Application of enhanced recovery after surgery in pediatric patients with obstructive sleep apnea-hypopnea syndrome

Abstract

Background

Enhanced Recovery After Surgery (ERAS) has demonstrated effectiveness in accelerating recovery and reducing complications across surgical fields, with limited application in Ear-Nose-Throat surgeries. Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS), a prevalent condition affecting pediatric patients, calls for innovative management due to its impact on health and the need for surgical interventions like tonsillectomy.

Objective

The present study aimed to investigate the efficacy of ERAS in pediatric patients with OSAHS.

Methods

Review and analyze 1100 cases of pediatric patients with OSAHS who underwent plasma-coblation tonsillectomy and adenoidectomy using nasal endoscopy from June 2016 to June 2022 in our hospital. Among these cases, a total of 564 patients were managed according to ERAS theory, while 536 patients were treated with classical theory. The incidence of preoperative discomfort, postoperative pain, bleeding, and other complications between the two groups were compared.

Results

ERAS group showed comparable preoperative-discomfort rates to the control (P = 0.799). However, ERAS patients exhibited significantly lower pain scores at 24-, 48-, and 72-h post-operation (P < 0.05). Mental state scores were similar between ERAS and control 4 h pre-surgery (P > 0.05), but notably lower in ERAS at 30 min pre-op and 6-, 12-, and 24-h post-operation (P < 0.05). ERAS had lower complication rates and intra/postoperative bleeding, quicker ambulation/oral intake, and shorter hospital stays than control (P < 0.05).

Conclusion

ERAS management in patients with OSAHS resulted in notable reductions in postoperative pain and incidence of complications, along with improved postoperative recovery and shorter hospital stays.

Keywords

obstructive sleep apnea-hypopnea syndrome perioperative period enhanced recovery after surgery

1 Introduction

Developed in 2001, the enhanced recovery after surgery (ERAS) protocol aims to integrate various elements of surgical patient care spanning from preadmission to the postoperative period into an auditable and measurable paradigm, and to develop and implement data-driven changes to perioperative practices, thereby improving quality of care and patient outcomes and reducing costs to health systems. Its 24 core elements of care emphasizes a multimodal approach and the collaboration of a multidisciplinary team to optimize patient recovery after surgery. Continuous audit during implementation is also an essential component to ensure compliance by team members and an objective assessment of its impact on patient outcomes.¹ The underlying mechanism that's central to all ERAS elements for optimizing patient outcomes is minimizing stress and improving the patient response to stress. For instance, preoperative nutritional support and early feeding after surgery improve patient nutritional status and avoid catabolism and loss of protein; preoperative carbohydrate loading and optimal pain control after surgery reduce stress hormone levels and minimize postoperative insulin resistance, permitting normal cellular functions; maintaining fluid balance ensures adequate perfusion to injured tissues for repair function, while avoiding salt and fluid overload reduces the risk of postoperative ileus.¹ So far, ERAS implementation guidelines have been established for many types of thoracic, abdominal and pelvic surgery, as well as for major head and neck cancer surgery. However, the expansion of ERAS implementation to other types of head and neck surgery has been spotty, thus there is an urgent need of data reporting from such studies.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common ear-nose-throat condition, with an incidence rate of 4.3%–5.4% in the general population and 2%–4% in children.^2,3 OSAHS is associated with neurobehavioral deficits and cardiovascular risks in children, necessitating prompt diagnosis and intervention. Anti-inflammatories, weight management, and oral appliances can benefit select mild cases. Craniofacial disorders like Pierre-Robin sequence demand tailored management due to increased OSAHS risk, while neurological disorders affect sleep patterns and may require continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP), and sometimes invasive ventilation. First-line therapy often involves tonsillectomy and adenoidectomy in treating OSAHS.³ Traditional tonsillectomy surgery has inherent drawbacks, including a higher risk of blind dissection, potential remnants of the tonsil tissue after surgery, increased susceptibility to intraoperative and postoperative bleeding, and a longer duration of postoperative pain.^4–6 Moreover, this approach is particularly unsuitable for pediatric patients. Recently developed plasma-coblation tonsillectomy and adenoidectomy methods not only overcome these disadvantages, but also improve eustachian tube function, which is widely praised by doctors and patients.^7,8

