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Hopper SJ, Fernstrum CJ, Phillips JB, Sink MC, Goza SD, Brown MI, Brown KW, Humphries LS, Hoppe IC. Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair. Ann Plast Surg 2024; 92:S401-S403. [PMID: 38857003 DOI: 10.1097/sap.0000000000003951] [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
OBJECTIVE This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not. DESIGN Retrospective cohort study. SETTING The study takes place at a single tertiary children's hospital. PATIENTS All patients who underwent cleft palate repair during a 10-year period (n = 242). INTERVENTIONS All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol. MAIN OUTCOME MEASURES Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery. RESULTS Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01). CONCLUSIONS Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.
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Affiliation(s)
- Samuel J Hopper
- From the University of Mississippi Medical Center, Jackson, MS
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Ringsten M, Kredo T, Ebrahim S, Hohlfeld A, Bruschettini M. Diclofenac for acute postoperative pain in children. Cochrane Database Syst Rev 2023; 12:CD015087. [PMID: 38078559 PMCID: PMC10712214 DOI: 10.1002/14651858.cd015087.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain. OBJECTIVES To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled'). SEARCH METHODS We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI). MAIN RESULTS We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results. AUTHORS' CONCLUSIONS We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.
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Affiliation(s)
- Martin Ringsten
- Department of Health Sciences, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tamara Kredo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sumayyah Ebrahim
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Surgery, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ameer Hohlfeld
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Matteo Bruschettini
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Thibault C, Pelletier É, Nguyen C, Trottier ED, Doré-Bergeron MJ, DeKoven K, Roy AM, Piché N, Delisle JF, Morin C, Paquette J, Kleiber N. The Three W's of Acetaminophen In Children: Who, Why, and Which Administration Mode. J Pediatr Pharmacol Ther 2023; 28:20-28. [PMID: 36777982 PMCID: PMC9901322 DOI: 10.5863/1551-6776-28.1.20] [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: 01/10/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023]
Abstract
Acetaminophen is one of the oldest medications commonly administered in children. Its efficacy in treating fever and pain is well accepted among clinicians. However, the available evidence supporting the use of acetaminophen's different modes of administration remains relatively scarce and poorly known. This short report summarizes the available evidence and provides a framework to guide clinicians regarding a rational use of acetaminophen in children.
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Affiliation(s)
- Céline Thibault
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Élaine Pelletier
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Christina Nguyen
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Evelyne D. Trottier
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pediatric Emergency Medicine (EDT), CHU Sainte Justine, Montreal, QC, Canada
| | - Marie-Joëlle Doré-Bergeron
- Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Kathryn DeKoven
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Anesthesiology (KD), CHU Sainte-Justine, Montreal, QC, Canada
| | - Anne-Marie Roy
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Nelson Piché
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jean-Francois Delisle
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Caroline Morin
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Julie Paquette
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Niina Kleiber
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Surgery (NP), CHU Sainte-Justine, Montreal, QC, Canada
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4
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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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5
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In search of the optimal pain management strategy for children undergoing cleft lip and palate repair: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:4221-4232. [DOI: 10.1016/j.bjps.2022.06.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 11/24/2022]
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Melhem AM, Ramly EP, Al Abyad OS, Chahine EM, Teng S, Vyas RM, Hamdan US. Enhanced Recovery After Cleft Lip Repair: Protocol Development and Implementation in Outreach Settings. Cleft Palate Craniofac J 2022; 60:724-733. [PMID: 35167405 DOI: 10.1177/10556656221078744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Clefts of the lip are of the most common congenital craniofacial anomalies. The development and implementation of an enhanced recovery after surgery (ERAS) protocol among patients undergoing cleft lip repair may decrease postoperative complications, accelerate recovery, and result in earlier postoperative discharge. Methods A modified ERAS program was developed and applied through Global Smile Foundation outreach craniofacial programs. The main components of this protocol include: (1) preoperative patient education, (2) nutrition screening, (3) smoking cessation when applicable, (4) use of topical anesthetic adjuncts, (5) facial nerve blocks, (6) postoperative analgesia, (7) preferential use of short-acting narcotics, (8) antibiotic administration, (9) use of elbow restraints, (10) early postoperative oral feeding and hydration, and (11) discharge planning. Results Between April 2019 and March 2020, GSF operated on 126 patients with cleft lip from different age groups and 58.8% of them were less than 1 year of age. Three patients (2.4%) had delayed wound healing and one (0.8%) had postoperative bleeding. There were no cases of mortality, length of hospital stay did not exceed 1 postoperative day, and patients were able to tolerate fluids intake at discharge. Conclusion The implementation of an ERAS protocol among patients undergoing cleft lip repair has shown to be highly effective in minimizing postoperative discomfort while reducing opioids use, decreasing the length of stay in hospital, and leading to early oral feeding resumption. The ERAS principles described carry increased relevance in the context of the ongoing COVID-19 pandemic and opioid crisis and can be safely applied in resource-constrained settings.
