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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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Stanek K, Alrayashi W, Nussbaum L, Ganske IM, Rogers-Vizena CR. Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children. Cleft Palate Craniofac J 2024:10556656241234595. [PMID: 38426799 DOI: 10.1177/10556656241234595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty. DESIGN Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon. SETTING Urban, academic, tertiary care children's hospital. PATIENTS, PARTICIPANTS Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30). INTERVENTIONS All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB. MAIN OUTCOME MEASURE(S) Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay. RESULTS When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB. CONCLUSIONS Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.
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Affiliation(s)
- Krystof Stanek
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Walid Alrayashi
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Lisa Nussbaum
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Ingrid M Ganske
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Carolyn R Rogers-Vizena
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med 2024:rapm-2023-105024. [PMID: 38124208 DOI: 10.1136/rapm-2023-105024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND/IMPORTANCE Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery. OBJECTIVES The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology. EVIDENCE REVIEW MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023. FINDINGS Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown. CONCLUSION The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients. PROSPERO REGISTRATION NUMBER CRD42022364788.
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Affiliation(s)
- Nergis Nina Suleiman
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology, Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Girish Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Geertrui Dewinter
- Department of Cardiovascular Sciences, Section Anesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Axel R Sauter
- Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
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Yu G, Jin S, Chen J, Xie H, Jin S, Chen Y, Song X. Comparison of postoperative analgesia in children following ropivacaine and lidocaine surgical field infiltration with epinephrine for cleft palate repair: A double-blinded, randomized controlled trial. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2024; 125:101762. [PMID: 38218334 DOI: 10.1016/j.jormas.2024.101762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/15/2024]
Abstract
STUDY OBJECTIVE The study aimed to evaluate the efficacy of ropivacaine in providing postoperative analgesia for children undergoing cleft palate repair. METHODS A double-blinded, randomized controlled trial was conducted on sixty-four children scheduled for cleft palate repair. The patients received either local infiltration with 1% lidocaine or 0.2% ropivacaine before incision. The primary outcome was the postoperative average pain score, and secondary outcomes included pain scores at various time points, consumption of flurbiprofen and hydromorphone, effectiveness of nurse-controlled analgesia pump, and incidence of bradycardia, vomiting, and respiratory depression. MAIN RESULTS The results showed that the postoperative average pain score was significantly lower in the ropivacaine group compared to the lidocaine group (1.27±0.28 vs. 1.75±0.29, P<0.001). Pain scores at multiple postoperative time points were also lower in the ropivac:aine group. Additionally, consumption of flurbiprofen and hydromorphone was lower, and ineffective compressions of the nurse-controlled analgesia pump were reduced in the ropivacaine group. The incidence of vomiting, bradycardia, and respiratory depression did not show significant differences between the two groups. CONCLUSION Local infiltration with ropivacaine effectively provided postoperative analgesia for children undergoing cleft palate repair without major side effects. It was found to be superior to lidocaine in reducing the need for additional rescue analgesia.
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Affiliation(s)
- Gaofeng Yu
- Department of Anesthesiology, Jinan University, Guangzhou, Guangdong, People's Republic of China; Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Shangyi Jin
- Department of Internal Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Lingnan Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Jinghui Chen
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Haihang Xie
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Saifen Jin
- Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Yiyang Chen
- Department of Stomatology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, People's Republic of China
| | - Xingrong Song
- Department of Anesthesiology, Jinan University, Guangzhou, Guangdong, People's Republic of China.
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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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Ganske IM, Langa OC, Cappitelli AT, Nuzzi LC, Staffa SJ, DiTullio N, Fullerton Z, Alrayashi W, Meara JG, Rogers-Vizena CR. Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study. Cleft Palate Craniofac J 2022; 60:577-585. [PMID: 35648409 DOI: 10.1177/10556656221075932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake. DESIGN This is a retrospective review from 2015 to 2018. PATIENTS Nonsyndromic patients undergoing primary palate repair. MAIN OUTCOMES MEASURES Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered. RESULTS Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05). CONCLUSION Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.
