Bilateral Suprazygomatic Maxillary Nerve Block for Cleft Palate Repair in Children

Demystifying the Suprazygomatic Maxillary Nerve Block in Paediatric Cleft Palate Surgery

OBJECTIVE

To consider the clinical anatomy, safety and effectiveness of the suprazygomatic maxillary nerve block in cleft palate surgery.

DESIGN

Observational case series.

SETTING

Single cleft centre in the United Kingdom.

PARTICIPANTS

Patients born with a cleft palate (with or without a cleft lip) undergoing palatal surgery between the ages of 9 months and 18 years.

INTERVENTION

Introduction of suprazygomatic maxillary nerve (SZMN) block using ropivacaine 0.2% into clinical protocol in February 2023.

MAIN OUTCOME MEASURES

Peri-procedure complications and post-operative opioid administration.

RESULTS

The clinical anatomy of the SZMN block is described in a stepwise and pictorial approach from superficial to deep structures. 43 patients underwent surgical interventions involving the palate (either intravelar veloplasty, Furlow palatoplasty or bilateral myomucosal buccinator flaps for palatal lengthening). 22 patients had a general anaesthetic and local anaesthetic infiltration and 21 had an additional SZMN block. There were no local or systemic complications associated with the SZMN block. There was no difference in the total dosing of post-operative (P = .79) opioids between the groups.

CONCLUSIONS

We demonstrate the feasibility and safety of this procedure without the use of ultrasound guidance in a heterogenous group of paediatric patients undergoing palatal surgery. Regional anaesthesia should be considered as part of the multi-modal analgesic strategy, although it may be difficult to demonstrate a change in opioid use in clinical settings where enhanced recovery techniques are established, and opioid use is already low.

Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND/IMPORTANCE

Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery.

OBJECTIVES

The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.

EVIDENCE REVIEW

MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023.

FINDINGS

Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown.

CONCLUSION

The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients.

PROSPERO REGISTRATION NUMBER

CRD42022364788.

Bilateral ultrasound-guided maxillary and mandibular combined nerves block reduces morphine consumption after double-jaw orthognathic surgery: a randomized controlled trial

BACKGROUND

Double-jaw surgeries are known to be painful and to require opioids. Maxillary (V2) and mandibular (V3) nerves block could provide adequate pain management with minimal opioid-related side effects. Our main objective was to evaluate the analgesic effect of bilateral ultrasound-guided V2 and V3 combined nerves block in patients undergoing double-jaw orthognathic surgery.

METHODS

In this single-blind, randomized control study, 50 patients were prospectively allocated to either bilateral ultrasound-guided V2 and V3 combined nerves block or intraoral infiltration of local anesthetic. Primary outcome was the cumulative oral morphine equivalent (OME) consumption assessed at postoperative day 1. Secondary outcomes were cumulative OME consumption and pain scores in recovery room and at postoperative day 2, intraoperative anesthetic consumption, and opioid-related side effects. Preoperative anxiety was investigated by the Amsterdam Preoperative Anxiety and Information Scale (APAIS).

RESULTS

Compared with infiltration, ultrasound-guided regional anesthesia reduced cumulative OME consumption on day 1 (45.7±37.6 mg vs 25.5±19.8 mg, respectively, mean difference of -20.1 (95% CI -37.4 to -2.9) mg, p=0.023) and day 2 (64.5±60 mg vs 35.8±30.2 mg, respectively, mean difference of -28.7 (95% CI -55.9 to -1.43) mg, p=0.040). Interestingly, worst pain score and cumulative OME consumptions on day 2 were positively correlated with the APAIS (Pearson's correlation coefficient of 0.42 (p=0.003) and 0.39 (p=0.006), respectively).

CONCLUSION

Bilateral ultrasound-guided V2 and V3 combined nerves block reduces postoperative opioid consumption by about 50% in patients undergoing double-jaw surgery.

TRIAL REGISTRATION NUMBER

NCT05351151.

Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy: A Randomized Clinical Trial

Importance

Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications.

Objective

To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications.

Design, Setting, and Participants

This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group).

Intervention

SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy.

Primary Outcomes and Measures

Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium.

Results

The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications.

Conclusions and Relevance

The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications.

Trial Registration

ClinicalTrials.gov Identifier: NCT04797559.

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration

INTRODUCTION

Although the maxillary nerve block (MNB) provides adequate pain relief in cleft palate surgery, it is not routinely used globally, and reported techniques are heterogeneous. This study aims to describe relevant anatomy and to present the preferred technique of MNB administration based on the current literature and the expert opinion of the authors.

