surgery? J Thorac Cardiovasc Surg 148:2642–2648. CrossRefGoogle Scholar
  2. 2.
    Lawrence EJ, Nguyen K, Morris SA, Hollinger I, Graham DA, Jenkins KJ et al (2013) Economic and safety implications of introducing fast tracking in congenital heart surgery. Circ Cardiovasc Qual Outcomes 6:201–207CrossRefGoogle Scholar
  3. 3.
    Howard F, Brown KL, Garside V, Walker I, Elliott MJ (2010) Fast-track pediatric cardiac surgery: the feasibility and benefits of a protocol for uncomplicated cases. Eur J Cardiothorac Surg 37:193–196CrossRefGoogle Scholar
  4. 4.
    Gurria J, Kuo P, Kao A, Christensen L, Holterman A (2018) General endotracheal vs. non-endotracheal regional anesthesia for elective inguinal hernia surgery in very preterm neonates: a single institution experience. J Pediatr Surg 52:56–59. CrossRefGoogle Scholar
  5. 5.
    Varghese J, Kutty S, Abdullah I, Hall S, Shostrom V, Hammel JM (2016) Preoperative and intraoperative predictive factors of immediate extubation after neonatal cardiac surgery. Ann Thorac Surg 102:1588–1595. CrossRefGoogle Scholar
  6. 6.
    Wielenga JM, Van den Hoogen A, Van Zanten HA, Helder O, Bol B, Blackwood B (2016) Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in newborn infants. Cochrane Database Syst Rev 3:CD011106. Google Scholar
  7. 7.
    Walsh MC, Morris BH, Wrage LA, Vohr BR, Poole WK, Tyson JE et al (2005) Extremely low birthweight neonates with protracted ventilation: mortality and 18-month neurodevelopmental outcomes. J Pediatr 146:798–804. CrossRefGoogle Scholar
  8. 8.
    Miller JD, Carlo WA (2008) Pulmonary complications of mechanical ventilation in neonates. Clin Perinatol 35:273–281. CrossRefGoogle Scholar
  9. 9.
    Robbins M, Trittmann J, Martin E, Reber KM, Nelin L, Shepherd E (2015) Early extubation attempts reduce length of stay in extremely preterm infants even if re-intubation is necessary. J Neonatal Perinatal Med 8:91–97. CrossRefGoogle Scholar
  10. 10.
    Biniwale M, Wertheimer F (2017) Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants. Resuscitation 116:33–38. CrossRefGoogle Scholar
  11. 11.
    Al-Mandari H, Shalish W, Dempsey E, Keszler M, Davis PG, Sant’anna G (2015) International survey on periextubation practices in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 100:F428–F431. CrossRefGoogle Scholar
  12. 12.
    Lago P, Boccuzzo G, Garetti E, Pirelli A, Pieragostini L, Merazzi D et al (2013) Pain management during invasive procedures at Italian NICUs: has anything changed in the last five years? J Matern Neonatal Med 26:303–305. CrossRefGoogle Scholar
  13. 13.
    Menon G, McIntosh N (2008) How should we manage pain in ventilated neonates? Neonatology 93:316–323CrossRefGoogle Scholar
  14. 14.
    Anand KJS, Hall RW (2007) Controversies in neonatal pain: an introduction. Semin Perinatol 31:273–274. CrossRefGoogle Scholar
  15. 15.
    Prestes ACY, Balda RDCX, Dos Santos GMS, Rugolo LMSDS, Bentlin MR, Magalhães M et al (2016) Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period? J Pediatr (Rio J) 92:88–95. CrossRefGoogle Scholar
  16. 16.
    Hall RW (2013) Anesthesia and analgesia in the NICU. NIH Public Access 39:239–254. Google Scholar
  17. 17.
    Fontánez-Nieves TD, Frost M, Anday E, Davis D, Cooperberg D, Carey AJ (2016) Prevention of unplanned extubation in neonates through process standardization. J Perinatol 36:469CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.NYU-Winthrop University HospitalMineolaUSA
  2. 2.University of South FloridaTampaUSA

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