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Affiliation(s)
- Ingrid M Ganske
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Olivia C Langa
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alex T Cappitelli
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura C Nuzzi
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nancy DiTullio
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Zoe Fullerton
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Walid Alrayashi
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital and Harvard Medical School, Boston MA, USA
| | - John G Meara
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carolyn R Rogers-Vizena
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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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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Peng ZZ, Wang YT, Zhang MZ, Zheng JJ, Hu J, Zhou WR, Sun Y. Preemptive analgesic effectiveness of single dose intravenous ibuprofen in infants undergoing cleft palate repair: a randomized controlled trial. BMC Pediatr 2021; 21:466. [PMID: 34674670 PMCID: PMC8532298 DOI: 10.1186/s12887-021-02907-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background Correction surgery for cleft palate is recommended between 9 and 18 months of age. Patients suffer from acute pain after palatoplasty. Clinicians are hesitant to use opioids for analgesia concerning the potential high risk of respiratory adverse events. Intravenous ibuprofen perhaps be a suitable adjuvant to pain relief. We try to assess whether preoperative administration of intravenous ibuprofen can decrease opioid requirements following cleft palate repair in infants. Methods This single center prospective randomized clinical trial was performed from February to April 2021 at Department of Anesthesiology in Shanghai Children’s Medical Center. Forty patients ASA I-II, aged 9–24 months with isolated cleft palate and undergoing palatoplasty were randomized in a 1:1 ratio to receive either a single dose of 10 mg/kg ibuprofen intravenously or normal saline at induction. Children and infants postoperative pain scale (CHIPPS) was used for pain assessment. Those patients CHIPPS pain score equal or higher than 4 received analgesic rescue with titrating intravenous fentanyl 0.5 μg/kg and repeated in 10 min if required. The primary outcome was the amount of postoperative fentanyl used for rescue analgesia in postanesthesia care unit (PACU). Results Patients (n = 20 in each group) in IV-Ibuprofen group required less postoperative fentanyl than those in placebo group (p<0.001). There was no significant difference between two groups in first rescue analgesia time (p = 0.079) and surgical blood loss (p = 0.194). No incidence of obvious adverse events had been found within the first 24 h after surgery in both groups. Conclusions Preemptive intravenous administration ibuprofen 10 mg/kg at induction had a significant opioid sparing effect in early postoperative period without obvious adverse effects in infants undergoing palatoplasty. Trial registration CHICTR, CTR2100043718, 27/02/2021 http://www.chictr.org.cn/showproj.aspx?proj=122187
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Affiliation(s)
- Zhe Zhe Peng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Ting Wang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ma Zhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ji Jian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Hu
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wan Ru Zhou
- School of Clinical Medicine, Xuzhou Medical University, Xuzhou, China
| | - Ying Sun
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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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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Kang JYJ. Anesthetic Implications of Common Congenital Anomalies. Anesthesiol Clin 2021; 38:621-642. [PMID: 32792188 DOI: 10.1016/j.anclin.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The most common congenital anomalies are congenital heart defects, cleft lip and palate, Down syndrome, and neural tube defects. Anesthetic considerations for Down syndrome include cervical spine instability, history of congenital heart disease, risk of bradycardia, hematologic, endocrine, and behavioral considerations. Patients with cleft lip and palate can have associated syndromes, and the potential for underlying abnormalities should be investigated prior to their anesthetic. A major anesthetic consideration for neural tube defect surgery is positioning for intubation. Fetal surgery for myelomeningocele has been shown to reduce the need for ventriculoperitoneal shunting and improved motor outcomes.
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Affiliation(s)
- Ji Yeon Jemma Kang
- Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.
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Abstract
BACKGROUND Cleft palate is a common craniofacial malformation, requiring surgical repair in late infancy or early toddlerhood. Postoperative use of opioids is common to mitigate pain following palatoplasty. To decrease opioid consumption, improve postoperative pain, and decrease complications associated with general anesthetics, intraoperative regional nerve blocks have been employed for multimodal pain relief. While the literature supports intraoperative nerve block use for postprocedural comfort in children undergoing palatoplasty, the topic has not been systematically summarized. OBJECTIVES The purpose of this review was to explore the efficacy of nerve block in palatoplasty, in addition to analyzing trends in nerve block modality and choice of local anesthetic on postoperative pain and opioid consumption. METHODS A systematic literature search was conducted through PubMed, Embase, Cochrane, and Web of Science databases for studies on cleft palate nerve block. Resulting reference lists were searched for potential eligible studies and then reviewed, with an emphasis on pain scores, postoperative analgesia consumption, and time to analgesia use. RESULTS A total of 259 articles were reviewed, of which 10 met inclusion criteria. Intraoperative suprazygomatic and greater palatine nerve blocks were the 2 most commonly reported blocks. Long acting agents, such as bupivacaine and ropivacaine, were the local anesthetic of choice. All modalities were effective in reducing postoperative pain scores and opioid consumption. CONCLUSION Intraoperative nerve blocks have been shown to be incredibly effective in reducing postoperative pain in children undergoing palatoplasty, minimizing both opioid consumption and recovery time. The existing literature suggests that suprazygomatic block with combined bupivacaine and dexmedetomidine is the preferred nerve block modality. Ultrasound guidance should be used when accessible.Level of Evidence: 2.