METHOD AND MATERIALS

First, a survey was sent to 432 registrants of the International Cleft Palate Master Course Amsterdam 2023. Second, MEDLINE (PubMed interface) was searched for relevant literature on maxillary artery (MA) anatomy and MNB administration in pediatric patients.

RESULTS

Survey response rate was 18% (n=78). Thirty-five respondents (44.9%) used MNB for cleft palate surgery before the course. A suprazygomatic approach with needle reorientation towards the ipsilateral commissure before incision was most frequently reported, mostly without the use of ultrasound. Ten and 20 articles were included on, respectively, MA anatomy and MNB administration. A 47.5% to 69.4% of the MA's run superficial to the lateral pterygoid muscle and 32% to 52.5% medially. The most frequently described technique for MNB administration is the suprazygomatic approach. Reorientation of the needle towards the anterior aspect of the contralateral tragus appears optimal. Needle reorientation angles do not have to be adjusted for age, unlike needle depth. The preferred anesthetics are either ropivacaine or (levo)bupivacaine, with dexmedetomidine as an adjuvant.

CONCLUSION

Described MNB techniques are heterogeneous throughout the literature and among survey respondents and not routinely used. Further research is required comparing different techniques regarding efficacy and safety.

Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair

OBJECTIVE

This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not.

DESIGN

Retrospective cohort study.

SETTING

The study takes place at a single tertiary children's hospital.

PATIENTS

All patients who underwent cleft palate repair during a 10-year period (n = 242).

INTERVENTIONS

All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol.

MAIN OUTCOME MEASURES

Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery.

RESULTS

Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01).

CONCLUSIONS

Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.

Rescue designs in analgesic trials from 0 to 2 years of age: scoping review

Pediatric analgesic trials are challenging, especially in newborns and infants. Following an FDA-academic consensus meeting, we analyzed pragmatic rescue designs in postoperative trials of local anesthetics, acetaminophen, opioids, and NSAIDs involving children ages 0-2 years and assessed surgical volumes to provide trial design recommendations. Searches of PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science were conducted. A scoping approach identified trends in analgesic trials with an emphasis on randomized controlled trials (RCTs) utilizing immediate rescue designs. Age-specific surgical volumes were estimated from French national databases. Of 3563 studies identified, 23 RCTs used study medication(s) of interest and immediate rescue paradigms in children ages 0-2 years. A total of 270 studies met at least one of these criteria. Add-on and head-to-head designs were common and often used sparing of non-opioid or opioid rescue medication as a primary outcome measure. According to French national data, inguinal and penile surgeries were most frequent in ages 1 month to 2 years; abdominal and thoracic surgeries comprise approximately 75% of newborn surgeries. Analgesic trials with rescue sparing paradigm are currently sparse among children ages 0-2 years. Future trials could consider age-specific surgical procedures and use of add-on or head-to-head designs. IMPACT: Clinical trials of analgesic medications have been challenging in pediatrics, especially in the group from newborns to 2 years of age. Following an FDA-academic workshop, we analyzed features of completed analgesic trials in this age group. Studies using immediate rescue in placebo control, add-on, and head-to-head trial designs are pragmatic approaches that can provide important information regarding clinical effectiveness, side effects, and safety. Using a French national dataset with a granular profile of inpatient, outpatient, and short-stay surgeries, we provide information to future investigators on relative frequencies of different operations in neonates and through the first 2 years of life.

Ultrasound-Guided Suprazygomatic Maxillary Nerve Block Is Effective in Reducing Postoperative Opioid Use Following Bimaxillary Osteotomy

BACKGROUND

Ultrasound-guided maxillary nerve block has recently been described, though its impact upon bimaxillary osteotomy has not been formally investigated.

PURPOSE

The present study was carried out to determine whether the addition of ultrasound-guided maxillary nerve block in subjects undergoing bimaxillary osteotomy reduces opioid use.

STUDY DESIGN, SETTING, SAMPLE

A randomized clinical trial was carried out in adults undergoing bimaxillary osteotomy between April 2019 and January 2020 at Teknon Medical Center (Barcelona, Spain).

PREDICTOR VARIABLE

The predictor variable was the treatment technique used (maxillary nerve block or no block). The subjects were randomized to either receive (test group) or not receive (control group) bilateral ultrasound-guided suprazygomatic maxillary nerve block (5 ml of 0.37% ropivacaine) before surgery.

MAIN OUTCOME VARIABLE(S)

The primary outcome variable was the intravenous methadone requirements in the first two postoperative hours. The secondary outcome variables were postoperative pain, rescue subcutaneous methadone, intravenous remifentanil used intraoperatively, the incidence of postoperative nausea-vomiting, and complications derived from maxillary nerve block.

