Pilot enhanced recovery after surgery protocol: Cranial vault remodeling for craniosynostosis.

Background: Enhanced recovery after surgery (ERAS) protocols are standardized procedural guidelines proven to decrease hospital stay and postoperative narcotic use and improve overall patient experience. There is no existing ERAS protocol for open cranial vault remodeling (CVR) in the pediatric population. We believe that CVR is one such surgery meriting an ERAS protocol given its multidisciplinary and longitudinal treatment course. Such protocol is of particular interest in San Bernardino County, where the vast geographic area and wide socioeconomic spectrum result in unique barriers to healthcare accessibility that favor open remodeling over endoscopic approaches. Methods: The primary purpose of an ERAS protocol is to minimize both psychological and physiologic stress associated with a given procedure. This can be targeted at various phases of the patient encounter, including the preoperative, intraoperative, and postoperative stages. Here, we introduce our pilot protocol for ERAS implemented at Loma Linda University Children's Hospital (LLUCH) starting since 2018. Results: Our CVR process begins at the craniofacial clinic, where interdisciplinary chart and imaging review ensure appropriate patient enrollment and clinical service engagement. Day of surgery checklists ensure standardized preoperative cleansing, fasting, and laboratory criteria. Intraoperative guidelines facilitate interdisciplinary transparency regarding antibiotics, blood transfusions, fluid status, pain control, and tranexamic acid and mannitol administration. Standardized postoperative criteria dictate progression through the intensive care unit through to discharge. Conclusion: Retrospective chart review will compare LLUCH outcomes to those reflected in the National Surgical Quality Improvement Program. We hope to demonstrate that the CVR process at LLUCH is comparable to the national average and that implementation of a standardized ERAS protocol can significantly improve clinical and social outcomes.