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Frawley G, Wilkes C, Hallett B, Chong D. Prediction of Early Postoperative Pain in Infants Undergoing Primary Cleft Palate Repair. Cleft Palate Craniofac J 2024; 61:1493-1498. [PMID: 37101364 DOI: 10.1177/10556656231172303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVE Identification of at risk patients before surgery could facilitate improved clinical communication, care pathways and postoperative pain management. DESIGN A retrospective cohort study was performed in all infants who had undergone cleft palate repair. SETTING Tertiary Institutional. PARTICIPANTS Infants < 36 months of age who underwent primary repair of cleft palate between March 2016 and July 2022. INTERVENTION Requirement for analgesic intervention in the post operative care unit. MAIN OUTCOME MEASURE Adverse perioperative event defined as pain or distress. Secondary outcomes were the incidence of airway obstruction, hypoxemia or unplanned intensive care admission. RESULTS Two hundred and ninety one patients (14.6 months,10.1 kg weight) were included. Cleft distribution included submucous (5.2%), Veau I (23.4%), Veau 2 (38.1%), Veau 3 (24.4%), and Veau 4 (8.9%). Overall 35% of 291 infants undergoing cleft palate repair experienced pain or distress requiring opiate intervention in the first hour after surgery. Infants with a Veau 4 cleft palate had 1.8 times and Veau 2 cleft palate had 1.5 times the risk of postoperative pain compared to infants with Veau 1 cleft palate (relative risk 1.82, 95%CI 1.04-3.18 and 1.49, 95%CI 0.96-2.32 respectively). The use of bilateral above elbow arm splints was significantly associated with postoperative pain or distress (odds ratio 2.23, 95%CI 1.01-5.16). CONCLUSIONS Post operative pain requiring intervention in PACU is common despite adequate intraoperative multimodal analgesia, local anaesthesia infiltration and postoperative opiate infusions. Infants undergoing soft palate alone or submucous palate repair may require less perioperative opiates.
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Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital Melbourne, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Murdoch Childrens Research Institute, Critical Care and Neurosciences Theme, Parkville, Australia
| | - Courtney Wilkes
- Department of Plastic and Maxillofacial Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Ben Hallett
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital Melbourne, Parkville, Australia
| | - David Chong
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Plastic and Maxillofacial Surgery, The Royal Children's Hospital, Melbourne, Australia
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Mirzaie S, Oberoi MK, Huang KX, Caprini RM, Malapati SH, Dejam D, Bedar M, Cronin BJ, Khetpal S, Lee JC. Association of Patient-Reported Anxiety and Pain After Alveolar Bone Grafting. Cleft Palate Craniofac J 2024; 61:1336-1343. [PMID: 37077147 PMCID: PMC11308277 DOI: 10.1177/10556656231169483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To evaluate the role of psychosocial well-being on perioperative pain and opioid use among patients with cleft lip and palate (CLP) undergoing alveolar bone grafting (ABG). DESIGN Retrospective review. SETTING Tertiary level craniofacial clinic. PARTICIPANTS 34 patients with CLP (median age: 11.7 years), including 25 (73.5%) unilateral CLP and 9 (26.5%) bilateral CLP, who underwent ABG from 2015 to 2022. INTERVENTIONS ABG using iliac crest bone graft. Patients were prospectively administered four patient-reported psychosocial instruments from the Patient-Reported Outcomes Measurement Information System. MAIN OUTCOME MEASURES Perioperative opioid use in morphine equivalent dosage/kilogram, patient-reported pain scores, and length of hospital stay after ABG. RESULTS Patient-reported anxiety (r = 0.41, p = 0.02) and depressive symptoms (r = 0.35, p = 0.04) correlated to higher perioperative opioid usage. Multivariable regression models including psychosocial scores, total acetaminophen usage, length of surgery, and other simultaneous surgeries were developed for total opioid usage, patient-reported pain, and length of hospital stay. Patient-reported anxiety was independently predictive of higher perioperative opioid use (β=0.36, p = 0.01) and higher pain scores (β=0.39, p = 0.02), but not length of hospital stay. CONCLUSIONS We identified an association for patient-reported anxiety and perioperative opioid use and pain in a CLP cohort undergoing ABG. Future considerations in preoperative patient and family consultation may be indicated in patients self-reporting higher anxiety in an effort to minimize perioperative opioid usage.