COVARIATES

Subject age, sex, weight, height, and anesthetic risk, and the duration of surgery were recorded.

ANALYSES

Descriptive and inferential analyses were performed using the χ2 test and Mann-Whitney U test. Statistical significance was considered for P < .05.

RESULTS

The baseline sample consisted of 68 subjects scheduled for bimaxillary osteotomy. The follow-up sample comprised 60 subjects: 30 in the control group (10 females and 20 males, aged 34.0 ± 10.2 years) and 30 in the test group (13 females and 17 males, aged 29.8 ± 10.8 years). The subjects who received maxillary nerve block showed less intravenous methadone use in the first 2 hours postsurgery (median 2.0 mg control group vs 0 mg test group; P < .001), lower pain levels at any time during the first 18 hours postsurgery (median visual analog score 4 control group vs 2 test group; P < .001), and a lesser percentage required methadone (33.3% control group vs 0% test group; P < .01) at 4-18 hours postsurgery.

CONCLUSION AND RELEVANCE

The results obtained suggest that ultrasound-guided maxillary nerve block is a promising anesthetic technique capable of reducing intraoperative and postoperative opioid use, with greater patient comfort in bimaxillary osteotomy.

Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children

OBJECTIVE

This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty.

DESIGN

Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon.

SETTING

Urban, academic, tertiary care children's hospital.

PATIENTS, PARTICIPANTS

Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30).

INTERVENTIONS

All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB.

MAIN OUTCOME MEASURE(S)

Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay.

RESULTS

When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB.

CONCLUSIONS

Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.

Utility of Regional Maxillary Nerve Blocks in Improving Cleft Palate Postoperative Outcomes

BACKGROUND

Palatoplasty procedures used to repair cleft palates are commonly associated with limiting postoperative pain. Regional anesthetic blocks have been utilized to improve pain outcomes and decrease opioid intake, yet additional data is needed to fully explore its utility in this setting.

OBJECTIVE

To explore whether ultrasound-guided suprazygomatic maxillary blocks (SMB) improve postoperative pain, postoperative opioid use, time to oral feeding, and length of stay compared with a palatal field block in cleft palate repair.

METHODS

In this retrospective chart review, 47 patients aged 9 to 25 months who underwent cleft palate repair between 2013 and 2020 were allocated into 2 groups: a control group where patients received only palatal local anesthetic in a field block fashion (N=29), and Maxillary block group who received ultrasound-guided SMB (N=18). Patients were matched by age and cleft Veau type. The primary outcomes were total postoperative morphine equivalent consumption, average pain scores, length of stay, and time to first oral feed.

RESULTS

Comparing field block versus SMB groups, there was not a statistical difference in the overall dose of postoperative morphine equivalent opioid administration (11.71 vs. 13.36 mg; P=0.483), average pain scores (5.78 vs. 5.27; P=0.194), time to first oral feed [17.21 vs. 14.48 h; P=0.407, 95% CI: (-3.85, 9.32)] or length of stay (P=0.292).

CONCLUSION

The use of SMBs did not demonstrate a difference in the postoperative outcomes evaluated by this study. Further study is needed to define its utility in cleft palate repair.

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

BACKGROUND

Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery.

METHODS

A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type.

RESULTS

Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery.

CONCLUSIONS

Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Enhanced recovery after cleft palate repair: A quality improvement project

BACKGROUND

Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.

AIMS

The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery.

METHODS

A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.

RESULTS

Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes.

CONCLUSION

Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.

Ultrasound-Guided Suprazygomatic Nerve Blocks to the Pterygopalatine Fossa: A Safe Procedure

OBJECTIVES

Large-scale procedural safety data on pterygopalatine fossa nerve blocks (PPFBs) performed via a suprazygomatic, ultrasound-guided approach are lacking, leading to hesitancy surrounding this technique. The aim of this study was to characterize the safety of PPFB.

METHODS

This retrospective chart review examined the records of adults who received an ultrasound-guided PPFB between January 1, 2016, and August 30, 2020, at the University of Florida. Indications included surgical procedures and nonsurgical pain. Clinical data describing PPFB were extracted from medical records. Descriptive statistics were calculated for all variables, and quantitative variables were analyzed with the paired t test to detect differences between before and after the procedure.