In recent years, with the rapid increase cases of pediatric patients with OSAHS and the tense relationship between pediatric doctors and patients, it is highly urgent to apply ERAS theory to pediatric surgical management. In light of the escalating prevalence of OSAHS among pediatric populations and the increasingly strained dynamics between pediatric healthcare providers and their young patients, the implementation of ERAS protocols in the surgical management of OSAHS is imperative. This urgency stems from the need to not only streamline perioperative care but also to mitigate postoperative discomfort, pain, and complications, thereby enhancing patient satisfaction and overall recovery outcomes. Therefore, in the present study, we investigated the efficacy of ERAS theory in the perioperative period of 1100 pediatric patients with OSAHS, specifically focusing on those who underwent a combined surgical intervention comprising plasma-mediated coblation tonsillectomy coupled with adenoidectomy, facilitated by nasal endoscopic guidance, and evaluated the postoperative discomfort, pain, and complications during the management.

2 Materials and methods

2.1 Data collection

Clinical data from a total of 1100 children with OSAHS admitted to the Department of Otolaryngology-Head and Neck Surgery in Zhengzhou Central Hospital from June 2016 to June 2022 were collected prospectively from 598 males and 502 females aged 4–14 years old. Patients who met the inclusion criteria were consecutively enrolled into our study. Those who consented to participate in the ERAS implementation program were enrolled into the ERAS group, whereas those who did not consent to ERAS were enrolled into the control group. Prior to initiating any study procedures, written informed consent was obtained from the parents of each participant. This study was conducted in accordance with the Declaration of Helsinki, ensuring the rights and welfare of all participating human subjects are safeguarded throughout the study. This research was approved by the ethical committee of Zhengzhou Central Hospital (Approval no. 21-ZCH-IRB-31).

Inclusion criteria: mainly refer to the literature,³ and the selected patients were diagnosed with OSAHS that met the surgical indications of tonsil with adenoid hypertrophy. Children presenting with one or more of the following symptoms were included: (1) Frequent or loud snoring; (2) Labored, paradoxical, or obstructed breathing observed during sleep; (3) Daytime consequences such as excessive sleepiness, hyperactivity, behavioral issues, or learning difficulties; (4) One or more episodes of obstructive or mixed apneas, obstructive hypopneas per hour of sleep; (5) Evidence of obstructive hypoventilation, defined as end-tidal CO2 (PETCO2) > 50 mm Hg for at least 25% of total sleep time, accompanied by snoring, flattened inspiratory nasal pressure waveform, or paradoxical thoracoabdominal movements.

Exclusion criteria: While exclusion criteria are not explicitly listed, certain conditions may preclude the direct application of standard diagnostic or therapeutic protocols for OSAHS. These might include: (1) Children with primary central sleep apnea where OSAHS is not the primary cause of symptoms; (2) Those with acute illnesses or infections that may transiently affect sleep patterns or respiratory function; (3) Children who have undergone recent upper airway surgeries that could influence PSG results; (4) Cases where the diagnostic certainty of OSAHS is confounded by other sleep disorders or comorbidities that require separate evaluation and management.

There are 564 cases included in the ERAS group, and 536 cases included in the control group. The sexual, age, gender, body mass index (BMI) had no significant differences between two groups (Table 1).

Table 1.
The basic information of the pediatric patients.

Basic information/Group ERAS (n = 564) Control (n = 536) x²/t P

Gender (n, Male/Female) 317/247 281/255 0.226 0.116

Age (year,`x ± s) 5.53 ± 0.31 5.54 ± 0.29 0.043 0.966

BMI (kg/m²,`x ± s) 14.49 ± 1.17 14.51 ± 1.16 0.282 0.778

Basic information/Group	ERAS (n = 564)	Control (n = 536)	x²/t	P
Gender (n, Male/Female)	317/247	281/255	0.226	0.116
Age (year,`x ± s)	5.53 ± 0.31	5.54 ± 0.29	0.043	0.966
BMI (kg/m²,`x ± s)	14.49 ± 1.17	14.51 ± 1.16	0.282	0.778

2.2 Managements during perioperative period

The two groups of patients both underwent nasal endoscopic plasma tonsillectomy and bilateral tonsillectomy. The control group received routine perioperative care, including preoperative psychological counseling, brief introduction of disease knowledge and surgical procedures, informing the patients and their families about precautions, fasting for 6 h before surgery, postoperative monitoring of the condition, as-needed pain management, initiation of clear liquid diet 6 h after surgery, intravenous fluid administration, and allowing the patient to decide the timing for ambulation based on their own condition.