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Stein JR, Mantilla-Rivas E, Aivaz M, Rana MS, Mamidi IS, Ichiuji BA, Manrique M, Rogers GF, Finkel JC, Oh AK. Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls. Cleft Palate Craniofac J 2021; 59:505-512. [PMID: 33942669 DOI: 10.1177/10556656211012864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To analyze safety and efficacy of single-dose ketorolac after primary palatoplasty (PP). DESIGN Consecutive cohort of patients undergoing PP, comparing to historical controls. Setting: A large academic children's hospital. PATIENTS, PARTICIPANTS A consecutive cohort of 111 patients undergoing PP (study n = 47) compared to historical controls (n = 64). INTERVENTIONS All patients received intraoperative acetaminophen, dexmedetomidine, and opioids while the study group received an additional single dose of ketorolac (0.5 mg/kg) at the conclusion of PP. MAIN OUTCOME MEASURES Safety of ketorolac was measured by significant bleeding complications and need for supplementary oxygen. Efficacy was assessed through bleeding, Face Legs Activity Cry Consolability (FLACC) scale, and opioid dose. RESULTS Length of stay was similar for both groups (control group 38.5 hours [95% CI: 3.6-43.3] versus study group 37.6 hours [95% CI: 31.3-44.0], P = .84). There were no significant differences in all postoperative FLACC scales. The mean dose of opioid rescue medication measured as morphine milligram equivalents did not differ between groups (P = .56). Significant postoperative hemorrhage was not observed. CONCLUSIONS This is the first prospective study to evaluate the safety and efficacy of single-dose ketorolac after PP. Although lack of standardization between study and historical control groups may have precluded observation of an analgesic benefit, analysis demonstrated a single dose of ketorolac after PP is safe. Further investigations with more patients and different postoperative regimens may clarify the role of ketorolac in improving pain after PP.
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Affiliation(s)
- Jason R Stein
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Marudeen Aivaz
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, DC, USA
| | - Ishwarya Shradha Mamidi
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brynne A Ichiuji
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Julia C Finkel
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
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Enhanced Recovery After Surgery Protocol for Primary Cleft Palate Repair: Improving Transition of Care. J Craniofac Surg 2020; 32:e72-e76. [DOI: 10.1097/scs.0000000000006985] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Mostafa MF, Aal FAA, Ali IH, Ibrahim AK, Herdan R. Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study. Korean J Pain 2020; 33:81-89. [PMID: 31888322 PMCID: PMC6944365 DOI: 10.3344/kjp.2020.33.1.81] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 12/23/2022] Open
Abstract
Background For children with cleft palates, surgeries at a young age are necessary to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedetomidine might prolong the postoperative analgesic duration when added to bupivacaine during nerve blocks. Methods Eighty patients of 1-5 years old were arbitrarily assigned to two equal groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum volume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 µg/kg dexmedetomidine (maximum volume 4 mL/side). Results The modified children's hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). Mean values of heart rate and blood pressure were significantly different between the groups, with lower mean values in group B (P < 0.001). Median time to the first analgesic demand in group A children was 10 hours (range 8-12 hr), and no patients needed analgesia in group B. The sedation score assessment was higher in children given dexmedetomidine (P = 0.03) during the first postoperative 30 minutes. Better parent satisfaction scores (5-point Likert scale) were recorded in group B and without serious adverse effects. Conclusions Addition of dexmedetomidine 0.5 µg/kg to bupivacaine 0.125% has accentuated the analgesic efficacy of bilateral suprazygomatic maxillary nerve block in children undergoing primary cleft palate repair with less postoperative supplemental analgesia or untoward effects.