RESULTS

A total of 833 distinct PPFBs were performed on 411 subjects (59% female, mean age 48.5 years). Minor oozing from the injection site was the only reported side effect, in a single subject. Although systolic blood pressure, heart rate, and oxygen saturation were significantly different before and after the procedure (132.3 vs 136.4 mm Hg, P < 0.0001; 78.2 vs 80.8, P = 0.0003; and 97.8% vs 96.3%, P < 0.0001; respectively), mean arterial pressure and diastolic blood pressure were not significantly different (96.2 vs 97.1 mm Hg, P = 0.1545, and 78.2 vs 77.4 mm Hg, P = 0.1314, respectively). Similar results were found within subgroups, including subgroups by sex, race, and indication for PPFB.

DISCUSSION

We have not identified clinically significant adverse effects from PPFB performed with an ultrasound-guided suprazygomatic approach in a large cohort in the hospital setting. PPFBs are a safe and well-tolerated pain management strategy; however, prospective multicenter studies are needed.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

BACKGROUND

Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair.

METHODS

A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated.

RESULTS

Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed.

CONCLUSIONS

The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study

OBJECTIVE

Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake.

DESIGN

This is a retrospective review from 2015 to 2018.

PATIENTS

Nonsyndromic patients undergoing primary palate repair.

MAIN OUTCOMES MEASURES

Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered.

RESULTS

Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05).

CONCLUSION

Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.

A Novel Pain Relief Approach for the Treatment of Multiple Dental Caries and Pulpitis

Anxiety and stress toward treatment can hamper treatment completion in patients with dental caries and pulpitis. Therefore, effective management of post-treatment pain is important because poor pain management can lead to patient dissatisfaction. Ultrasound-guided nerve blocks provide good postoperative analgesia in maxillofacial surgeries. These surgeries can be performed under general or local anesthesia without complications. Here, we present the case of a patient with dental phobia who was successfully treated with these techniques. The patient was a 22-year-old woman with a history of manic-depressive illness who presented with 23 decayed teeth. She had previously undergone vital pulp therapy; however, post-treatment pain led to treatment-related stress, and the patient discontinued the dental treatment. She preferred the dental treatment to be completed with as little pain as possible and wanted to avoid a pulpectomy. The patient’s history of heavy use of non-steroidal anti-inflammatory drugs (NSAIDs) made her resistant to NSAIDs. As a result, the analgesic effect of NSAIDs could not be expected. After intravenous midazolam and propofol sedation, an ultrasound-guided inferior alveolar nerve block was performed bilaterally, and 0.375% ropivacaine was used as a local anesthetic. The patient did not complain of post-operative pain, and no post-operative analgesics were required.

Assessment of intraoperative hemodynamics and recovery characteristics in pediatric patients receiving buprenorphine and propofol anesthesia for cleft palate surgery: A prospective observational study

Background:

Children with cleft palate are usually operated on before 18 months of age. Cleft palate surgery demands stable hemodynamic parameters, a bloodless surgical field, and an awake and pain-free child after surgery.

Aims:

We aimed to study the anesthesia technique using buprenorphine and propofol for cleft palate surgery.

Settings and Design:

The design involves prospective observational study. The study was conducted at a tertiary care hospital.

Materials and Methods:

After the Institutional Ethics Committee approval, 42 patients aged 6 months to 12 years undergoing cleft palate surgery were enrolled. Anesthesia induction commenced with sevoflurane or propofol 3 mg.kg⁻¹. After intubation, buprenorphine 3 μg.kg⁻¹ was given, and propofol infusion was started at 2–8 mg.kg⁻¹.h⁻¹. Hemodynamic parameters, awakening time, and surgeon's satisfaction score were noted. After extubation, pain score, emergence agitation (EA) score, sedation score, recovery score, and adverse events were noted.

Statistical Analysis:

All statistical analyses were performed using the 20.0 version of the Statistical Package for the Social Science (SPSS) software program. Continuous data were summarized as mean and standard deviation, and were analyzed using a two-sided Student's unpaired t-test. Categorical data were represented using frequencies and proportions.

Results:

The single dose of buprenorphine with propofol infusion started immediately postintubation causes a significant decrease in heart rate after 1 h. This contributed to a favorable operative field, increasing the surgeon's satisfaction score. In the recovery room, patients were essentially pain-free till 2.5 h after surgery, with only one patient requiring rescue analgesia. Furthermore, 90% of patients showed a smooth and calm recovery with no EA. The Steward's recovery score remained high throughout without any complication.

Conclusions:

In cleft palate surgeries, a single-dose buprenorphine 3 μg.kg⁻¹ and propofol maintenance infusion 2–8 mg.kg⁻¹.h⁻¹ were effective in maintaining hemodynamic parameters and a bloodless surgical field and managing postoperative pain with a good recovery profile.