In the ERAS group, perioperative management was performed under the ERAS theory,⁹ the method details are listed as following: (1) Preoperative education: inform the family members about various matters related to ERAS perioperative period, introduce the OSAHS professional knowledge in detail through PowerPoint, pictures and videos, emphasize the importance of perioperative coordination, solve doubts for the family members patiently, and to relief the anxiety of children together with the family members and the medical staff, and inform the detailed steps of postoperative rehabilitation. (2) Preoperative diet restriction: patients were fasted 6 h before the surgy, and were given an oral 5% glucose solution at 10 mL/kg body weight 2 h preoperatively.¹⁰ (3) Analgesic intervention: preoperative health guidance on pain knowledge was given to the children and their families, explaining that the operation would produce pain, introducing the anesthesia method and the safety of the drugs used, so as to prevent the children from appearing emotional agitation and affecting the anesthesia effect. At the same time, multi-mode analgesia was used, lidocaine was injected locally in the operative area before tonsillectomy after anesthesia, and AutoMed 3300 electronic analgesia pump (ACE MEDICAL CO. LTD) self-controlled intravenous analgesia pump (10 mg/kg fentanyl and 60 g/kg haloperidol is added into 0.9% sodium chloride per 100 ml) was given after surgery for sustained analgesia. (4) Preoperative detailed examination: preoperative detailed examination was given to the child to check the health status of torus tubarius, pharyngotympanic tube, and to determine whether the child had rhinitis or sinusitis. Based on the examination results, the surgical method was adjusted as appropriate after discussion with the surgeon. (5) Postoperative nutrition: if patients had no nausea or vomiting behavior, encourage them to intake cold liquid food orally at 2–4 h post operation. A semi-liquid diet may be taken on the second day after surgery as appropriate, and soft diet may be taken during 5–7 days after surgery (food-intake volume ≤ 200 mL/time). For children with pain in the throat who refuse to eat, calm their emotions and inform them of the positive significance of oral intake for the recovery, and encourage them to follow the principle of eating less each time with nutrient meals. Guide the patients to carry out oral intervention, the next day after surgery, after eating, suggest them to use mouthwash to ensure the cleanliness of the mouth. (6) Postoperative ambulation: encourage the patients to get out of bed for ambulation 6 h after surgery. (7) Discharge instruction: before discharge, briefly introduce the recover precautions to the family members of the patients. After discharge, establish a clear “green channel” for readmission, and routine telephone follow-up or guidance were given within 1–2 d. Inform the families to visit the outpatient department 7–10 d after surgery, and the clinical follow-up lasted until 30 d after surgery.

2.3 Observation index

Preoperative discomfort was assessed through a structured questionnaire designed to capture subjective feelings of anxiety, pain, and nausea 2 h before the operation. The questionnaire employed a Likert scale ranging from 0 (no discomfort) to 10 (extreme discomfort), with scores aggregated to provide a comprehensive preoperative discomfort index. In addition to the initial parameters, the following were also meticulously documented. The discomfort feeling at 2 h before operation, intraoperative and postoperative bleeding volume, postoperative pain, postoperative mental state, postoperative ambulation time, postoperative oral-intake time, the hospital stay length, and the onset of other complications were recorded. The postoperative pain score of pediatric patients was measured by visual analogue scale (VAS) methods at 24-, 48-, 72 h after the surgery.¹¹ The mental state score was evaluated at 4 h, 30 min preoperatively and 6-, 12-, 24 h postoperatively, according to Mini-Mental State Examination methods.¹²

2.4 Statistical analysis

The Statistic Package for Social Science (SPSS) 20 statistical software (IBM, Armonk, NY, USA) was used for data analysis. Shapiro-Wilk tests were used to assess the normality of the postoperative pain scores and mental state scores. Levene's tests were performed to examine the homogeneity of variances between the ERAS and control groups for these variables. Data are presented as “`x ± s”, and t-tests was used for comparison between groups. For count data, the x² test was used. A P-value less than 0.05 was considered statistically significant.

3 Results

3.1 Discomfort at 2 h preoperatively

There were 39 patients (6.91%) in ERAS group with discomfort (including thirst, hunger, tension and irritability, etc.) and 35 patients (6.53%) in control group with discomfort. There was no statistical significance in preoperative discomfort between the two groups (x²= 0.065, P = 0.799) (Table 2).

Table 2.
Discomfort at 2 h preoperatively.