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Affiliation(s)
- Mohamed F Mostafa
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Fatma A Abdel Aal
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ibrahim Hassan Ali
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed K Ibrahim
- Department of Public Health, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
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Bilateral suprazygomatic maxillary nerve block versus palatal block for cleft palate repair in children: A randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2018.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Jonnavithula N, Bachu D, Sriramoju V, Devraj R, Gunta R, Pisapati MVLN. Effect of infraorbital nerve block on postoperative pain and 30-day morbidity at the donor site in buccal mucosal graft urethroplasty. J Anaesthesiol Clin Pharmacol 2019; 35:114-118. [PMID: 31057252 PMCID: PMC6495633 DOI: 10.4103/joacp.joacp_211_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Buccal mucosa harvest for substitution urethroplasty can be painful, and may be associated with long-term complications such as perioral numbness, persistent difficulty with mouth opening, and change in salivary function. This study was designed to evaluate the efficacy of infraorbital nerve block (IOB) in relieving postoperative pain at the donor site of the buccal mucosal graft (BMG) and its associated morbidity at 30 days. Material and Methods Thirty adults scheduled for BMG urethroplasty were enrolled in this study and were randomized to receive either no block group I (control) and IOB group II intraorally with 1 mL of 0.5% bupivacaine. Pain was assessed by visual analog scale, intraoral morbidity, and patient satisfaction in the immediate postoperative period. All patients were reviewed after 1 month for morbidity such as perioral numbness, pain on mastication, and tightness on mouth opening. Statistical analysis was done using Mann-Whitney's U and Chi-square tests. Results Median time to pain-free oral intake for liquids (group I: 2-5 days, group II: 1 day, P < 0.001) and solids (group I: 4 days, group II: 2 days, P < 0.001) was earlier in group II. At the follow-up after 1 month, one patient in group II and three patients in group I showed perioral numbness (P = 0.026), and five patients had pain on mastication in group I (P = 0.016). Conclusion IOB is associated with postoperative analgesia and facilitation of early food intake, mitigating the morbidity of the donor site and provides satisfaction.
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Affiliation(s)
- Nirmala Jonnavithula
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Deepak Bachu
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Vidyasagar Sriramoju
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Rahul Devraj
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Ramachandraiah Gunta
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Murthy V L N Pisapati
- Department of Urology and Renal Transplantation, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair. Eur J Anaesthesiol 2019; 36:40-47. [DOI: 10.1097/eja.0000000000000900] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Palatoplasty. J Craniofac Surg 2018; 29:e525-e528. [PMID: 29762332 DOI: 10.1097/scs.0000000000004591] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Liposomal bupivacaine (LB) is a long-acting local anesthetic reported to decrease postoperative pain in adults. The authors demonstrate the safe use of LB in pediatric patients with improved pain control following palatoplasty. MATERIALS AND METHODS Retrospective patient series of all single-surgeon palatoplasty patients treated at a tertiary craniofacial center from August 2014 to December 2015 were included. All patients received 1.3% LB intraoperatively as greater palatal nerve and surgical field blocks in 2-flap V-Y pushback palatoplasty. Postoperative oral intake, opioids administered, duration of hospitalization, and FLACC (face, legs, activity, cry, consolability) pain scores were measured. RESULTS Twenty-seven patients (16 males and 11 females, average age of 10.8 months, weight 8.8 kg) received 2.9 ± 0.9 mL (2.6 ± 1.9 mg/kg) 1.3% LB. Average FLACC scores were 2.4 ± 2.2/10 in the postanesthesia care unit and 3.8 ± 1.8/10 while inpatients. Oral intake was first tolerated 10.3 ± 11.5 hours postoperatively and tolerated 496.4 ± 354.2 mL orally in the first 24 hours postoperatively. Patients received 8.5 ± 8.4 mg hydrocodone equivalents (0.46 ± 0.45 mg/kg per d hydrocodone equivalents) and were discharged 2.1 ± 1.3 days postoperatively. Opioid-related adverse events included emesis in 7.4% and pruritis in 3.7% of patients. CONCLUSIONS The LB may be used safely in pediatric patients. Intraoperative injection of LB during palatoplasty can yield low postoperative opioid use and an early and adequate volume of oral intake over an average hospital stay. Further cost-efficacy studies of LB are needed to assess its value in pediatric plastic surgery.
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Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Pharyngoplasty. J Craniofac Surg 2018; 29:726-730. [DOI: 10.1097/scs.0000000000004312] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Mostafa MF, Herdan R, Elshazly M. Comparative study of levobupivacaine and bupivacaine for bilateral maxillary nerve block during pediatric primary cleft palate surgery: a randomized double-blind controlled study. Korean J Anesthesiol 2018; 71:135-140. [PMID: 29619786 PMCID: PMC5903109 DOI: 10.4097/kjae.2018.71.2.135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/23/2022] Open
Abstract
Background Cleft lip and palate are common major congenital anomalies. Cleft palate (CP) repair causes pain and needs large doses of intravenous opioids. The risk of postoperative airway obstruction or respiratory depression is high, requiring continuous and vigilant monitoring. The primary outcome was to evaluate the efficacy of using different local anesthetics during bilateral maxillary nerve block (MNB) with general anesthesia on quality of recovery after primary CP repair. We hypothesized that levobupivacaine would be better than bupivacaine. Also, to investigate the potency of bilateral MNB in improving quality of postoperative analgesia. Methods Sixty children undergoing primary CP repair surgery were enrolled in the study. Combined general anesthesia and regional bilateral MNB were used for all patients. Group L (n = 30): children received 0.15 ml/kg of 0.2% levobupivacaine, while in Group B (n = 30): children received 0.15 ml/kg of 0.2% bupivacaine. Results Face, Legs, Activity, Cry, and Consolability pain score readings were 0 score in 7 cases of the Group L and 10 cases of Group B, 1 score in 14 cases of the Group L and 12 cases of Group B, and 2 score in 9 cases of the Group L and 8 cases of Group B. We found no statistically significant difference between the two study groups as regarding pain score or serious complications. Conclusions Levobupivacaine is as effective and safe as bupivacaine to be used for MNB block with a lower incidence of complications. Bilateral suprazygomatic MNB is an effective, easy, and safe method for pain relief in children undergoing primary cleft palate repair surgeries.