Ensuring the effectiveness and safety of peripheral blockades

Adequate analgesia determines the success of the performed surgical intervention. In modern surgery, most of postoperative complications are directly related to ineffective therapy of pain syndrome in the perioperative period. The main principle of modern analgesia is its multicomponence, when analgesia, neurovegetative blockade and relaxation are achieved and potentiated by different drugs and methods. The blockade of nociceptive impulses with a local anesthetic at the transmission stage provides effective, targeted analgesia, hyporefl exia and muscle relaxation, prevents the sensitization of neuroaxial structures, hyperalgesia and the development of postoperative chronic pain syndrome. At the same time, providing analgesia with drugs of central action leads to the ineffectiveness of therapy in 80 % of cases, which has serious consequences.The aim. According to the literature review, to evaluate the effectiveness and safety of peripheral blockades on the example of performing a blockade of the pterygopalatine ganglion.Conclusion. The pterygopalatine blockade has broad indications for use in ophthalmology, which is explained by the complex structure of the pterygopalatine ganglion and the possibility of simultaneous infl uence on sympathetic, parasympathetic and nociceptive innervation. All the presented methods of pterygopalatine blockade performance have their advantages and disadvantages. Ultrasound navigation eliminates technical difficulties and the possibility of damage of the pterygopalatine fossa anatomical structures, ensuring the effectiveness and safety of the pterygopalatine blockade.

Application of ultrasound guidance in the oral and maxillofacial nerve block

Introduction

Nerve block technology is widely used in clinical practice for pain management. Conventional nerve localization methods, which only rely on palpation to identify anatomical landmarks, require experienced surgeons and can be risky. Visualization technologies like ultrasound guidance can help prevent complications by helping surgeons locate anatomical structures in the surgical area and by guiding the operation using different kinds of images. There are several important and complex anatomical structures in the oral and maxillofacial regions. The current article reviews the application of ultrasound guidance in oral and maxillofacial nerve blocks.

Methods

We searched the literature on the use of ultrasound guidance for the main nerve block techniques in the oral and maxillofacial regions using both PubMed and MEDLINE and summarized the findings.

Results and Discussion

A review of the literature showed that ultrasound guidance improves the safety and effectiveness of several kinds of puncture procedures, including nerve blocks. There are two approaches to blocking the mandibular nerve: intraoral and extraoral. This review found that the role of ultrasound guidance is more important in the extraoral approach. There are also two approaches to the blocking of the maxillary nerve and the trigeminal ganglion under ultrasound guidance: the superazygomatic approach and the infrazygomatic approach. The infrazygomatic approach can be further divided into the anterior approach and the posterior approach. It is generally believed that the anterior approach is safer and more effective. This review found that the effectiveness and safety of most oral and maxillofacial nerve block operations can be improved through the use of ultrasound guidance.

Effectiveness of analgesia with hydromorphone hydrochloride for postoperative pain following surgical repair of structural congenital malformations in children: a randomized controlled trial

Background

Effective postoperative analgesia is needed to prevent the negative effects of postoperative pain on patient outcomes. To compare the effectiveness of hydromorphone hydrochloride and sufentanil, combined with flurbiprofen axetil, for postoperative analgesia in pediatric patients.

Methods

This prospective randomized controlled trial included 222 pediatric patients scheduled for repair of a structural congenital malformation under general anesthesia. Patients were randomized into 3 groups: hydromorphone hydrochloride 0.1 mg/kg (H1), hydromorphone hydrochloride 0.2 mg/kg; (H2) or sufentanil 1.5 µg/kg (S). Analgesics were diluted in 0.9% saline to 100 ml and infused continuously at a basic flow rate of 2 mL per h. The primary outcome measure was the Face, Legs, Activity, Cry, and Consolability (FLACC) pain score. Secondary outcomes included heart rate (HR), respiration rate (RR), SpO₂, Ramsay sedation scores, scores on the Paediatric Anaesthesia Emergence Delirium (PAED) scale, adverse reactions, parent satisfaction with analgesia.

Results

The FLACC score was significantly lower in H1 and H2 groups compared to S. The Ramsay sedation score was significantly higher in H1 and H2 groups compared to S. Recovery time was shorter in H1 group compared to patients H2 group or S group. There were no significant differences in the PAED scale, HR, RR, SpO2, adverse reactions, satisfaction of parents with analgesia, or length and cost of hospital stay.

Conclusions

Hydromorphone hydrochloride is a more effective analgesic than sufentanil for postoperative pain in pediatric patients following surgical repair of a structural congenital malformation, however, hydromorphone hydrochloride and sufentanil had similar safety profiles in this patient population.