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Affiliation(s)
| | - Elie P. Ramly
- Global Smile Foundation, Norwood, USA
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Sarena Teng
- Departments of Anesthesiology & Pediatrics, Ochsner Medical Center, New Orleans, LA, USA
| | - Raj M. Vyas
- Department of Plastic Surgery, University of California, Irvine, Orange, CA, USA
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7
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'Desire for more analgesic treatment': pain and patient-reported outcome after paediatric tonsillectomy and appendectomy. Br J Anaesth 2021; 126:1182-1191. [PMID: 33685632 DOI: 10.1016/j.bja.2020.12.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/25/2020] [Accepted: 12/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Insufficiently treated pain after paediatric appendectomy and tonsillectomy is frequent. We aimed to identify variables associated with poor patient-reported outcomes. METHODS This analysis derives from the European PAIN OUT infant registry providing information on perioperative pharmacological data and patient-reported outcomes 24 h after surgery. Variables associated with the endpoint 'desire for more pain treatment' were evaluated by elastic net regularisation (odds ratio [95% confidence interval]). RESULTS Data from children undergoing appendectomy (n=472) and tonsillectomy (n=466) between 2015 and 2019 were analysed. Some 24.8% (appendectomy) and 20.2% (tonsillectomy) wished they had received more pain treatment in the 24 h after surgery. They reported higher composite pain scores (5.2 [4.8-5.5] vs 3.6 [3.5-3.8]), more pain-related interference, and more adverse events than children not desiring more pain treatment, and they received more opioids after surgery (morphine equivalents (81 [60-102] vs 50 [43-56] μg kg-1). Regression analysis revealed that pain-related sleep disturbance (appendectomy odds ratio: 2.8 [1.7-4.6], tonsillectomy 3.7 [2.1-6.5]; P<0.001) and higher pain intensities (1.5-fold increase) increased the probability of desiring more pain treatment. There was an inverse association between the number of different classes of non-opioids administered preventively, and the desire for more analgesics postoperatively. Children not receiving any non-opioid analgesics before the end of a tonsillectomy had a 3.5-fold (2.1-6.5-fold) increase in the probability of desiring more pain treatment, compared with children receiving at least two classes of different non-opioid analgesics. CONCLUSIONS Preventive administration of at least two classes of non-opioid analgesics is a simple strategy and may improve patient-reported outcomes.
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Kearney AM, Gart MS, Brandt KE, Gosain AK. Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair. Plast Reconstr Surg 2020; 146:371-379. [PMID: 32740590 DOI: 10.1097/prs.0000000000007018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States. METHODS Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles. RESULTS Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics. CONCLUSIONS This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.
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Affiliation(s)
- Aaron M Kearney
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Michael S Gart
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Keith E Brandt
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
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Rugytė D, Gudaitytė J. Intravenous Paracetamol in Adjunct to Intravenous Ketoprofen for Postoperative Pain in Children Undergoing General Surgery: A Double-Blinded Randomized Study. ACTA ACUST UNITED AC 2019; 55:medicina55040086. [PMID: 30939851 PMCID: PMC6524359 DOI: 10.3390/medicina55040086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/28/2019] [Accepted: 03/26/2019] [Indexed: 02/07/2023]
Abstract
Background and objectives: The combination of non-steroidal anti-inflammatory drugs and paracetamol is widely used for pediatric postoperative pain management, although the evidence of superiority of a combination over either drug alone is insufficient. We aimed to find out if intravenous (i.v.) paracetamol in a dose of 60 mg kg-1 24 h-¹, given in addition to i.v. ketoprofen (4.5 mg kg-1 24 h-¹), improves analgesia, physical recovery, and satisfaction with postoperative well-being in children and adolescents following moderate and major general surgery. Materials and Methods: Fifty-four patients were randomized to receive either i.v. paracetamol or normal saline as a placebo in adjunct to i.v. ketoprofen. For rescue analgesia in patients after moderate surgery, i.v. tramadol (2 mg kg-¹ up two doses in 24 h), and for children after major surgery, i.v. morphine-patient-controlled analgesia (PCA) were available. The main outcome measure was the amount of opioid consumed during the first 24 h after surgery. Pain level at 1 and over 24 h, time until the resumption of normal oral fluid intake, spontaneous urination after surgery, and satisfaction with postoperative well-being were also assessed. Results: Fifty-one patients (26 in the placebo group and 25 in the paracetamol group) were studied. There was no difference in required rescue tramadol doses (n = 11 in each group) or 24-h morphine consumption (mean difference (95% CI): 0.06 (⁻0.17; 0.29) or pain scores between placebo and paracetamol groups. In patients given morphine-PCA, time to normal fluid intake was faster in the paracetamol than the placebo subgroup: median difference (95% CI): 7.5 (1.3; 13.7) h, p = 0.02. Parental satisfaction score was higher in the paracetamol than the placebo group (mean difference: ⁻1.3 (⁻2.5; ⁻0.06), p = 0.04). Conclusions: There were no obvious benefits to opioid requirement or analgesia of adding regular intravenous paracetamol to intravenous ketoprofen in used doses. However, intravenous paracetamol may contribute to faster recovery of normal functions and higher satisfaction with postoperative well-being.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/adverse effects