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Affiliation(s)
- Mohamed F Mostafa
- Department of Anesthesia and Intensive Care, Assiut University Faculty of Medicine, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Assiut University Faculty of Medicine, Assiut, Egypt
| | - Mohamed Elshazly
- Department of Plastic Surgery, Assiut University Faculty of Medicine, Assiut, Egypt
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Saini D, Yadav U. Study of Wound Instillation Technique for Effective Postoperative Analgesia using Ropivacaine in Lumbar Spine Surgery. Anesth Essays Res 2018; 12:685-689. [PMID: 30283176 PMCID: PMC6157229 DOI: 10.4103/aer.aer_87_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Instillation of local anaesthetics over incision site is a simple technique done as a part of multimodal analgesia targetting incisional pain for post-operative pain relief following lumbar laminectomy. Aim: To determine postoperative analgesic effect of ropivacaine in wound instillation for lumbar laminectomy. Study Design: Prospective, randomised, double blind study. Methodology: Forty patients scheduled for elective lumbar laminectomy under general anaesthesia were enrolled and randomly allocated into two groups namely Group R (n=20 receiving 20ml of 0.25% ropivacaine) and Group N (n=20 receiving 20ml normal saline) as instillation over incision site. If the NRS exceeded ‘4’ at any point of time, rescue analgesia with inj. Diclofenac 75 mg deep intramuscular was administered. Post- operative pain score, duration of analgesia and total rescue analgesic required in 24 h were compared between the groups. Results: The pain score was less in ropivacaine group as compared to normal saline group (p value 0.0001). Duration of analgesia in normal saline group (N) is 4.3± 1.03 and in ropivacaine group(R) is 12.15±1.49. Mean amount of rescue analgesic required in normal saline group was 191.25± 38.28mg and in ropivacaine group was 97.5± 35.26 mg. Conclusion: The patients who received ropivacaine wound instillation had better pain control, longer duration of analgesia and less analgesic requirement as compared to patients who received normal saline wound instillation.
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Affiliation(s)
- Dimpal Saini
- Department of Anaesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India
| | - Urvashi Yadav
- Department of Anaesthesiology, Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India
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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: 26] [Impact Index Per Article: 3.3] [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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Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children. Pain 2015. [DOI: 10.1097/j.pain.0000000000000305] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Jonnavithula N, Khandelia H, Durga P, Ramachandran G. Role of wound instillation with bupivacaine through surgical drains for postoperative analgesia in modified radical mastectomy. Indian J Anaesth 2015; 59:15-20. [PMID: 25684808 PMCID: PMC4322096 DOI: 10.4103/0019-5049.149443] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Aims: Modified Radical Mastectomy (MRM) is the commonly used surgical procedure for operable breast cancer, which involves extensive tissue dissection. Therefore, wound instillation with local anaesthetic may provide better postoperative analgesia than infiltration along the line of incision. We hypothesised that instillation of bupivacaine through chest and axillary drains into the wound may provide postoperative analgesia. Methods: In this prospective randomised controlled study 60 patients aged 45–60 years were divided into three groups. All patients were administered general anaesthesia. At the end of the surgical procedure, axillary and chest wall drains were placed before closure. Group C was the control with no instillation; Group S received 40 ml normal saline, 20 ml through each drain; and Group B received 40 ml of 0.25% bupivacaine and the drains were clamped for 10 min. After extubation, pain score for both static and dynamic pain was evaluated using visual analog scale and then 4th hourly till 24 h. Rescue analgesia was injection tramadol, if the pain score exceeds 4. Statistical analysis was performed using SPSS version 13. Results: There was a significant difference in the cumulative analgesic requirement and the number of analgesic demands between the groups (P: 0.000). The mean duration of analgesia in the bupivacaine group was 14.6 h, 10.3 in the saline group and 4.3 h in the control group. Conclusion: Wound instillation with local anaesthetics is a simple and effective means of providing good analgesia without any major side-effects.