Preoperative Time ERAS group (n = 564) Control group (n = 536) x ² P

2 h 39 (6.91%) 35 (6.53%) 0.065 0.799

Preoperative Time	ERAS group (n = 564)	Control group (n = 536)	x ²	P
2 h	39 (6.91%)	35 (6.53%)	0.065	0.799

3.2 Postoperative pain

The score of postoperative pain in ERAS group of patients was significantly lower comparing with control at 24, 48 and 72 h postoperatively (p < 0.05, Table 3).

Table 3.
The score of postoperative pain in ERAS and control groups (`x ± s).

Postoperative Time ERAS group (n = 564) Control group (n = 536) t P

24 h 1.66 ± 0.54 2.35 ± 0.82 16.624 <0.001

48 h 2.29 ± 0.67 3.38 ± 0.79 24.614 <0.001

72 h 1.11 ± 0.41 2.09 ± 0.63 30.690 <0.001

Postoperative Time	ERAS group (n = 564)	Control group (n = 536)	t	P
24 h	1.66 ± 0.54	2.35 ± 0.82	16.624	<0.001
48 h	2.29 ± 0.67	3.38 ± 0.79	24.614	<0.001
72 h	1.11 ± 0.41	2.09 ± 0.63	30.690	<0.001

3.3 Preoperative and postoperative mental state

The mental score at 4 h before the surgery did not vary between ERAS and control group (p > 0.05). At 30 min before surgery and at 6-, 12-, 24 h after surgery, the mental scores of patients in ERAS group were significantly lower than control (p < 0.05, Table 4).

Table 4.
The mental score of ERAS and control groups of patients at different time points measured (`x ± s).

Measuring time ERAS group (n = 564) Control group (n = 536) t P

Preoperative 4 h 5.67 ± 1.23 5.80 ± 1.42 1.742 0.082

Preoperative 30 min 3.49 ± 1.32 4.41 ± 1.46 10.977 <0.001

Postoperative 6 h 3.38 ± 0.53 5.38 ± 0.88 45.821 <0.001

Postoperative 12 h 2.54 ± 0.49 3.45 ± 0.79 23.269 <0.001

Postoperative 24 h 1.65 ± 0.48 3.12 ± 0.71 40.405 <0.001

Measuring time	ERAS group (n = 564)	Control group (n = 536)	t	P
Preoperative 4 h	5.67 ± 1.23	5.80 ± 1.42	1.742	0.082
Preoperative 30 min	3.49 ± 1.32	4.41 ± 1.46	10.977	<0.001
Postoperative 6 h	3.38 ± 0.53	5.38 ± 0.88	45.821	<0.001
Postoperative 12 h	2.54 ± 0.49	3.45 ± 0.79	23.269	<0.001
Postoperative 24 h	1.65 ± 0.48	3.12 ± 0.71	40.405	<0.001

3.4 Intraoperative and postoperative bleeding volume, ambulation time, oral intake time, hospital stay length, and the incidence of complications

The intraoperative and postoperative bleeding volume, ambulation time, oral intake time, hospital stay length in the ERAS group of patients were significantly lower than the control group (p < 0.05). Complications were rare in both groups; there was only 1 case of infection in the ERAS group (0.18%), compared to 3 cases of infection, 2 cases of pyrexia, and 2 cases of secretory otitis media in the control group (1.31%, p < 0.05, Table 5).

Table 5.
Intraoperative and postoperative bleeding volume, ambulation time, oral intake time, hospital stay length, and the incidence of complications in ERAS and control groups.

Index ERAS group (n = 564) Control group (n = 536) x²/t P

Intraoperative bleeding volume (mL) 21.5 ± 11.2 34.2 ± 12.4 17.821 <0.001

Postoperative bleeding volume (mL) 1.5 ± 0.6 2.1 ± 0.4 17.898 <0.001

Ambulation time (d) 0.6 ± 0.2 0.9 ± 0.3 17.162 <0.001

Oral intake time(d) 0.9 ± 0.4 1.1 ± 0.6 7.107 <0.001

Hospital stays length (d) 2.3 ± 0.8 3.5 ± 1.2 17.109 <0.001

Complications (cases) 1 7 0.034 0.029

Index	ERAS group (n = 564)	Control group (n = 536)	x²/t	P
Intraoperative bleeding volume (mL)	21.5 ± 11.2	34.2 ± 12.4	17.821	<0.001
Postoperative bleeding volume (mL)	1.5 ± 0.6	2.1 ± 0.4	17.898	<0.001
Ambulation time (d)	0.6 ± 0.2	0.9 ± 0.3	17.162	<0.001
Oral intake time(d)	0.9 ± 0.4	1.1 ± 0.6	7.107	<0.001
Hospital stays length (d)	2.3 ± 0.8	3.5 ± 1.2	17.109	<0.001
Complications (cases)	1	7	0.034	0.029

