Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair

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.

Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review

BACKGROUND

Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery.

METHODS

A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type.

RESULTS

Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery.

CONCLUSIONS

Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.

Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study

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.

Variability and Excess in Opioid Prescribing Patterns After Cleft and Craniosynostosis Repairs

OBJECTIVE

To critically analyze pediatric opioid prescription patterns after cleft and craniosynostosis repairs.

DESIGN

Observational study 1) retrospectively reviewing pediatric opioid prescriptions from July 2018 to June 2019 and 2) prospectively surveying patients about actual opioid use from August 2019 to February 2020.

SETTING

Academic tertiary care pediatric hospital.

PATIENTS

133 pediatric patients undergoing cleft lip and/or palate or craniosynostosis repairs. Prospective surveys were offered at postoperative visits; 45 of 69 eligible patients were enrolled.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Opioid doses prescribed at discharge and actual home opioid use.

RESULTS

90 patients with cleft lip and/or palate and 43 patients with craniosynostosis were included. Median prescribed opioid doses were 10.3 for cleft lip and/or palate procedures (range 0-75), and 14.3 for craniosynostosis repairs (range 0-50). In patients with cleft lip and/or palate, there was a negative correlation between age at surgery and prescribed opioid doses (r_s  =  -0.228, p  =  0.031). 45 patients completed surveys of home opioid use. No patients used more than 10 doses. Forty percent used no opioids at home, 33% used 1 to 2 doses, 18% used 3 to 5 doses, and 9% used 6 to 10 doses.

CONCLUSIONS

Opioid prescriptions vary widely after common craniofacial procedures. Younger patients with cleft lip and/or palate may be more likely to be prescribed more doses. Actual home opioid use is less than prescribed amounts, with most patients using five or fewer doses. A prescribing guideline is proposed.

Assessment of intraoperative hemodynamics and recovery characteristics in pediatric patients receiving buprenorphine and propofol anesthesia for cleft palate surgery: A prospective observational study

Background:

Children with cleft palate are usually operated on before 18 months of age. Cleft palate surgery demands stable hemodynamic parameters, a bloodless surgical field, and an awake and pain-free child after surgery.

Aims:

We aimed to study the anesthesia technique using buprenorphine and propofol for cleft palate surgery.

Settings and Design:

The design involves prospective observational study. The study was conducted at a tertiary care hospital.

Materials and Methods:

After the Institutional Ethics Committee approval, 42 patients aged 6 months to 12 years undergoing cleft palate surgery were enrolled. Anesthesia induction commenced with sevoflurane or propofol 3 mg.kg⁻¹. After intubation, buprenorphine 3 μg.kg⁻¹ was given, and propofol infusion was started at 2–8 mg.kg⁻¹.h⁻¹. Hemodynamic parameters, awakening time, and surgeon's satisfaction score were noted. After extubation, pain score, emergence agitation (EA) score, sedation score, recovery score, and adverse events were noted.

Statistical Analysis:

All statistical analyses were performed using the 20.0 version of the Statistical Package for the Social Science (SPSS) software program. Continuous data were summarized as mean and standard deviation, and were analyzed using a two-sided Student's unpaired t-test. Categorical data were represented using frequencies and proportions.

Results:

The single dose of buprenorphine with propofol infusion started immediately postintubation causes a significant decrease in heart rate after 1 h. This contributed to a favorable operative field, increasing the surgeon's satisfaction score. In the recovery room, patients were essentially pain-free till 2.5 h after surgery, with only one patient requiring rescue analgesia. Furthermore, 90% of patients showed a smooth and calm recovery with no EA. The Steward's recovery score remained high throughout without any complication.

Conclusions:

In cleft palate surgeries, a single-dose buprenorphine 3 μg.kg⁻¹ and propofol maintenance infusion 2–8 mg.kg⁻¹.h⁻¹ were effective in maintaining hemodynamic parameters and a bloodless surgical field and managing postoperative pain with a good recovery profile.

Administration of Intravenous Dexmedetomidine and Acetaminophen for Improved Postoperative Pain Management in Primary Palatoplasty

OBJECTIVE

Suboptimal pain management after primary palatoplasty (PP) may lead to complications such as hypoxemia, and increased hospital length of stay. Opioids are the first option for postoperative acute pain control after PP; however, adverse effects include excessive sedation, respiratory depression, and death, among others. Thus, optimizing postoperative pain control using opioid-sparing techniques is critically important. This paper aims to analyze efficacy and safety of combined intravenous (IV), dexmedetomidine, and IV acetaminophen during PP.

METHODS

Review of a cohort of patients who underwent PP from April 2009 to July 2018 at a large free-standing children's hospital was performed, comparing patients who received combined IV dexmedetomidine and acetaminophen with those who did not receive either of the 2 medications. Efficacy was measured through opioid and nonopioid analgesic dose and timing, pain scores, duration to oral intake, and length of stay. Safety was measured by 30-day complication rates including readmission for bleeding and need for supplementary oxygen.

RESULTS

Total postoperative acetaminophen (P = 0.01) and recovery room fentanyl (P < 0.001) requirements were significantly lower in the study group compared with the control group. Length of stay, oral intake duration, pain scores, total postoperative opioid requirements, and complications rates trended favorably in the study group, though differences did not reach statistical significance.

CONCLUSIONS

Intraoperative IV dexmedetomidine and acetaminophen during PP provides safe and effective perioperative pain control, resulting in statistically significant decreased need for postoperative acetaminophen and fentanyl. Larger studies are necessary to determine if other trends identified in this study may be significant.

Safety and Efficacy of Single-Dose Ketorolac for Postoperative Pain Management After Primary Palatoplasty: A Prospective Cohort Study With Historical Controls

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.

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction

INTRODUCTION

Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair.

METHOD

The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey.

RESULTS

Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%).

CONCLUSION

Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

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

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.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery

BACKGROUND

Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.

METHODS

After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.

RESULTS

The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).

CONCLUSIONS

Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.