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Affiliation(s)
- Nirmala Jonnavithula
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Harsh Khandelia
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Padmaja Durga
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Gopinath Ramachandran
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
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Suresh S, Schaldenbrand K, Wallis B, De Oliveira G. Regional anaesthesia to improve pain outcomes in paediatric surgical patients: a qualitative systematic review of randomized controlled trials. Br J Anaesth 2014; 113:375-390. [DOI: 10.1093/bja/aeu156] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Visoiu M. Outpatient analgesia via paravertebral peripheral nerve block catheter and On-Q pump--a case series. Paediatr Anaesth 2014; 24:875-8. [PMID: 24815589 DOI: 10.1111/pan.12427] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 11/30/2022]
Abstract
Outpatient pain management after iliac crest bone harvesting can be challenging. We report the use of home L2 paravertebral nerve block catheter (L2PVBC) in a series of five children. The pain scores were low, and analgesic medication consumption was minimal. No complications were reported related with these catheters, and the patients reported very high pain control satisfaction scores. Outpatient L2PVBC can be beneficial as part of a multimodal analgesia strategy in selected pediatric patients.
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Affiliation(s)
- Mihaela Visoiu
- Department of Anesthesiology, Acute Interventional Pediatric Perioperative Pain Service, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
Abstract
Background:
The authors investigated the efficacy of bilateral suprazygomatic maxillary nerve block (SMB) for postoperative pain relief in infants undergoing cleft palate repair.
Methods:
In this prospective, double-blind, single-site, randomized, and parallel-arm controlled trial, 60 children were assigned to undergo bilateral SMB with general anesthesia with either 0.15 ml/kg of 0.2% ropivacaine (Ropi group) or 0.15 ml/kg of isotonic saline (Saline group) on each side. The primary endpoint was total postoperative morphine consumption at 48 h. Pain scores and respiratory- and SMB-related complications were noted.
Results:
The overall dose of intravenous morphine after 48 h (mean [95% CI]) was lower in the Ropi group compared with that in the Saline group (104.3 [68.9 to 139.6] vs. 205.2 [130.7 to 279.7] μg/kg; P = 0.033). Continuous morphine infusion was less frequent in the Ropi group compared with that in the Saline group (1 patient [3.6%] vs. 9 patients [31%]; P = 0.006). Three patients in the Saline group had an episode of oxygen desaturation requiring oxygen therapy. There were no technical failures or immediate complications of the SMB. Intraoperative hemodynamic parameters, doses of sufentanil, pain scores, and postoperative hydroxyzine requirements were not different between the two groups.
Conclusion:
Bilateral SMB is an easy regional anesthesia technique that reduces total morphine consumption at 48 h after cleft palate repair in children and the use of continuous infusion of morphine and may decrease postoperative respiratory complications.
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McIlvaine E, Borzabadi-Farahani A, Lane CJ, Azen SP, Yen SLK. Apriori feasibility testing of randomized clinical trial design in patients with cleft deformities and Class III malocclusion. Int J Pediatr Otorhinolaryngol 2014; 78:725-30. [PMID: 24630053 PMCID: PMC4336545 DOI: 10.1016/j.ijporl.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/06/2014] [Accepted: 01/08/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the feasibility of randomizing treatment (surgical vs. non-surgical) for correction of a Class III malocclusion (underbite) resulting from an earlier repair of cleft lip and palate. MATERIALS AND METHODS Surveys about willingness to accept randomized treatment during adolescence were mailed to the parents of cleft lip and palate patients under the care of Children's Hospital Los Angeles between 2005 and 2010. The inclusion criteria were patients with cleft lip and palate, Class III malocclusion due to maxillary deficiency, and absence of medical and cognitive contraindications to treatment. RESULTS Out of 287 surveys, 82 (28%) were completed and returned; 47% of the subjects held a strong treatment preference (95% CI, 35-58%), while 30% were willing to accept randomization (95% CI, 20-41%). Seventy-eight percent would drop out of a randomized trial if dissatisfied with the assigned treatment (95% CI, 67-86%). The three most commonly cited reasons for being unwilling to accept random treatment assignment were 1) the desire for doctors to choose the best treatment, 2) the desire for parents to have input on treatment, and 3) the desire to correct the underbite as early as possible. CONCLUSION Based on this study, parents and patients would be unwilling to accept a randomly assigned treatment and would not remain in an assigned group if treatment did not meet expectations. This highlight the limitations associated with randomization trials involving surgical modalities and provide justification for other research models (e.g., cohort studies) to compare two treatment options when randomization is not feasible.
