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Yessaillian A, Reese M, Clark RC, Becker M, Lopes K, Alving-Trinh A, Llaneras J, McPherson M, Gosman A, Reid CM. A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions. J Plast Reconstr Aesthet Surg 2024; 95:142-151. [PMID: 38909598 DOI: 10.1016/j.bjps.2024.06.001] [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: 02/20/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature. METHODS Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation. RESULTS Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion. CONCLUSION There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
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Affiliation(s)
- Andrea Yessaillian
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - McKay Reese
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Robert Craig Clark
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Miriam Becker
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Kelli Lopes
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Alexandra Alving-Trinh
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Jason Llaneras
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Mary McPherson
- University of Maryland School of Pharmacy, 20 N Pine St, Baltimore, MD 21201, United States
| | - Amanda Gosman
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Chris M Reid
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States.
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Swift CA, Fernstrum CJ, Howell HM, Phillips JB, Aultman RB, Baker KE, Thames CB, Bryant GC, Velazquez AE, Boydstun AG, Sullivan JM, Lebhar MS, Hecox EE, Humphries LS, Hoppe IC. Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures. Cleft Palate Craniofac J 2024:10556656241255940. [PMID: 38841797 DOI: 10.1177/10556656241255940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.
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Affiliation(s)
- Clarice A Swift
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Colton J Fernstrum
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
| | - Haven M Howell
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John B Phillips
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Rebekah B Aultman
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Katherine E Baker
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Clay B Thames
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gidarell C Bryant
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Anna G Boydstun
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John M Sullivan
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
| | - Michael S Lebhar
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
| | - Emily E Hecox
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
| | - Laura S Humphries
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
| | - Ian C Hoppe
- Department of Surgery, Division of Plastic Surgery, University of Mississippi, Jackson, MS, USA
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The management of perioperative pain in craniosynostosis repair: a systematic literature review of the current practices and guidelines for the future. Maxillofac Plast Reconstr Surg 2022; 44:33. [PMID: 36239849 PMCID: PMC9568638 DOI: 10.1186/s40902-022-00363-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Craniosynostosis is a condition characterized by a premature fusion of one or more cranial sutures. The surgical repair of craniosynostosis causes significant pain for the child. A key focus of craniosynostosis repair is developing effective strategies to manage perioperative pain. This study aimed to review perioperative pain control strategies for craniosynostosis repair systematically. Methods Guidelines for reporting systematic reviews and meta-analyses were used in the design of this review. In May 2022, the following databases were used to conduct the literature search: MEDLINE, Cochrane, EMBASE, and Google Scholar. A search was performed using MeSH terms “craniosynostosis,” “pain management,” and “cranioplasty.” Results The literature review yielded 718 publications. After applying our inclusion criteria, 17 articles were included, accounting for a total of 893 patients. During the postoperative period, most studies used multimodal analgesia, primarily opioids, and acetaminophen. In the postoperative period, oral ibuprofen was the most commonly used NSAID, rectal codeine, and acetaminophen were the most commonly used weak opioids, and continuous remifentanil infusion was the most commonly used potent opioid. Conclusion The authors determined the best pain management options for pediatric patients undergoing cranioplasty by analyzing the most commonly used analgesics. A high-quality clinical trial comparing different types of analgesic combinations would be a valuable addition to the present literature.
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Zubovic E, Skolnick GB, AuBuchon JD, Waters EA, Snyder-Warwick AK, Patel KB. Variability and Excess in Opioid Prescribing Patterns After Cleft and Craniosynostosis Repairs. Cleft Palate Craniofac J 2022:10556656221083082. [PMID: 35226537 DOI: 10.1177/10556656221083082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To critically analyze pediatric opioid prescription patterns after cleft and craniosynostosis repairs. DESIGN Observational study 1) retrospectively reviewing pediatric opioid prescriptions from July 2018 to June 2019 and 2) prospectively surveying patients about actual opioid use from August 2019 to February 2020. SETTING Academic tertiary care pediatric hospital. PATIENTS 133 pediatric patients undergoing cleft lip and/or palate or craniosynostosis repairs. Prospective surveys were offered at postoperative visits; 45 of 69 eligible patients were enrolled. INTERVENTION None. MAIN OUTCOME MEASURES Opioid doses prescribed at discharge and actual home opioid use. RESULTS 90 patients with cleft lip and/or palate and 43 patients with craniosynostosis were included. Median prescribed opioid doses were 10.3 for cleft lip and/or palate procedures (range 0-75), and 14.3 for craniosynostosis repairs (range 0-50). In patients with cleft lip and/or palate, there was a negative correlation between age at surgery and prescribed opioid doses (rs = -0.228, p = 0.031). 45 patients completed surveys of home opioid use. No patients used more than 10 doses. Forty percent used no opioids at home, 33% used 1 to 2 doses, 18% used 3 to 5 doses, and 9% used 6 to 10 doses. CONCLUSIONS Opioid prescriptions vary widely after common craniofacial procedures. Younger patients with cleft lip and/or palate may be more likely to be prescribed more doses. Actual home opioid use is less than prescribed amounts, with most patients using five or fewer doses. A prescribing guideline is proposed.
