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Yu V, Pham J, Lukomski L, Joseph J, Guo Y. Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases. Cleft Palate Craniofac J 2024; 61:1149-1156. [PMID: 36786023 DOI: 10.1177/10556656231156509] [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: 02/15/2023] Open
Abstract
BACKGROUND Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs. DESIGN Retrospective cohort study. SETTING Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016-2019. PATIENTS Cases of palatoplasty in children under 3 years of age. OUTCOMES Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation. RESULTS A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors. CONCLUSIONS In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.
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Affiliation(s)
- Victor Yu
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jason Pham
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Jeremy Joseph
- Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Yifan Guo
- Plastic and Oral Maxillofacial Surgery, Children's Hospital of the King's Daughters, Norfolk, VA, USA
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Thompson AR, Vernamonti JP, Rollins P, Speck KE. Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments. J Surg Res 2024; 298:371-378. [PMID: 38669783 DOI: 10.1016/j.jss.2024.03.039] [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: 08/14/2023] [Revised: 02/25/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.
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Affiliation(s)
- Allison R Thompson
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Jack P Vernamonti
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Department of Surgery, Maine Medical Center, Portland, Maine
| | - Paris Rollins
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - K Elizabeth Speck
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Phillips JB, Galarza LI, Sink MC, Goza SD, Brown MI, Hopper SJ, Brown KW, Fernstrum CJ, Hoppe IC, Humphries LS. Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution. Ann Plast Surg 2024; 92:S404-S407. [PMID: 38857004 DOI: 10.1097/sap.0000000000003957] [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: 06/11/2024]
Abstract
INTRODUCTION Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.
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Affiliation(s)
- John B Phillips
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | | | - Matthew C Sink
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Shelby D Goza
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Madyson I Brown
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Samuel J Hopper
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS
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Taylor JM, Moman PD, Chevalier JM, Tseng CY, Festekjian JH, Delong MR. Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Tissue Expander-based Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5879. [PMID: 38855130 PMCID: PMC11161298 DOI: 10.1097/gox.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/11/2024]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have demonstrated success in reducing hospital stay and opioid consumption, but are less well studied in patients undergoing tissue expander-based breast reconstruction (TEBR). This study evaluates the effectiveness of an ERAS postoperative protocol for TEBR at a high-volume center. Methods All patients undergoing immediate tissue expander reconstruction after the introduction of ERAS were prospectively included from April 2019 to June 2023. An equivalent number of similar patients were retrospectively reviewed before this date as the non-ERAS control. Data included demographics, operative details, postoperative length of stay, inpatient and discharge narcotic quantities, inpatient pain assessments, postoperative radiation, and complications within 90 days. Results There were 201 patients in each cohort with statistically similar demographics. Patients in the ERAS cohort were more likely to undergo prepectoral reconstruction (83.1% versus 4.5%, P < 0.001), be discharged by day 1 (96.5% versus 70.2%, P < 0.001) and consume lower inpatient milligram morphine equivalent (MME) median (79.8 versus 151.8, P < 0.001). Seroma rates (17.4% versus 3.5%, P < 0.001) and hematoma incidence (4.5% versus 0%, P = 0.004) were higher in the ERAS cohort. Adjusting for implant location, ERAS was associated with a 60.7 MME reduction (β=-60.7, P < 0.001) and a shorter inpatient duration by 0.4 days (β =-0.4, P < 0.001). Additionally, prepectoral reconstruction significantly decreased MME (β=-30.9, P = 0.015) and was the sole predictor of seroma development (odds ratio = 5.2, P = 0.009). Conclusions ERAS protocols significantly reduce opioid use and hospital stay after TEBR.
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Affiliation(s)
- Jeremiah M. Taylor
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Precious D. Moman
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jose M. Chevalier
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Charles Y. Tseng
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Jaco H. Festekjian
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Michael R. Delong
- From the Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif
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Sitzman TJ, Verhey EM, Kirschner RE, Pollard SH, Baylis AL, Chapman KL. Cleft Palate Repair Postoperative Management: Current Practices in the United States. Cleft Palate Craniofac J 2024; 61:827-833. [PMID: 36536584 PMCID: PMC10277312 DOI: 10.1177/10556656221146891] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe current postoperative management practices following cleft palate repair. DESIGN A survey was administered to cleft surgeons to collect information on their demographic characteristics, surgical training, surgical practice, and postoperative management preferences. SETTING Eighteen tertiary referral hospitals across the United States.Participants: Surgeons (n = 67) performing primary cleft palate repair. RESULTS Postoperative diet restrictions were imposed by 92% of surgeons; pureed foods were allowed at one week after surgery by 90% of surgeons; a regular diet was allowed at one month by 80% of surgeons. Elbow immobilizers and/or mittens were used by 85% of surgeons, for a median duration of two weeks. There was significant disagreement about postoperative use of bottles (61% allow), sippy cups (68% allow), pacifiers (29% allow), and antibiotics (45% prescribe). Surgeon specialty was not associated with any aspect of postoperative management (p > 0.05 for all comparisons). Surgeon years in practice, a measure of surgeon experience, was associated only with sippy cup use (p < 0.01). The hospital at which the surgeon practiced was associated with diet restrictions (p < 0.01), bottle use (p < 0.01), and use of elbow immobilizers or mittens (p < 0.01); however, many hospitals still had disagreement among their surgeons. CONCLUSIONS Surgeons broadly agree on diet restrictions and the use of elbow immobilizers or mittens following palate repair. Almost all other aspects of postoperative management, including the type and duration of diet restriction as well as the duration of immobilizer use, are highly individualized.