Trial registration

Chinese Clinical Trial Register ChiCTR-INR-17013935). Clinical trial registry URL: Date of registration: December 14, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01412-8.

Analgesic Efficacy of Intraoperative Nerve Blocks for Primary Palatoplasty

BACKGROUND

Cleft palate is a common craniofacial malformation, requiring surgical repair in late infancy or early toddlerhood. Postoperative use of opioids is common to mitigate pain following palatoplasty. To decrease opioid consumption, improve postoperative pain, and decrease complications associated with general anesthetics, intraoperative regional nerve blocks have been employed for multimodal pain relief. While the literature supports intraoperative nerve block use for postprocedural comfort in children undergoing palatoplasty, the topic has not been systematically summarized.

OBJECTIVES

The purpose of this review was to explore the efficacy of nerve block in palatoplasty, in addition to analyzing trends in nerve block modality and choice of local anesthetic on postoperative pain and opioid consumption.

METHODS

A systematic literature search was conducted through PubMed, Embase, Cochrane, and Web of Science databases for studies on cleft palate nerve block. Resulting reference lists were searched for potential eligible studies and then reviewed, with an emphasis on pain scores, postoperative analgesia consumption, and time to analgesia use.

RESULTS

A total of 259 articles were reviewed, of which 10 met inclusion criteria. Intraoperative suprazygomatic and greater palatine nerve blocks were the 2 most commonly reported blocks. Long acting agents, such as bupivacaine and ropivacaine, were the local anesthetic of choice. All modalities were effective in reducing postoperative pain scores and opioid consumption.

CONCLUSION

Intraoperative nerve blocks have been shown to be incredibly effective in reducing postoperative pain in children undergoing palatoplasty, minimizing both opioid consumption and recovery time. The existing literature suggests that suprazygomatic block with combined bupivacaine and dexmedetomidine is the preferred nerve block modality. Ultrasound guidance should be used when accessible.Level of Evidence: 2.

A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost

BACKGROUND

This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States.

METHODS

Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics.

RESULTS

Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all).

CONCLUSIONS

Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway

OBJECTIVE

To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair.

DESIGN

Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40).

PATIENTS

Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital.

INTERVENTIONS

A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized.

MAIN OUTCOME MEASURES

Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively.

RESULTS

Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups.

CONCLUSIONS

Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction

INTRODUCTION

Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair.

METHOD

The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey.

RESULTS

Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%).

CONCLUSION

Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

Is the Use of Opioids Safe after Primary Cleft Palate Repair? A Systematic Review

Pharmacologic treatment of postoperative pain after cleft palate repair includes opioids and nonopioid analgesics, nerve blocks, and local anesthetic infiltration. Use of opioids in infants has concerns regarding sedation, risk of aspiration, respiratory depression, and respiratory distress. The main objective of this review was to analyze information available on the safety of the use of opioids during perioperative management of pain related to primary cleft palate repair in published studies.

Methods

A systematic review of the literature for studies published until March 2020 was performed to evaluate the safety of opioid drugs during primary cleft palate repair pain management. The authors chose the following MesH terms for this systematic review: cleft lip and palate AND opioids AND pain management. The investigators performed a systematic literature search using the Pubmed/MEDLINE, Embase, Web of Science, and Cochrane Library databases.

Results

After a literature search resulting in 70 identified studies, 9 were qualified for the final analysis, which included 772 patients. There was a high level of evidence in the selected studies according to the Oxford CEBM Level of Evidence classification and GRADE scale. The most common adverse event reported was postoperative nausea and vomiting (from 5% to 25%). Episodes of oxygen desaturation have been reported from 2.5% to 7.4% of the studied patients.

Conclusion

s: Definitive conclusions about the safety of opioid drugs during primary cleft palate repair pain management cannot be drawn. Vomiting and oxygen desaturation have been associated with the use of opioids in the studied population.

Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage

BACKGROUND

Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal.

METHODS

This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement.

RESULTS

Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6-11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min.

CONCLUSIONS

PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.

Suprazygomatic maxillary nerve block: an ultrasound and cadaveric study to identify correct sonoanatomical landmarks

​PURPOSE: Suprazygomatic maxillary nerve blocks (SMB) are used in adult and pediatric patients to provide analgesia for midface surgery and chronic maxillofacial pain syndromes. The ultrasound-guided SMB technique ensures visualisation of the needle tip, avoidance of the maxillary artery and confirmation of local anesthetic spread. The goal of this study was to correctly identify SMB sonoanatomical landmarks to ensure the nerve block is performed safely and effectively.