4 Discussion

The ERAS theory has been successfully applied in patients undergoing surgical operation, with large benefits in reducing the incidence of stress responses and complications to promote the full recovery of patients.¹³ In the present study, we investigate the effect of ERAS theory in OSAHS pediatric patients, and found that the hospital stay length, pain, complications postoperatively were significantly lower in patients undergoing ERAS theory, with better postoperative recovery. The advantages of this method can be attributed to several aspects, including preoperative and postoperative guidance, nutritional support, surgical approach, pain management, and reduction of complications.

Due to the direct impact of parents on pediatric patients, it is important for healthcare professionals to establish a good relationship with parents in a kind and friendly manner. This helps parents to gain understanding of the disease itself, which in turn enables them to correctly guide the emotions of their child and promote the child's postoperative recovery throughout the entire treatment process. In this study, we found that encouraging parents to eliminate tension and other negative emotions may help correctly guide the emotions of the patients. Since most of the children were not completely recovered at the time of discharge, the professional discharge guidance under ERAS theory on the basis of patient's condition may improve the quality of rehabilitation.

Nutritional support is important in preoperative prepare and postoperative recovery. It is suggested that shortening the preoperative fasting time is beneficial in reducing adverse reactions such as hunger, thirst, irritability, and anxiety in pediatric patients before surgery.¹⁴ As the pediatric patient drank 10% glucose solution according to their body weight before surgery, and the drinking time meets the surgical requirements, there is no solid food residue in their gastrointestinal tract. Therefore, it will not increase the risk of intraoperative gastroesophageal reflux. It can be seen that for pediatric patients before surgery, drinking an appropriate amount of glucose solution before surgery can improve their preoperative experience. The postoperative diet of pediatric patients with OSAHS has a very important relationship with the prognosis of OSAHS surgery. After the surgery, many pediatric patients refuse to eat due to throat pain, which affects their nutritional status and can have adverse effects on the healing of surgical wounds. Based on the recovery status of individuals, we gradually transitioning from cold liquid and semi-liquid food to soft food while controlling the amount of food intake to ensure their nutritional status. Additionally, we encouraged small and frequent meals for pediatric patients, together with enhancing oral care. Furthermore, we encourage pediatric patients to engage bed activities and walking after surgery, which also helped to increase postoperative food intake, replenish energy and nutrition, and promote the healing of the surgical incision area. Therefore, providing nutrition support postoperatively according to the ERAS theory is essential for pediatric patients, which can further improve their nutritional level and promote postoperative recovery.

In this study, we used plasma-coblation tonsillectomy and adenoidectomy as the surgical approach to manage OSAHS. Studies suggested that this method is able to relief the symptoms of OSAHS in pediatric patients with promising property and enhanced sleeping quality.¹⁵ The plasma-coblation tonsillectomy and adenoidectomy under nose-endoscopy provides a clearer surgical field that can reduce damage to surrounding tissues, resulting in less bleeding during and after surgery, faster postoperative healing, fewer postoperative reactions, shorter pain duration, and less suffering.¹⁶ Therefore, it can be considered as the preferred clinical treatment for pediatric patients with OSAHS, according with ERAS theory.

Pain management is a core process of ERAS theory. Insufficient pain intervention or treatment causes elevated catecholamine levels, leading to increased blood pressure and heart rate in pediatric patients, and thereby increasing the occurrence of postoperative complications.^17,18 Adequate analgesia can effectively ameliorate pain and reduce stress response, promoting early recovery of the pediatric patients.¹⁹ Studies suggested that a better postoperative ambulation is closely related to the successful ERAS pain management.²⁰ In the present study, we gave adequate analgesic medication together with sufficient nursing to OSAHS patients according to ERAS theory. Lidocaine, an amide local anesthetic, was injected preoperatively to relief pain, which can be fully absorbed by intramuscular injection and maintains analgesic effect for at least 2 h. After the operation, a self-controlled intravenous analgesic pump with fentanyl and haloperidol was given to the patients for continuous analgesia, that also reduced the dose of analgesics with little accumulation after repeated administration.²¹ Meanwhile, the parents and child were introduced with the pain managements and were encouraged to positively participate in the pain intervention and rehabilitation nursing activities. We found that the pain score of the patients under ERAS managements was significantly decreased comparing with control at 24-, 48-, 72 h post operation, indicating that ERAS is helpful to further enhance the analgesic effect of OSAHS surgery. Moreover, early and continuous analgesic intervention based on the ERAS theory not only relieves pain and surgical stress, but also facilitates the recuperation of psychological or physiological state, reduces intraoperative or postoperative hemorrhage, ultimately providing patients with a greater sense of comfort and better recovery outcome.