- Administration, Intravenous
- Adolescent
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Child
- Child, Preschool
- Double-Blind Method
- Drug Therapy, Combination
- Female
- Follow-Up Studies
- Humans
- Infant
- Ketoprofen/administration & dosage
- Male
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain, Postoperative/drug therapy
- Patient Satisfaction
- Statistics, Nonparametric
- Tramadol/administration & dosage
- Tramadol/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Danguolė Rugytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
| | - Jūratė Gudaitytė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307Kaunas, Lithuania.
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Muzaffar AR, Warren A, Baker L. Use of the On-Q Pain Pump in Alveolar Bone Grafting: Effect on Hospit Length of Stay. Cleft Palate Craniofac J 2018; 53:e23-7. [DOI: 10.1597/14-174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-). Design A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q– group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test. Setting Tertiary care academic medical center. Patients Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014. Main Outcome Measure Length of postoperative hospital stay. Result Mean length of stay in the On-Q– patients was 0.52 days versus 0.37 days for the On-Q– patients. This difference between the two cohorts was not statistically significant (P = .234). Conclusion Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.
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Milchak M, Dalal PG, McCloskey DE, Samson T. Postoperative Pain and Analgesia in Children Undergoing Palatal Surgery: A Retrospective Chart Review. J Perianesth Nurs 2017; 32:279-286. [PMID: 28739059 DOI: 10.1016/j.jopan.2015.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 10/20/2022]
Abstract
PURPOSE Pediatric patients undergoing palatal surgery may experience significant postoperative pain. Undertreatment of acute postoperative pain may impact postoperative bleeding and recovery. The primary objectives of this study were to evaluate the severity of acute postoperative pain scores, analgesia management, and discharge times after palatal surgery. DESIGN AND METHODS A retrospective chart review was performed for all patients aged <18 years, born with cleft palate who underwent palatal surgery over a 1-year period. The primary outcome variable was the highest pain score recorded by the nursing staff at various time frames postoperatively. FINDINGS Overall, the infant/toddler group demonstrated higher postoperative pain scores throughout the first 24 hours (1- to 6-hour period, P = .015). The duration of hospital stay was significantly greater in the infant/toddler age group (P < .001). CONCLUSION The results of our study indicate that frequent pain monitoring, multimodal approach, and "round-the-clock" analgesics may be warranted in this vulnerable patient population.
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Kaye A, Thaete K, Snell A, Chesser C, Goldak C, Huff H. Initial Nutritional Assessment of Infants With Cleft Lip and/or Palate: Interventions and Return to Birth Weight. Cleft Palate Craniofac J 2016; 54:127-136. [PMID: 26882024 DOI: 10.1597/15-163] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess and quantify cleft team practices with regard to nutritional support in the neonatal period Design : Retrospective review. SETTING Tertiary pediatric hospital. PATIENTS One hundred consecutive newborn patients with a diagnosis of cleft lip and/or cleft palate between 2009 and 2012. MAIN OUTCOME MEASURES Birth weight, cleft type, initial cleft team weight measurements, initial feeding practices, recommended nutritional interventions, and follow-up nutritional assessments. RESULTS All patients in the study were evaluated by a registered dietitian and an occupational feeding therapist. Average birth weight and average age at the first cleft team visit were similar for each cleft type: cleft lip (CL), cleft lip and palate (CLP), and cleft palate (CP). The calculated age (in days) for return to birth weight was significantly different between cleft types: CL = 13.58 days, CLP = 15.88 days, and CP = 21.93 days. Exclusive use of breast milk was 50% for patients with CL, 30.3% for patients with CLP, and 21.4% for patients with CP. Detailed nutritional interventions were made for 31 patients at the first visit: two with CL, 14 with CLP, and 15 with CP. CONCLUSIONS Distinct differences were seen in neonatal weight gain between cleft types. There was significantly greater total weight gain for patients with CL at their first visit and significantly slower return to birth weight for patients with isolated CP. Patients with CL required far fewer interventions at the initial assessment and were more likely to be provided breast milk exclusively or in combination with formula. Infants with CP were far less likely to receive any breast milk. Patients with CLP and CP required frequent nutritional interventions.