METHODS

Following an ultrasound-guided SMB with dye injection on 2 embalmed cadavers, pre-tragal face-lift style incision with a full thickness flap dissection was performed allowing accurate visualization of the bony landmarks being used for sonography and identification of the location of the injected dye.

RESULTS

This study identifies the correct sonoanatomic landmarks as the maxilla and the coronoid process of the mandible which suggests that the block needle tip and local anesthetic injection are within the infratemporal fossa as opposed to the previously reported pterygopalatine fossa.

CONCLUSION

An improved understanding of the sonoanatomy will aid clinicians who are learning, performing and teaching the ultrasound-guided suprazygomatic approach to the maxillary nerve block.

Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized, Prospective, Double-Blind Study

OBJECTIVES

Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery?

DESIGN

Randomized, controlled, and double-blind study.

SETTING

Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India).

PARTICIPANTS

A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders.

INTERVENTIONS

Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG.

MAIN OUTCOME MEASURE

The primary end point was the incidence of emergence agitation.

RESULTS

There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed.

CONCLUSIONS

The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.

Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair

BACKGROUND

As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States.

METHODS

Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles.

RESULTS

Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics.

CONCLUSIONS

This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.

Trigeminal Nerve Blockade in the Pterygopalatine Fossa for the Management of Postoperative Pain in Three Adults Undergoing Tonsillectomy: A Proof-of-Concept Report

Setting

Post-tonsillectomy pain in adults can be severe and is often poorly controlled. Pain can lead to decreased oral intake, bleeding, longer hospital stays, emergency department visits, dehydration, and weight loss. Due to persistent pain despite scheduled medications, other methods for pain control are needed. Local/regional anesthetic options have been previously studied in this population. Unfortunately, neither the injection of local anesthetics into the tonsillar fossa nor the postoperative topical application of local anesthetics to the tonsillar bed has demonstrated efficacy in large systematic reviews.

Patients

Here we report on the post-tonsillectomy pain experience of three patients who were treated with perioperative nerve blocks placed in the pterygopalatine fossa. This represents an as-yet unexplored option for post-tonsillectomy pain control.

Intervention

After induction of general anesthesia, before surgical incision, a 25-gauge spinal needle was advanced into the pterygopalatine fossa using a suprazygomatic, ultrasound-guided approach. Ropivacaine and dexamethasone were deposited into the pterygopalatine fossa.

Results

All three patients experienced excellent pain control for the duration of their recovery and required ≤10 mg of oxycodone over the two weeks after surgery.

Conclusions

Our case series of three patients provides proof of concept that use of nerve blocks in the pterygopalatine fossa can be useful for the control of post-tonsillectomy pain. Further study is needed to confirm these initial results.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery

BACKGROUND

Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.

METHODS

After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.

RESULTS

The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).

CONCLUSIONS

Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Ultrasound-guided maxillary nerve block: an anatomical study using the suprazygomatic approach

PURPOSE

Although a maxillary nerve (MN) block reportedly provides satisfactory analgesia for midface surgery and chronic maxillofacial pain syndromes, a safe and reliable MN block technique has not been reported. The goal of this anatomical study was to quantify the various angles and depth of the block needle, as well as to evaluate the impact of volume on the extent of injectate spread that might influence anesthetic coverage and block-related complications.

METHODS

Following an ultrasound-guided suprazygomatic MN block with dye injection, a dissection was performed in the pterygopalatine fossa (PPF) of four lightly embalmed cadaveric specimens. Half of the specimens were injected with 5 mL of dye, and the other half with 1 mL of dye. The needle depth was measured from the ultrasound images and using rubber markers. Following injection, dissection was performed to map the area of dye spread.

RESULTS

The median [interquartile range (IQR)] distance from the skin to the PPF was 37 [36-43] mm and 47 [40-50] mm by ultrasound and rubber marker methods, respectively. The median [IQR] needle orientation was 14 [11-32] degrees inferiorly and 15 [10-17] degrees posteriorly. The PPF was consistently dyed in the 5 mL group, but sporadically dyed in the 1 mL group. In the 5 mL group, spread outside of the PPF was seen.

CONCLUSIONS

We showed that 5 mL of injectate far exceeds the capacity of the PPF, leading to drug spread outside of the PPF. Moreover, we found that 1 mL of injectate largely covered the nerve, suggesting a more efficacious and safer block procedure. This finding will need confirmation in future clinical studies.