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Affiliation(s)
- Sarah Mirzaie
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Michelle K. Oberoi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kelly X. Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Rachel M. Caprini
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sri Harshini Malapati
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Dillon Dejam
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Brendan J. Cronin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Justine C. Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Peters JJ, Jacobs K, Munill M, Top AP, Stevens MF, Ronde EM, Don Griot JPW, Lachkar N, Breugem CC. The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration. J Craniofac Surg 2024; 35:1356-1363. [PMID: 38861198 PMCID: PMC11198960 DOI: 10.1097/scs.0000000000010343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/03/2024] [Indexed: 06/12/2024] Open
Abstract
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.
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Affiliation(s)
- Jess J. Peters
- Departments of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Karl Jacobs
- Medical Biology, Section Clinical Anatomy and Embryology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Oral Pain and Dysfunction, Functional Anatomy, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands
| | - Montserrat Munill
- Oral and Maxillofacial Surgery, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Anke P.C. Top
- Anaesthesiology, Amsterdam UMC, location University of Amsterdam
| | | | - Elsa M. Ronde
- Departments of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J. Peter W. Don Griot
- Departments of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Nadia Lachkar
- Departments of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Corstiaan C. Breugem
- Departments of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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Applebaum SA, Aronson S, Termanini KM, Gosain AK. Evidence-Based Practices in Cleft Palate Surgery. Plast Reconstr Surg 2024; 153:448e-461e. [PMID: 38266141 DOI: 10.1097/prs.0000000000011035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.
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Affiliation(s)
- Sarah A Applebaum
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Sofia Aronson
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Kareem M Termanini
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
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Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med 2024:rapm-2023-105024. [PMID: 38124208 DOI: 10.1136/rapm-2023-105024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Nergis Nina Suleiman
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Girish Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Geertrui Dewinter
- Department of Cardiovascular Sciences, Section Anesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Axel R Sauter
- Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
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Aycart MA, Caterson EJ. Advances in Cleft Lip and Palate Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1932. [PMID: 38003981 PMCID: PMC10672985 DOI: 10.3390/medicina59111932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/21/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
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.
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Affiliation(s)
- Mario A. Aycart
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Nemours Children’s Health-Delaware, 1600 Rockland Road, Wilmington, DE 19803, USA;
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Alaniz L, Vu C, Arora J, Stulginski A, Zhu X, Cordero J, Vyas RM, Pfaff MJ. Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5151. [PMID: 37534108 PMCID: PMC10393085 DOI: 10.1097/gox.0000000000005151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/13/2023] [Indexed: 08/04/2023]
Abstract
Intraoperative nerve blocks have shown promise in managing pain after nasal surgery. The purpose of this systematic review and meta-analysis was to analyze existing level I and II evidence on intraoperative nerve blocks in nasal surgery to optimize postoperative recovery. Methods The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability. Results Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001). Conclusions These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.
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Affiliation(s)
- Leonardo Alaniz
- From the School of Medicine, University of California Irvine, Irvine, Calif
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
| | - Cindy Vu
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Jagmeet Arora
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Avril Stulginski
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Xiao Zhu
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Justin Cordero
- University of California Riverside, School of Medicine, Riverside, Calif
| | - Raj M. Vyas
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
- Pediatric Plastic Surgery, Children’s Hospital of California, Orange, Calif
| | - Miles J. Pfaff
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
- Pediatric Plastic Surgery, Children’s Hospital of California, Orange, Calif
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Hughes EB, Tatum SA. Current trends in unilateral cleft lip repair. Curr Opin Otolaryngol Head Neck Surg 2023:00020840-990000000-00065. [PMID: 37144507 DOI: 10.1097/moo.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The purpose of this review is to provide an in-depth look at the current perioperative and intraoperative practices for unilateral cleft lip repair. The contemporary literature reveals trends towards incorporation of curvilinear and geometric hybrid lip repairs. Perioperative practices are trending in new directions as well with the use of enhanced recovery after surgery (ERAS) protocols to reduce morbidity and length of stay, continued use of nasoalveolar molding, and a tendency to favor outpatient repair with more utilization of same day surgery centers. There is much room for growth, with new and exciting technologies on the horizon to improve upon cosmesis, functionality, and the operative experience.
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Affiliation(s)
- Evan B Hughes
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, New York, USA
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Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review. J Craniofac Surg 2022; 34:979-986. [PMID: 36730883 DOI: 10.1097/scs.0000000000009094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/04/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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