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Sharif MR, Haji Rezaei M, Aalinezhad M, Sarami G, Rangraz M. Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e27932. [PMID: 26889398 PMCID: PMC4753024 DOI: 10.5812/ircmj.27932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 07/01/2015] [Accepted: 07/28/2015] [Indexed: 01/03/2023]
Abstract
Background Fever is the most common complaint in pediatric medicine and its treatment is
recommended in some situations. Paracetamol is the most common antipyretic drug, which
has serious side effects such as toxicity along with its positive effects. Diclofenac is
one of the strongest non-steroidal anti-inflammatory (NSAID) drugs, which has received
little attention as an antipyretic drug. Objectives This study was designed to compare the antipyretic effectiveness of the rectal form of
Paracetamol and Diclofenac. Patients and Methods This double-blind controlled clinical trial was conducted on 80 children aged six
months to six years old. One group was treated with rectal Paracetamol suppositories at
15 mg/kg dose and the other group received Diclofenac at 1 mg/kg by rectal
administration (n = 40). Rectal temperature was measured before and one hour after the
intervention. Temperature changes in the two groups were compared. Results The average rectal temperature in the Paracetamol group was 39.6 ± 1.13°C,
and 39.82 ± 1.07°C in the Diclofenac group (P = 0.37). The average rectal
temperature, one hour after the intervention, in the Paracetamol and the Diclofenac
group was 38.39 ± 0.89°C and 38.95 ± 1.09°C, respectively (P =
0.02). Average temperature changes were 0.65 ± 0.17°C in the Paracetamol group
and 1.73 ± 0.69°C in the Diclofenac group (P < 0.001). Conclusions In the first one hour, Diclofenac suppository is able to control the fever more
efficient than Paracetamol suppositories.
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Affiliation(s)
- Mohammad Reza Sharif
- Autoimmune Diseases Research Center, Kashan University of
Medical Sciences, Kashan, IR Iran
- Trauma Research Center, Kashan University of Medical
Sciences, Kashan, IR Iran
| | - Mostafa Haji Rezaei
- Trauma Research Center, Kashan University of Medical
Sciences, Kashan, IR Iran
| | - Marzieh Aalinezhad
- Department of Radiology, Isfahan University of Medical
Sciences, Isfahan, IR Iran
- Medical Student Research Center, Isfahan University of
Medical Sciences, Isfahan, IR Iran
| | - Golbahareh Sarami
- Department of Pediatrcis, Kashan University of Medical
Sciences, Kashan, IR Iran
| | - Masoud Rangraz
- Department of Pediatrcis, Kashan University of Medical
Sciences, Kashan, IR Iran
- Corresponding Author: Masoud Rangraz, Department of
Pediatrcis, Kashan University of Medical Sciences, Kashan, IR Iran. Tel: +98-3155540021,
Fax: +98-3155540111, E-mail:
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Imantalab V, Mirmansouri A, Sedighinejad A, Naderi Nabi B, Farzi F, Atamanesh H, Nassiri N. Comparing the effects of morphine sulfate and diclofenac suppositories on postoperative pain in coronary artery bypass graft patients. Anesth Pain Med 2014; 4:e19423. [PMID: 25346897 PMCID: PMC4205802 DOI: 10.5812/aapm.19423] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/12/2014] [Accepted: 08/18/2014] [Indexed: 12/31/2022] Open
Abstract
Background: Simple and efficient way of pain management after Coronary Artery Bypass Graft (CABG) surgery is an important aspect of patients' care. Objectives: This study aimed to compare the effects of morphine and diclofenac suppositories on postoperative pain management. Patients and Methods: In this double-blinded clinical trial study, 120 patients aged 30-65 years old, undergone CABG, were equally divided into two groups of A (morphine) and B (diclofenac). All patients were anesthetized with intravenous fentanyl 10 μg/kg, etomidate 0.2 mg/kg and cisatracurium 0.2 mg/kg. Anesthesia was maintained with oxygen 50% and air 50%, propofol 50 μg/kg/min, fentanyl 1-2 μg/kg/h and atracurium 0.6 mg/kg/h. Analgesics were administered after the operation at intensive care unit (ICU) and Visual Analogue Score (VAS) was evaluated in both groups in 4-hour intervals after extubation for 24 hours. After extubation in case of VAS > 3, morphine suppository 10 mg (group A) or diclofenac suppository 50 mg (group B) was administered for patients. Results: No significant statistical relationship was found between the two groups regarding gender, age, BMI, paracetamol consumption, length of operation time, cardiopulmonary bypass pump (CPB) time, and stay time at ICU (P Value ≥ 0.05). Total dosage of used morphine was 22 ± 8.3 mg in each patient and total dosage of used diclofenac was 94 ± 32.01 mg. Average variation of VAS at measured intervals was significant (P Value ≤ 0.0001), but these variations were not significantly different when comparing the two groups (P Value = 0.023). Conclusions: Both morphine and diclofenac suppositories reduced pain significantly and similarly after CABG surgery.