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Affiliation(s)
- Ema Zubovic
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Gary B Skolnick
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Jacob D AuBuchon
- Department of Anesthesiology, 12275Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Erika A Waters
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Alison K Snyder-Warwick
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kamlesh B Patel
- Department of Surgery, 12275Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Stein JR, Mantilla-Rivas E, Aivaz M, Rana MS, Mamidi IS, Ichiuji BA, Manrique M, Rogers GF, Finkel JC, Oh AK. Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls. Cleft Palate Craniofac J 2021; 59:505-512. [PMID: 33942669 DOI: 10.1177/10556656211012864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To analyze safety and efficacy of single-dose ketorolac after primary palatoplasty (PP). DESIGN Consecutive cohort of patients undergoing PP, comparing to historical controls. Setting: A large academic children's hospital. PATIENTS, PARTICIPANTS A consecutive cohort of 111 patients undergoing PP (study n = 47) compared to historical controls (n = 64). INTERVENTIONS All patients received intraoperative acetaminophen, dexmedetomidine, and opioids while the study group received an additional single dose of ketorolac (0.5 mg/kg) at the conclusion of PP. MAIN OUTCOME MEASURES Safety of ketorolac was measured by significant bleeding complications and need for supplementary oxygen. Efficacy was assessed through bleeding, Face Legs Activity Cry Consolability (FLACC) scale, and opioid dose. RESULTS Length of stay was similar for both groups (control group 38.5 hours [95% CI: 3.6-43.3] versus study group 37.6 hours [95% CI: 31.3-44.0], P = .84). There were no significant differences in all postoperative FLACC scales. The mean dose of opioid rescue medication measured as morphine milligram equivalents did not differ between groups (P = .56). Significant postoperative hemorrhage was not observed. CONCLUSIONS This is the first prospective study to evaluate the safety and efficacy of single-dose ketorolac after PP. Although lack of standardization between study and historical control groups may have precluded observation of an analgesic benefit, analysis demonstrated a single dose of ketorolac after PP is safe. Further investigations with more patients and different postoperative regimens may clarify the role of ketorolac in improving pain after PP.
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Affiliation(s)
- Jason R Stein
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, DC, USA
| | - Ishwarya Shradha Mamidi
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brynne A Ichiuji
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Julia C Finkel
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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Clinical Practice Patterns in Nonsyndromic Craniosynostosis: A Review of Continuous Certification Tracer Data From the American Board of Plastic Surgery. J Craniofac Surg 2021; 32:2029-2034. [PMID: 33654035 DOI: 10.1097/scs.0000000000007592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Simplified Postoperative Care After Spring-assisted Strip Craniotomy for Sagittal Synostosis: A Prospective Before-and-After Study. J Craniofac Surg 2021; 32:1507-1510. [PMID: 33534314 DOI: 10.1097/scs.0000000000007498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Since the development of spring-assisted techniques for corrective craniofacial surgery, routine postoperative admission to intensive care units (ICUs) has been questioned. However, close monitoring is necessary if the continuous infusion of morphine is used as recommended for better pain relief. In this study, the authors evaluated a simplified postoperative protocol without continuous morphine infusion and no indwelling urinary catheter following spring-assisted surgery (SAS) for sagittal synostosis. Ten children were cared for according to a standard protocol with postoperative intravenous (i.v.) infusion of morphine and an indwelling urinary catheter, and 11 consecutive children were treated according to a simplified protocol with pain relief based on intermittent injections of morphine and clonidine [according to Face, Legs, Activity, Cry, Consolability (FLACC) scores >4] without the indwelling catheter. A Mann-Whitney U test was used for comparison of distributions between the two groups. The results revealed no differences between groups regarding the proportion of FLACC scores >4, total amount of administered i.v. morphine and clonidine, total volume of buffered glucose infused, time to first feeding on breast milk or substitute, or the length of stay. Despite the inherent limitations of our small observational study, the authors concluded that at our institution, it was possible to exclude a standard continuous i.v. infusion of morphine and an indwelling urinary catheter from our postoperative care protocol without decreasing the quality of pain relief in children submitted to SAS for sagittal synostosis. This finding supports downgrading the level of care from the ICU to a regular ward after limited immediate postoperative observation.