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Affiliation(s)
- Thomas J. Sitzman
- Division of Plastic Surgery, Phoenix Children’s Hospital, Phoenix, Arizona
- University of Arizona College of Medicine – Phoenix, Phoenix, Arizona
- Department of Surgery, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Erik M. Verhey
- Department of Surgery, Mayo Clinic College of Medicine, Scottsdale, Arizona
| | - Richard E. Kirschner
- Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, and The Ohio State University Medical College, Columbus, Ohio
| | - Sarah Hatch Pollard
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah
| | - Adriane L. Baylis
- Department of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital, and The Ohio State University Medical College, Columbus, Ohio
| | - Kathy L. Chapman
- Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, Utah
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Kavoosi T, Pillai A, Rajasekaran A, Obayemi A. Enhanced Recovery After Surgery Protocols in Craniofacial Surgery. Facial Plast Surg Clin North Am 2024; 32:181-187. [PMID: 37981413 DOI: 10.1016/j.fsc.2023.07.004] [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: 11/21/2023]
Abstract
Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. ERAS protocols are generally substantiated on 3 phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined.
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Affiliation(s)
- Tazheh Kavoosi
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Anjali Pillai
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Anindita Rajasekaran
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Adetokunbo Obayemi
- Department of Otolaryngology - Head and Neck Surgery, SUNY Upstate Medical University, Syracuse, NY, USA.
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Qamar F, Cray JJ, Halsey J, Rottgers SA. A Survey of Bone Grafting Practice Patterns in North American Cleft Surgeons. Cleft Palate Craniofac J 2023; 60:1366-1375. [PMID: 36314735 DOI: 10.1177/10556656221104937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure. METHODS A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests. RESULTS The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0-5 years) appeared more likely to use non-autologous materials (p < .01) for grafting. CONCLUSION Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted.
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Affiliation(s)
- Fatima Qamar
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
| | - James J Cray
- Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, and Division of Biosciences, The Ohio State University College of Dentistry, Columbus, OH, USA
| | - Jordan Halsey
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine; Tampa, FL, USA
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL, USA
- Department of Plastic and Reconstructive Surgery, University of South Florida Morsani College of Medicine; Tampa, FL, USA
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Asadourian PA, Lu Wang M, Demetres MR, Imahiyerobo TA, Otterburn DM. Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair. Cleft Palate Craniofac J 2023; 60:1230-1240. [PMID: 35582828 DOI: 10.1177/10556656221096631] [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: 11/17/2022] Open
Abstract
OBJECTIVE Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. DESIGN A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. SETTING New York-Presbyterian Hospital. PATIENTS/PARTICIPANTS Patients with cleft palate undergoing primary palatoplasty. INTERVENTIONS Meta-analysis of reported patient outcomes in ERAS and control cohorts. MAIN OUTCOME MEASURE(S) Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. RESULTS Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. CONCLUSIONS ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.
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Mitchell DT, Obinero C, Ekeoduru RA, Nye J, Green JC, Talanker M, Nguyen PD, Greives MR. It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate. J Craniofac Surg 2023; 34:2191-2194. [PMID: 37646360 DOI: 10.1097/scs.0000000000009693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established. METHODS A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined. RESULTS Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery. CONCLUSION The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.
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Affiliation(s)
- David T Mitchell
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Chioma Obinero
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Rhashedah A Ekeoduru
- Department of Anesthesiology, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Jessica Nye
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Jackson C Green
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Michael Talanker
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Phuong D Nguyen
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
| | - Matthew R Greives
- Division of Plastic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital
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Cepeda A, Johnson ML, Kelagere K, Obinero CG, Nguyen PD, Greives MR. The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization. J Craniofac Surg 2023; 34:1713-1716. [PMID: 37381130 DOI: 10.1097/scs.0000000000009503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use. METHODS A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022. RESULTS A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P =0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P =0.003), 48 hours (0 versus 1.5, P <0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P =0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P =0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort. CONCLUSIONS This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.
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Affiliation(s)
- Alfredo Cepeda
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Madysen L Johnson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Kavya Kelagere
- Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Chioma G Obinero
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Phuong D Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew R Greives
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX
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Thompson AR, Glick H, Rubalcava NS, Vernamonti JP, Speck KE. Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair. J Surg Res 2023; 283:313-323. [PMID: 36423481 DOI: 10.1016/j.jss.2022.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.