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Affiliation(s)
- Vali Imantalab
- Anesthesiology Department, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Mirmansouri
- Anesthesia Research Center, Dr. Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding author: Ali Mirmansouri, Anesthesia Research Center, Dr. Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran. Tel: +98-9111315314, Fax: +98-1316668718,, E-mail:
| | - Abbas Sedighinejad
- Anesthesiology Department, Guilan University of Medical Sciences, Rasht, Iran
| | - Bahram Naderi Nabi
- Anesthesiology Department, Guilan University of Medical Sciences, Rasht, Iran
| | - Farnoush Farzi
- Anesthesiology Department, Guilan University of Medical Sciences, Rasht, Iran
| | - Hadi Atamanesh
- Anesthesiology Department, Guilan University of Medical Sciences, Rasht, Iran
| | - Nassir Nassiri
- Cardiac Surgery Department, Guilan University of Medical Sciences, Rasht, Iran
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Hunter D, Chai C, Barr GA. Effects of COX inhibition and LPS on formalin induced pain in the infant rat. Dev Neurobiol 2014; 75:1068-79. [PMID: 25205468 DOI: 10.1002/dneu.22230] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/29/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022]
Abstract
In the adult, immune and neural processes jointly modulate pain. During development, both are in transition and little is known about the role that the immune system plays in pain processing in infants and children. The objective of this study was to determine if inhibition or augmentation of the immune system would alter pain processing in the infant rat, as it does in the adult. In Experiment 1, rat pups aged 3, 10, or 21 (PN3, PN10, and PN21) days of age were pretreated with NS398 (selective cyclooxygenase (COX)-2 inhibitor) or SC560 (selective COX-1 inhibitor) and tested in the intraplantar formalin test to assess effects of COX inhibition on nociception. Neither drug had an effect on the behavioral response at PN3 or PN10 pups but both drugs attenuated nociceptive scores in PN21 pups. cFos expression in the spinal cord likewise was reduced only at PN21. In Experiment 2, pups were injected with lipopolysaccharide (LPS) prior to the formalin test at PN3 or PN21. LPS increased the nociceptive response more robustly at PN21 than at PN3, while increasing cytokine mRNA equally at both ages. The augmentation of pain responding at PN21 was largely during the late stages of the formalin test, as reported in the adult. These data support previous findings demonstrating late maturing immune modulation of nociceptive behaviors.
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Affiliation(s)
- Deirtra Hunter
- Department of Developmental Neuroscience, New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York
| | - Christina Chai
- Department of Psychology, Mercy College, Dobbs Ferry, New York, 10522
| | - Gordon A Barr
- Department of Developmental Neuroscience, New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York
- Department of Psychology, Hunter College, City University of New York, New York
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Jannin V, Lemagnen G, Gueroult P, Larrouture D, Tuleu C. Rectal route in the 21st Century to treat children. Adv Drug Deliv Rev 2014; 73:34-49. [PMID: 24871671 DOI: 10.1016/j.addr.2014.05.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 02/07/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023]
Abstract
The rectal route can be considered a good alternative to the oral route for the paediatric population because these dosage forms are neither to be swallowed nor need to be taste-masked. Rectal forms can also be administered in an emergency to unconscious or vomiting children. Their manufacturing cost is low with excipients generally regarded as safe. Some new formulation strategies, including mucoadhesive gels and suppositories, were introduced to increase patient acceptability. Even if recent paediatric clinical studies have demonstrated the equivalence of the rectal route with others, in order to enable the use of this promising route for the treatment of children in the 21st Century, some effort should be focused on informing and educating parents and care givers. This review is the first ever to address all the aforementioned items, and to list all drugs used in paediatric rectal forms in literature and marketed products in developed countries.