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Affiliation(s)
- Elizabeth McIlvaine
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ali Borzabadi-Farahani
- Orthodontics, Warwick Dentistry, Warwick Medical School, University of Warwick, Coventry, UK,Formerly, Craniofacial Orthodontics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christianne J. Lane
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stanley P. Azen
- Statistical Consultation and Research Center, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stephen L.-K. Yen
- Craniofacial Orthodontics, Children's Hospital Los Angeles, Los Angeles, CA, USA,Center for Craniofacial Molecular Biology, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA,Corresponding author at: CCMB, CSA103, 2250 Alcazar St., Los Angeles, CA 90027, USA., Tel.: +1 323 442 1747; fax: +1 323 442 2981
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Holman SD, Campbell-Malone R, Ding P, Gierbolini-Norat EM, Lukasik SL, Waranch DR, German RZ. Swallowing kinematics and airway protection after palatal local anesthesia in infant pigs. Laryngoscope 2014; 124:436-45. [PMID: 23686446 PMCID: PMC4319539 DOI: 10.1002/lary.24204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 04/02/2013] [Accepted: 04/13/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Abnormal kinematics during swallowing can result in aspiration, which may become life threatening. We tested the role of palatal sensation in the motor control of pharyngeal swallow in infants. STUDY DESIGN In eight infant pigs, we reduced palatal sensation using local anesthesia (PLA) and measured the impact on swallowing kinematics and airway protection. METHODS The pigs drank milk containing barium while we simultaneously recorded videofluoroscopy and electromyography from fine wire bipolar electrodes in several hyolaryngeal muscles. We compared these results to control feedings and feedings following palatal saline injections. RESULTS After PLA, four pigs had extreme jaw movements and abnormal tongue movement uncharacteristic of sucking. For this reason, we evaluated differences between these group B pigs and the others that could suck normally after PLA (group A). In the four group A pigs, after PLA there was less hyoid elevation (P < .001) but normal jaw and tongue movements. In group B, in addition to greater jaw movement (P < .001) there was more anterior and superior tongue movement (P < .001) and a larger range of hyoid movement (P < .001). CONCLUSIONS The airway was protected in all of the pigs, indicating that these changes allowed successful adaptation to the reduction in palatal sensation. However, the oral and pharyngeal phases of the swallow were functionally linked, and trigeminal sensation influenced the motor control of the pharyngeal swallow. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Shaina Devi Holman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
- Department of Neural and Pain Sciences, University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD 21201, USA
| | - Regina Campbell-Malone
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
| | - Peng Ding
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
| | - Estela M. Gierbolini-Norat
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
| | - Stacey L. Lukasik
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
| | - Danielle R. Waranch
- Department of Neural and Pain Sciences, University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD 21201, USA
| | - Rebecca Z. German
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD 21231, USA
- Department of Neural and Pain Sciences, University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD 21201, USA
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Holman SD, Gierbolini-Norat EM, Lukasik SL, Campbell-Malone R, Ding P, German RZ. Duration of action of bupivacaine hydrochloride used for palatal sensory nerve block in infant pigs. J Vet Dent 2014; 31:92-5. [PMID: 25185333 PMCID: PMC4337394 DOI: 10.1177/089875641403100205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bupivacaine hydrochloride is frequently used in veterinary dental procedures to reduce the amount of general anesthesia needed and to reduce post-procedural pain. The aim of this study was to develop a novel method to test local anesthetic duration in mammals. Six infant pigs were placed under deep/surgical anesthesia with 3 % isoflurane and oxygen while 0.5 ml of 0.5% bupivacaine hydrochloride was injected to block the two greater palatine and the nasopalatine nerves. They were then maintained under light anesthesia with 0.5-1.0% isoflurane. Beginning 15-minutes after the injection, 7 sites in the oral cavity were stimulated using a pointed dental waxing instrument, including 3 sites on the hard palate. The response, or lack of response, to the stimulus was recorded on video and in written record The bupivacaine hydrochloride injections lasted 1 to 3-hours before the animals responded to the sensory stimulation with a reflexive movement This study provides evidence that bupivacaine used to anesthetize the hard palate has a relatively short and variable duration of action far below what is expected based on its pharmacokinetic properties.