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Variations in Postoperative Management of Pediatric Open-Vault Craniosynostosis. J Craniofac Surg 2020; 32:305-309. [PMID: 32969932 DOI: 10.1097/scs.0000000000007094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
ABSTRACT Craniosynostosis is the premature fusion of 1 or more of the calvarial sutures causing a secondary distortion of the skull shape due to lack of growth perpendicular to the fused suture and compensatory overgrowth parallel to the suture. Open vault craniosynostosis repair requires extensive dissection and reshaping of the skull and can be associated with significant pain, commonly undervalued, and underreported in the pediatric cohort. Although there is an extensive body of literature focusing on the operative treatment of craniosynostosis, there is little consensus about optimal postoperative management protocols, including pain control regimens. The purpose of this study was to assess variation in immediate postoperative management protocols within the United States. A Qualtrics-based survey was submitted to all 112 American Cleft Palate-Craniofacial Association-approved craniofacial teams regarding their routine postoperative management protocol. Nineteen responses were obtained. All surgeons reported routine post-op intensive care unit stay. Mean overall length of stay was 3.5 days. Pain control agents included acetaminophen (100%), intravenous opioids (95%), oral opioids (79%), and ketorolac (53%). Eighty-eight percent of surgeons reported utilizing vital signs and observational parameters for pain assessment with 47% reporting the use of a formal pain scale. Sixty-three percent of those surveyed used a drain, 88% used a foley catheter, 75% used postoperative prophylactic antibiotics, and 75% routinely used arterial line monitoring postoperatively. The results of this survey will be the basis for future direction in understanding the efficacy of differing management protocols and further study of pain management in the pediatric craniosynostosis population.
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Hush SE, Brady C, Soldanska M, Williams JK. Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty. Cleft Palate Craniofac J 2020; 57:1190-1196. [PMID: 32567352 DOI: 10.1177/1055665620932000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We have previously shown the efficacy of an enhanced recovery after surgery (ERAS) protocol in pediatric cleft palatoplasty for proof of concept (POC). We sought to validate the efficacy of ERAS when expanded to patients of variable age and complexity undergoing primary palatoplasty. MAIN OUTCOME MEASURE(S) Between April 2017 and December 2018, 100 patients were collected prospectively for the expanded assessment (ERAS2) and POC (ERAS1) and compared to historical controls both independently and in aggregate (ERAS(T)). We compared patient demographics, perioperative narcotic administration, length of stay (LOS), and rates of return to service (RTS). RESULTS Despite increased complexity, total narcotic usage (morphine equivalents normalized per weight) during each phase of care was significantly greater in controls when compared to ERAS1, ERAS2, or ERAST, respectively (intraoperative: 0.44 mg/kg vs 0.013 mg/kg vs 0.016 mg/kg vs 0.014 mg/kg; postanesthesia care unit: 0.061 mg/kg vs 0.006 mg/kg vs 0.007 mg/kg vs 0.007 mg/kg; postoperative: 0.389 mg/kg vs 0.009 mg/kg vs 0.026 mg/kg vs 0.017 mg/kg). ERAS1 and ERAS2 groups each demonstrated a decrease in LOS (-36.6%, -26.3%) when compared to controls. Overall, application of ERAS led to a 95.7% reduction in narcotic administration and a 31.7% decrease in LOS when compared to controls. The incidence of RTS was higher in ERAS2 (13.0%) when compared to ERAS1 (2.1%) or controls (2.4%), with the strongest independent predictor being a positive perioperative respiratory viral panel (PRVP). CONCLUSIONS Application of ERAS to palatoplasty patients of advanced age and complexity evidenced consistency with respect to decreased perioperative narcotic administration and shortened LOS. A positive PRVP was found to be an independent predictor of RTS even when ERAS was applied.
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Affiliation(s)
- Stefanie E Hush
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Colin Brady
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Magdalena Soldanska
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
| | - Joseph K Williams
- Center for Cleft and Craniofacial Disorders, Children's Healthcare of Atlanta, GA, USA
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Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs. J Craniofac Surg 2019; 30:2154-2158. [DOI: 10.1097/scs.0000000000005718] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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