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Wong I, St John-Green C, Walker SM. Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children. Paediatr Anaesth 2013; 23:475-95. [PMID: 23570544 PMCID: PMC4272569 DOI: 10.1111/pan.12163] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Perioperative pain in children can be effectively managed with systemic opioids, but addition of paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce opioid requirements and potentially improve analgesia and/or reduce adverse effects. METHODS A systematic literature search was conducted to identify trials evaluating postoperative opioid requirements in children and comparing NSAID and/or paracetamol with placebo. Studies were stratified according to design: continuous availability of intravenous opioid (PCA/NCA) vs intermittent 'as needed' bolus; and single vs multiple dose paracetamol/NSAIDs. Primary outcome data were extracted, and the percentage decrease in mean opioid consumption was calculated for statistically significant reductions compared with placebo. Secondary outcomes included differences in pain intensity, adverse effects (sedation, respiratory depression, postoperative nausea and vomiting, pruritus, urinary retention, bleeding), and patient/parent satisfaction. RESULTS Thirty-one randomized controlled studies, with 48 active treatment arms compared with placebo, were included. Significant opioid sparing was reported in 38 of 48 active treatment arms, across 21 of the 31 studies. Benefit was most consistently reported when multiple doses of study drug were administered, and 24 h PCA or NCA opioid requirements were assessed. The proportion of positive studies was less with paracetamol, but was influenced by dose and route of administration. Despite availability of opioid for titration, a reduction in pain intensity by NSAIDs and/or paracetamol was reported in 16 of 29 studies. Evidence for clinically significant reductions in opioid-related adverse effects was less robust. CONCLUSION This systematic review supports addition of NSAIDs and/or paracetamol to systemic opioid for perioperative pain management in children.
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Affiliation(s)
- Ivan Wong
- Department of Anaesthesia, Great Ormond St Hospital for Children NHS Foundation TrustLondon, UK,School of Clinical Medicine, University of Cambridge, Addenbrooke's HospitalCambridge, UK
| | - Celia St John-Green
- School of Clinical Medicine, University of Cambridge, Addenbrooke's HospitalCambridge, UK
| | - Suellen M Walker
- Department of Anaesthesia, Great Ormond St Hospital for Children NHS Foundation TrustLondon, UK,Portex Unit: Pain Research, UCL Institute of Child HealthLondon, UK
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de Ladeira PRS, Alonso N. Protocols in cleft lip and palate treatment: systematic review. PLASTIC SURGERY INTERNATIONAL 2012; 2012:562892. [PMID: 23213503 PMCID: PMC3503280 DOI: 10.1155/2012/562892] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 09/24/2012] [Indexed: 11/17/2022]
Abstract
Objectives. To find clinical decisions on cleft treatment based on randomized controlled trials (RCTs). Method. Searches were made in PubMed, Embase, and Cochrane Library on cleft lip and/or palate. From the 170 articles found in the searches, 28 were considered adequate to guide clinical practice. Results. A scarce number of RCTs were found approaching cleft treatment. The experimental clinical approaches analyzed in the 28 articles were infant orthopedics, rectal acetaminophen, palatal block with bupivacaine, infraorbital nerve block with bupivacaine, osteogenesis distraction, intravenous dexamethasone sodium phosphate, and alveoloplasty with bone morphogenetic protein-2 (BMP-2). Conclusions. Few randomized controlled trials were found approaching cleft treatment, and fewer related to surgical repair of this deformity. So there is a need for more multicenter collaborations, mainly on surgical area, to reduce the variety of treatment modalities and to ensure that the cleft patient receives an evidence-based clinical practice.
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Affiliation(s)
| | - Nivaldo Alonso
- Division of Burns and Plastic Surgery, Department of Surgery, School of Medicine, University of São Paulo, São Paulo, SP, Brazil
- Rua Afonso Brás, 473 cj 65 Vila Nova Conceição, 04511-000 São Paulo, SP, Brazil
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