Some pediatric patients experience postoperative complications, such as bleeding, infection, fever, and secretory otitis media. The plasma-coblation tonsillectomy and adenoidectomy approach combining with ERAS managements have the ability to reduce bleeding, protect mucosa, shorten the recovery time, and decrease the incidence of complications.^22–24 In our study, we found that the occurrence of complications in patients under ERAS managements was notably lower than that of classical managements, indicating the further improvement of surgical safety, in accordance with previous reports.⁹ It is reported that thermal damage of the mucosa in the surgical section caused collagen degeneration, and the collagen was absorbed to cause fever and infection.²⁵ Besides, the pediatric patients are sensitive to pain feeling, they may refuse to drink or eat after the surgery that leads to bacterial reproduction in the pharynx wound surface, which also sever the infection. By enhancing analgesic intervention and nutritional support, ERAS can promote the recovery of children after surgery, accelerate wound healing and prevent wound infection, thus helping to prevent fever symptoms. Postoperative bleeding is also one of the common postoperative complications in children with OSAHS, which is usually caused by incomplete intraoperative hemostasis or damage to the surrounding tissues. ERAS managements given to the patients may prevent further damages to normal tissues, and reduce postoperative blood loss.^26–28 Moreover, the occurrence of secretory otitis media after OSAHS operation are associated with the torus tubarius swelling and pharyngotympanic tube compression that causes negative pressure in the ear, and the sinusitis or rhinitis illness. Under ERAS, patients undergo comprehensive preoperative examinations to understand the health status of the nasopharynx, and receive reasonable adjustment of surgical plans to prevent secretory otitis media.

Our study has several strengths. First, we enrolled patients consecutively into the study for a period of several years, which minimizes the distortion of association by selection bias. The large patient population serviced by this tertiary academic hospital each year is a fair representation of the regional general population, boosting the generalizability of our results. Second, the large sample size of our study ensures sufficient statistical power to detect differences between study groups. Third, the exposure and outcome data, particularly postoperative pain, mental scores and return to oral intake and activity were prospectively collected, eliminating the possibility of recall bias. There are also some limitations to our study. Due to the non-randomized study design, the results could be subject to confounding. However, we did not find any significant differences in key baseline characteristics and preoperative variables between the groups. Besides, the multiple aspects of the ERAS protocol cover the entire process of patient care, making it a complex exposure consisting of many separable elements, which reduces the relative impact of confounding by unmeasured baseline variables. Another limitation that has been noted in other ERAS studies results from the interaction between ERAS and control group patients, which could not be prevented in the surgical wards, and would increase the awareness of the benefits of ERAS practices among control patients, thereby modulating their behavior. But this tends to bias the association towards the null, and would be unlikely to threaten the internal validity of any significant findings.

5 Conclusion

Overall, ERAS management in OSAHS patients led to significantly lower postoperative hospital stay, postoperative pain and incidence of postoperative complications, resulting in better postoperative recovery. The ERAS concept is feasible and has good clinical application value in children with OSAHS, and is worth popularizing.

Footnotes

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Ljungqvist

Scott

Fearon

. Enhanced recovery after surgery: a review. JAMA Surg 2017; 152: 292–298.

, et al. Epidemiology of obstructive sleep apnoea syndrome in Chinese children: a two-phase community study. Thorax 2010; 65: 991–997.

Bitners

Arens

. Evaluation and management of children with obstructive sleep apnea syndrome. Lung 2020; 198: 257–270.

Noordzij

Affleck

. Coblation versus unipolar electrocautery tonsillectomy: a prospective, randomized, single-blind study in adult patients. Laryngoscope 2006; 116: 1303–1309.