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Affiliation(s)
- Allison R Thompson
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan.
| | - Hannah Glick
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nathan S Rubalcava
- Department of Surgery, Creighton University School of Medicine Phoenix Regional Campus, Phoenix, Arizona; Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Jack P Vernamonti
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; Department of Surgery, Maine Medical Center, Portland, Maine
| | - K Elizabeth Speck
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Daniel Pereira D, Market MR, Bell SA, Malic CC. Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review. J Plast Reconstr Aesthet Surg 2023; 79:101-110. [PMID: 36907019 DOI: 10.1016/j.bjps.2023.01.036] [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: 09/24/2022] [Revised: 01/07/2023] [Accepted: 01/29/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives. METHODS English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria. CONCLUSIONS Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.
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Affiliation(s)
- D Daniel Pereira
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada.
| | - Marisa R Market
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephanie A Bell
- Department of Plastic Surgery, Children's Hospital of Eastern Ontario, Canada
| | - Claudia C Malic
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada; Department of Plastic Surgery, Children's Hospital of Eastern Ontario, Canada
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Esfahanian M, Marcott SC, Hopkins E, Burkart B, Khosla RK, Lorenz HP, Wang E, De Souza E, Algaze-Yojay C, Caruso TJ. Enhanced recovery after cleft palate repair: A quality improvement project. Paediatr Anaesth 2022; 32:1104-1112. [PMID: 35929340 DOI: 10.1111/pan.14541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Mohammad Esfahanian
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Stephen Craig Marcott
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elena Hopkins
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA
| | - Brendan Burkart
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA
| | - Rohit Kumar Khosla
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - H Peter Lorenz
- Lucile Packard Children's Hospital Stanford, Plastic and Reconstructive Surgery, Cleft and Craniofacial Center, Palo Alto, California, USA.,Division of Plastic & Reconstructive Surgery, Department of Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellen Wang
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth De Souza
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Claudia Algaze-Yojay
- Center for Pediatric & Maternal Value (CPMV), Lucile Packard Children's Hospital Stanford, Analytics & Clinical Effectiveness, Palo Alto, California, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
| | - Thomas J Caruso
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California, USA
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Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Plast Reconstr Surg 2022; 150:145e-156e. [PMID: 35579433 DOI: 10.1097/prs.0000000000009231] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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15
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Enhanced Recovery After Surgery for Pediatric Cleft Repair. J Craniofac Surg 2022; 33:1709-1713. [DOI: 10.1097/scs.0000000000008544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/21/2022] [Indexed: 02/07/2023] Open
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Flowers T, Winters R. Postoperative pain management in pediatric cleft lip and palate repair. Curr Opin Otolaryngol Head Neck Surg 2021; 29:294-298. [PMID: 34183559 DOI: 10.1097/moo.0000000000000719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There has been an increased interest in the literature on methods to improve perioperative outcomes in surgical patients while minimizing opioid use. Pediatric cleft palate repair can be a painful procedure, and this postoperative pain can lead to longer hospital stays and worse surgical outcomes. RECENT FINDINGS Recent literature has explored four key areas surrounding analgesia after cleft lip and palate repair. These areas are management of postoperative pain with nonopioid oral analgesics, peripheral nerve blockade, liposomal bupivacaine for donor-site analgesia in bone grafting, and enhanced recovery after surgery (ERAS) protocols. SUMMARY The included studies indicate that patients undergoing palatoplasty may have a decreased opioid requirement if nonopioid analgesics such as acetaminophen and ibuprofen are started early in the postoperative setting. Peripheral nerve blockade is an important adjunct to analgesia in these patients. Suprazygomatic maxillary nerve blockade may improve pain management over traditional infraorbital nerve blockade. In patients undergoing alveolar bone grafting, injection of liposomal bupivacaine into the donor site can significantly decrease oral opioid requirements. Finally, ERAS protocols are emerging ways to decrease postoperative pain in cleft palate patients.
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Affiliation(s)
| | - Ryan Winters
- Department of Otolaryngology, Tulane University
- Department of Otolaryngology, Ochsner Clinic Foundation, New Orleans, LA, USA
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Cawthorn TR, Todd AR, Hardcastle N, Spencer AO, Harrop AR, Fraulin FOG. Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway. Cleft Palate Craniofac J 2021; 59:561-567. [PMID: 34000856 DOI: 10.1177/10556656211017409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas R Cawthorn
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Anna R Todd
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Nina Hardcastle
- Section of Pediatric Anesthesiology, Department of Anesthesiology, University of Calgary, Alberta, Canada
| | - Adam O Spencer
- Section of Pediatric Anesthesiology, Department of Anesthesiology, University of Calgary, Alberta, Canada
| | - A Robertson Harrop
- Sections of Pediatric Surgery and Plastic Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Frankie O G Fraulin
- Sections of Pediatric Surgery and Plastic Surgery, Department of Surgery, University of Calgary, Alberta, Canada
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