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Affiliation(s)
- Shaina Devi Holman
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
| | - Estela M. Gierbolini-Norat
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
| | - Stacey L. Lukasik
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
| | - Regina Campbell-Malone
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
| | - Peng Ding
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
| | - Rebecca Z. German
- Department of Physical Medicine and Rehabilitation (All Authors), Johns Hopkins University School of Medicine, 98 North Broadway, Baltimore, MD, 21231; and, the Department of Neural and Pain Sciences (Holman, German), University of Maryland, School of Dentistry, 650 West Baltimore Street, Baltimore, MD, 21201
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Holman SD, Waranch DR, Campbell-Malone R, Ding P, Gierbolini-Norat EM, Lukasik SL, German RZ. Sucking and swallowing rates after palatal anesthesia: an electromyographic study in infant pigs. J Neurophysiol 2013; 110:387-96. [PMID: 23636723 PMCID: PMC3727070 DOI: 10.1152/jn.00064.2013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/29/2013] [Indexed: 12/20/2022] Open
Abstract
Infant mammalian feeding consists of rhythmic suck cycles and reflexive pharyngeal swallows. Although we know how oropharyngeal sensation influences the initiation and frequency of suck and swallow cycles, the role of palatal sensation is unknown. We implanted EMG electrodes into the mylohyoid muscle, a muscle active during suckling, and the thyrohyoid muscle, a muscle active during swallowing, in eight infant pigs. Pigs were then bottle-fed while lateral videofluoroscopy was simultaneously recorded from the electrodes. Two treatments were administered prior to feeding and compared with control feedings: 1) palatal anesthesia (0.5% bupivacaine hydrochloride), and 2) palatal saline. Using the timing of mylohyoid muscle and thyrohyoid muscle activity, we tested for differences between treatment and control feedings for swallowing frequency and suck cycle duration. Following palatal anesthesia, four pigs could not suck and exhibited excessive jaw movement. We categorized the four pigs that could suck after palatal anesthesia as group A, and those who could not as group B. Group A had no significant change in suck cycle duration and a higher swallowing frequency after palatal saline (P = 0.021). Group B had significantly longer suck cycles after palatal anesthesia (P < 0.001) and a slower swallowing frequency (P < 0.001). Swallowing frequency may be a way to predict group membership, since it was different in control feedings between groups (P < 0.001). The qualitative and bimodal group response to palatal anesthesia may reflect a developmental difference. This study demonstrates that palatal sensation is involved in the initiation and frequency of suck and swallow cycles in infant feeding.
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Affiliation(s)
- Shaina Devi Holman
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Jha AK, Bhardwaj N, Yaddanapudi S, Sharma RK, Mahajan JK. A randomized study of surgical site infiltration with bupivacaine or ketamine for pain relief in children following cleft palate repair. Paediatr Anaesth 2013; 23:401-6. [PMID: 23445320 DOI: 10.1111/pan.12124] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Wound infiltration with ketamine reduces postoperative pain after tonsillectomy by NMDA receptor blockade and local anesthetic effect. OBJECTIVES To evaluate the postoperative analgesia after surgical site infiltration with bupivacaine or ketamine in children undergoing cleft palate surgery. MATERIALS AND METHODS After institutional ethics committee approval and parental consent, 50 ASA-1 children of age 1-6 years undergoing palatoplasty were included in this prospective randomized double-blind study. A standardized technique of general anesthesia was used. The surgical site was infiltrated with either 2 mg·kg(-1) of bupivacaine (Group B) or 0.5 mg·kg(-1) of ketamine (Group K). Pain (Children Hospital Eastern Ontario Pain Score), sedation, dysphagia, nausea, vomiting, and sleep pattern were assessed postoperatively up to 24 h. RESULTS CHEOPS scores were similar in both the groups up to 12 h but were lower with ketamine compared with bupivacaine at 24 h postoperatively (P = 0.01). Fewer children required rescue analgesics in Group K (28%) than in Group B (64%; P < 0.01). The time to first rescue analgesic and the amount of analgesics used in 24 h were similar in the two groups. Fewer children suffered from dysphagia in Group K (52%) than in Group B (88%; P < 0.01). More children in Group B had disturbed sleep than in Group K at 6 (88% vs 56%; P = 0.012) and 12 h (60% vs 24%; P = 0.01) postoperatively. None of the children had deep sedation, desaturation or respiratory depression. CONCLUSION Surgical site infiltration with either bupivacaine or ketamine provides adequate analgesia and is devoid of major side effects. Ketamine is superior to bupivacaine in terms of requirement of rescue analgesic, peaceful sleep pattern and early resumption of feeding.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India
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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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