Magdy

Elwany

El-Daly

, et al. Coblation tonsillectomy: a prospective, double-blind, randomised, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies. J Laryngol Otol 2008; 122: 282–290.

Tan

Hsu

Eng

, et al. Coblation vs electrocautery tonsillectomy: postoperative recovery in adults. Otolaryngol Head Neck Surg 2006; 135: 699–703.

Gülşen

Çikrikçi

. Comparison of endoscope-assisted coblation adenoidectomy to conventional curettage adenoidectomy in terms of postoperative eustachian tube function. J Craniofac Surg 2020; 31: 919–923.

Calvo-Henriquez

RuedaFernandez-Rueda

Garcia-Lliberos

, et al. Coblator adenoidectomy in pediatric patients: a state-of-the-art review. Eur Arch Otorhinolaryngol 2023; 280: 4339–4349.

Rafeeqi

Pearson

. Enhanced recovery after surgery in children. Transl Gastroenterol Hepatol 2021; 6: 46.

10.

Jiang

Liu

, et al. Safety and benefit of pre-operative oral carbohydrate in infants: a multi-center study in China. Asia Pac J Clin Nutr 2018; 27: 975–979.

11.

Sung

. The visual analogue scale for rating, ranking and paired-comparison (VAS-RRP): a new technique for psychological measurement. Behav Res Methods 2018; 50: 1694–1715.

12.

Trivedi

. Cochrane review summary: mini-mental state examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations. Prim Health Care Res Dev 2017; 18: 527–528.

13.

Nygren

Thorell

Ljungqvist

. Preoperative oral carbohydrate therapy. Curr Opin Anaesthesiol 2015; 28: 364–369.

14.

Smith

Kranke

Murat

, et al. Perioperative fasting in adults and children: guidelines from the European society of anaesthesiology. Eur J Anaesthesiol 2011; 28: 556–569.

15.

Qiao

Chen

. Efficacy of low-temperature plasma-assisted unilateral/bilateral tonsillectomy and adenoidectomy in children with obstructive sleep apnea hypopnea syndrome. Med Sci Monit 2021; 27: e930792.

16.

Tang

Liao

Tian

, et al. Effectiveness of low-temperature plasma tonsillectomy for chronic tonsillitis. A protocol of systematic review and meta-analysis. Ann Ital Chir 2022; 92: 280–285.

17.

Mitchell

Archer

Ishman

, et al. Clinical practice guideline: tonsillectomy in children (update)-executive summary. Otolaryngol Head Neck Surg 2019; 160: 187–205.

18.

Zhang

, et al. Effect of comprehensive nursing intervention on wound pain and wound complications in patients with tonsillectomy: a meta-analysis. Int Wound J 2024; 21: e14619.

19.

Daneshmand

Bazargani

, et al. Postoperative pain management after radical cystectomy: comparing traditional versus enhanced recovery protocol pathway. J Urol 2015; 194: 1209–1213.

20.

Vlug

Wind

Hollmann

, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011; 254: 868–875.

21.

van de Donk

Ward

Langford

, et al. Pharmacokinetics and pharmacodynamics of sublingual sufentanil for postoperative pain management. Anaesthesia 2018; 73: 231–237.

22.

Temple

Timms

. Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2001; 61: 195–198.

23.

Di Rienzo Businco

Coen Tirelli

. Paediatric tonsillectomy: radiofrequency-based plasma dissection compared to cold dissection with sutures. Acta Otorhinolaryngol Ital 2008; 28: 67–72.

24.

Wang

Liu

Tang

, et al. Effects of low-temperature plasma treatment on pulmonary function in children with obstructive sleep apnea-hypopnea syndrome. Ir J Med Sci 2020; 189: 603–609.

25.

Sun

Wang

Yang

, et al. Complications analysis of adenoidectomy and tonsillectomy assisted with ablation on children. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2017; 31: 1720–1723.

26.

Stefura

Dros

Kacprzyk

, et al. Influence of preoperative weight loss on outcomes of bariatric surgery for patients under the enhanced recovery after surgery protocol. Obes Surg 2019; 29: 1134–1141.

27.

Jonsson

Lin

Patel

, et al. Barriers to enhanced recovery after surgery after laparoscopic sleeve gastrectomy. J Am Coll Surg 2018; 226: 605–613.

28.

Huang

Guilleminault

Hwang

, et al. Inflammatory cytokines in pediatric obstructive sleep apnea. Medicine (Baltimore) 2016; 95: e4944.