Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration

INTRODUCTION

Although the maxillary nerve block (MNB) provides adequate pain relief in cleft palate surgery, it is not routinely used globally, and reported techniques are heterogeneous. This study aims to describe relevant anatomy and to present the preferred technique of MNB administration based on the current literature and the expert opinion of the authors.

METHOD AND MATERIALS

First, a survey was sent to 432 registrants of the International Cleft Palate Master Course Amsterdam 2023. Second, MEDLINE (PubMed interface) was searched for relevant literature on maxillary artery (MA) anatomy and MNB administration in pediatric patients.

RESULTS

Survey response rate was 18% (n=78). Thirty-five respondents (44.9%) used MNB for cleft palate surgery before the course. A suprazygomatic approach with needle reorientation towards the ipsilateral commissure before incision was most frequently reported, mostly without the use of ultrasound. Ten and 20 articles were included on, respectively, MA anatomy and MNB administration. A 47.5% to 69.4% of the MA's run superficial to the lateral pterygoid muscle and 32% to 52.5% medially. The most frequently described technique for MNB administration is the suprazygomatic approach. Reorientation of the needle towards the anterior aspect of the contralateral tragus appears optimal. Needle reorientation angles do not have to be adjusted for age, unlike needle depth. The preferred anesthetics are either ropivacaine or (levo)bupivacaine, with dexmedetomidine as an adjuvant.

CONCLUSION

Described MNB techniques are heterogeneous throughout the literature and among survey respondents and not routinely used. Further research is required comparing different techniques regarding efficacy and safety.

Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital.

DESCRIPTION

Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized.

RESULTS

During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged.

CONCLUSION

This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

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.

Cleft Palate Repair Postoperative Management: Current Practices in the United States

OBJECTIVE

To describe current postoperative management practices following cleft palate repair.

DESIGN

A survey was administered to cleft surgeons to collect information on their demographic characteristics, surgical training, surgical practice, and postoperative management preferences.

SETTING

Eighteen tertiary referral hospitals across the United States.Participants: Surgeons (n = 67) performing primary cleft palate repair.

RESULTS

Postoperative diet restrictions were imposed by 92% of surgeons; pureed foods were allowed at one week after surgery by 90% of surgeons; a regular diet was allowed at one month by 80% of surgeons. Elbow immobilizers and/or mittens were used by 85% of surgeons, for a median duration of two weeks. There was significant disagreement about postoperative use of bottles (61% allow), sippy cups (68% allow), pacifiers (29% allow), and antibiotics (45% prescribe). Surgeon specialty was not associated with any aspect of postoperative management (p > 0.05 for all comparisons). Surgeon years in practice, a measure of surgeon experience, was associated only with sippy cup use (p < 0.01). The hospital at which the surgeon practiced was associated with diet restrictions (p < 0.01), bottle use (p < 0.01), and use of elbow immobilizers or mittens (p < 0.01); however, many hospitals still had disagreement among their surgeons.

CONCLUSIONS

Surgeons broadly agree on diet restrictions and the use of elbow immobilizers or mittens following palate repair. Almost all other aspects of postoperative management, including the type and duration of diet restriction as well as the duration of immobilizer use, are highly individualized.

Utility of Regional Maxillary Nerve Blocks in Improving Cleft Palate Postoperative Outcomes

BACKGROUND

Palatoplasty procedures used to repair cleft palates are commonly associated with limiting postoperative pain. Regional anesthetic blocks have been utilized to improve pain outcomes and decrease opioid intake, yet additional data is needed to fully explore its utility in this setting.

OBJECTIVE

To explore whether ultrasound-guided suprazygomatic maxillary blocks (SMB) improve postoperative pain, postoperative opioid use, time to oral feeding, and length of stay compared with a palatal field block in cleft palate repair.

METHODS

In this retrospective chart review, 47 patients aged 9 to 25 months who underwent cleft palate repair between 2013 and 2020 were allocated into 2 groups: a control group where patients received only palatal local anesthetic in a field block fashion (N=29), and Maxillary block group who received ultrasound-guided SMB (N=18). Patients were matched by age and cleft Veau type. The primary outcomes were total postoperative morphine equivalent consumption, average pain scores, length of stay, and time to first oral feed.

RESULTS

Comparing field block versus SMB groups, there was not a statistical difference in the overall dose of postoperative morphine equivalent opioid administration (11.71 vs. 13.36 mg; P=0.483), average pain scores (5.78 vs. 5.27; P=0.194), time to first oral feed [17.21 vs. 14.48 h; P=0.407, 95% CI: (-3.85, 9.32)] or length of stay (P=0.292).

CONCLUSION

The use of SMBs did not demonstrate a difference in the postoperative outcomes evaluated by this study. Further study is needed to define its utility in cleft palate repair.

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.