Technical considerations for approaches to the ultrasound-guided maxillary nerve block via the pterygopalatine fossa: a literature review

Background and objectives

Blockade of the trigeminal nerve and its branches is an effective diagnostic tool and potential treatment of facial pain. Ultrasound-guided injections in the pterygopalatine fossa (PPF) to block the trigeminal nerve divisions and sphenopalatine ganglion have been described but a consensus has yet to be reached over the ideal approach. We sought to delineate and compare the various approaches to the ultrasound-guided trigeminal divisions blockade via the PPF.

Methods

The literature search was performed by searching the National Library of Medicine’s PubMed database, the Cochrane Database of Systematic Reviews and Google Scholar within the date range of January 2009–March 2019 for keywords targeted toward “trigeminal nerve,” “maxillary nerve,” or “pterygopalatine fossa,” “ultrasound,” and “nerve block,” using an English language restriction. Six papers were included in the final review: one prospective double-blinded randomized controlled trial, one prospective descriptive study, one case series, two case reports, and one cadaveric study.

Results

There are three main approaches to the ultrasound-guided trigeminal nerve branches blockade via the PPF: anterior infrazygomatic in-plane, posterior infrazygomatic in-plane, and suprazygomatic out-of-plane approaches. Each showed injectate spread to the PPF in cadaver, adult and pediatric patients, respectively.1–5 Injectate used varied from 3 to 5 mL to 0.15 mL/kg.

Conclusions

These studies demonstrated that the PPF is a readily accessible target for the ultrasound-guided maxillary nerve block via three main approaches.2 The ideal approach is yet to be determined and must be further explored.

Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

Background

For children with cleft palates, surgeries at a young age are necessary to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedetomidine might prolong the postoperative analgesic duration when added to bupivacaine during nerve blocks.

Methods

Eighty patients of 1-5 years old were arbitrarily assigned to two equal groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum volume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 µg/kg dexmedetomidine (maximum volume 4 mL/side).

Results

The modified children's hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). Mean values of heart rate and blood pressure were significantly different between the groups, with lower mean values in group B (P < 0.001). Median time to the first analgesic demand in group A children was 10 hours (range 8-12 hr), and no patients needed analgesia in group B. The sedation score assessment was higher in children given dexmedetomidine (P = 0.03) during the first postoperative 30 minutes. Better parent satisfaction scores (5-point Likert scale) were recorded in group B and without serious adverse effects.

Conclusions

Addition of dexmedetomidine 0.5 µg/kg to bupivacaine 0.125% has accentuated the analgesic efficacy of bilateral suprazygomatic maxillary nerve block in children undergoing primary cleft palate repair with less postoperative supplemental analgesia or untoward effects.

Management of postoperative pain in maxillofacial surgery

In this review we describe the evidence base for postoperative analgesia after maxillofacial surgery. We discuss the implications of poorly managed pain, risk factors for the development of severe pain, and pharmacological and non-pharmacological analgesic strategies to manage it.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus

BACKGROUND

Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM.

METHODS

Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection.

RESULTS

Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001).

CONCLUSION

The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.

Comparative study of levobupivacaine and bupivacaine for bilateral maxillary nerve block during pediatric primary cleft palate surgery: a randomized double-blind controlled study

Background

Cleft lip and palate are common major congenital anomalies. Cleft palate (CP) repair causes pain and needs large doses of intravenous opioids. The risk of postoperative airway obstruction or respiratory depression is high, requiring continuous and vigilant monitoring. The primary outcome was to evaluate the efficacy of using different local anesthetics during bilateral maxillary nerve block (MNB) with general anesthesia on quality of recovery after primary CP repair. We hypothesized that levobupivacaine would be better than bupivacaine. Also, to investigate the potency of bilateral MNB in improving quality of postoperative analgesia.

Methods

Sixty children undergoing primary CP repair surgery were enrolled in the study. Combined general anesthesia and regional bilateral MNB were used for all patients. Group L (n = 30): children received 0.15 ml/kg of 0.2% levobupivacaine, while in Group B (n = 30): children received 0.15 ml/kg of 0.2% bupivacaine.

Results

Face, Legs, Activity, Cry, and Consolability pain score readings were 0 score in 7 cases of the Group L and 10 cases of Group B, 1 score in 14 cases of the Group L and 12 cases of Group B, and 2 score in 9 cases of the Group L and 8 cases of Group B. We found no statistically significant difference between the two study groups as regarding pain score or serious complications.

Conclusions

Levobupivacaine is as effective and safe as bupivacaine to be used for MNB block with a lower incidence of complications. Bilateral suprazygomatic MNB is an effective, easy, and safe method for pain relief in children undergoing primary cleft palate repair surgeries.