Perioperative respiratory complications in cleft lip and palate repairs: An audit of 1000 cases under 'Smile Train Project'

Prediction of Early Postoperative Pain in Infants Undergoing Primary Cleft Palate Repair

OBJECTIVE

Identification of at risk patients before surgery could facilitate improved clinical communication, care pathways and postoperative pain management.

DESIGN

A retrospective cohort study was performed in all infants who had undergone cleft palate repair.

SETTING

Tertiary Institutional.

PARTICIPANTS

Infants < 36 months of age who underwent primary repair of cleft palate between March 2016 and July 2022.

INTERVENTION

Requirement for analgesic intervention in the post operative care unit.

MAIN OUTCOME MEASURE

Adverse perioperative event defined as pain or distress. Secondary outcomes were the incidence of airway obstruction, hypoxemia or unplanned intensive care admission.

RESULTS

Two hundred and ninety one patients (14.6 months,10.1 kg weight) were included. Cleft distribution included submucous (5.2%), Veau I (23.4%), Veau 2 (38.1%), Veau 3 (24.4%), and Veau 4 (8.9%). Overall 35% of 291 infants undergoing cleft palate repair experienced pain or distress requiring opiate intervention in the first hour after surgery. Infants with a Veau 4 cleft palate had 1.8 times and Veau 2 cleft palate had 1.5 times the risk of postoperative pain compared to infants with Veau 1 cleft palate (relative risk 1.82, 95%CI 1.04-3.18 and 1.49, 95%CI 0.96-2.32 respectively). The use of bilateral above elbow arm splints was significantly associated with postoperative pain or distress (odds ratio 2.23, 95%CI 1.01-5.16).

CONCLUSIONS

Post operative pain requiring intervention in PACU is common despite adequate intraoperative multimodal analgesia, local anaesthesia infiltration and postoperative opiate infusions. Infants undergoing soft palate alone or submucous palate repair may require less perioperative opiates.

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series

BACKGROUND

Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population.

CASE PRESENTATION

A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 μg/kg was administered within 10 minutes, and a maintenance dose of 1.5 μg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients.

CONCLUSION

Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

Retrospective Survey and Analysis of Anaesthesia and Outcomes in Paediatric Cleft Lip or Palate Surgery in a Tertiary Care Center, Portugal

INTRODUCTION

Orofacial clefts are the most common craniofacial abnormalities, affecting approximately one in 700 newborns each year. The anaesthetic management of these patients is challenging, including difficulties in airway approach and respiratory complications that have direct implications in the final outcome.

AIM

The present study aimed to characterize the anesthetic approach to paediatric patients undergoing cleft palate or lip surgical repair and review the perioperative anesthetic complications in a tertiary Portuguese hospital.

METHODS

Data were collected from a retrospective review of the patient records which included anaesthesia perioperative notes of paediatric patients submitted to cleft surgery repair during a five-year period (2016 to 2021). Demographic, pre-anaesthetic characteristics, anaesthetic management and perioperative complications were recorded.

RESULTS

A total of 102 patients were included, with a median age of 1.5 years. Congenital syndromes were present in 14 (13.7%) of the children included. Inhalational induction of anaesthesia with sevoflurane was the preferred approach in 86 cases (84.3%), with neuromuscular blockade being used in 59 cases (57.8%). Intubation was achieved at first attempt in 91 (89.2%) cases with four (3.9%) patients needing three or more attempts. Intraoperative respiratory-related complications were the most frequent, occurring in 22 (21.6%) cases. These include multiple attempts to intubation, desaturation due to bronchospasm or laryngospasm. The average length of stay was two days. Postoperative complications were recorded in 17 (16.7%) of patients.

DISCUSSION

The predominance of airway and respiratory complications occurring in cleft is consistent with previous studies. Care must be taken in order to avoid such complications in the perioperative period by following protocols, having skilled personnel, appropriate monitoring equipment and airway devices available during cleft surgeries to minimise morbidity.

Enhanced recovery after cleft palate repair: A quality improvement project

BACKGROUND

Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.

AIMS

The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery.

METHODS

A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.

RESULTS

Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes.

CONCLUSION

Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.

Association of Patient Factors and Follow-Up in an International Volunteer Cleft Lip and Palate Repair Clinic in El Salvador

BACKGROUND

In countries which lack robust health care systems, congenital conditions such as cleft lip and/or palate deformities are often untreated in certain individuals. Many volunteer organizations have stepped in to fill this gap but certain factors, such as continuity of care, are yet to be studied for these clinics.

METHODS

This is a retrospective cohort study of 167 pediatric patients with cleft lip and/or palate residing in El Salvador treated by a nongovernmental organizations between 2011 and 2020. This data was used in univariate and multivariable models to associate particular patient factors to their likelihood of following up to their annual clinic visits.

RESULTS

Each 1-year increase in duration of follow-up was associated with a 27% decrease in the odds of attending a visit. In addition, 33.7% of cleft lip and 49.7% of cleft palate/cleft lip and palate patients returned at least once. Males had 36% higher odds of attending a return visit compared with females but this difference was not statistically significant. Time spent travelling to the clinic had no effect on follow-up rates.

CONCLUSION

Nongovernmental organizations utilizing a diagonal care model should consider using more strategies to maximize continuity of care by increasing communication with patients and emphasizing the need of following up during clinic visits. Continued and increased collaboration with the local team is also of great importance.

Palatoplasty in children: nursing diagnoses and interventions related to the immediate postoperative period

OBJECTIVE

To identify the main nursing diagnoses and interventions in children in the immediate postoperative period of palatoplasty.

METHOD

Documentary and retrospective study, developed in a Brazilian public and tertiary hospital, between August and September 2020. Children who underwent only palatoplasty, between January and December 2019, aged between 10 and 24 months, were included. Those with medical syndromes and/or comorbidities were excluded. The Theoretical Framework of Basic Human Needs and the NANDA International and Nursing Interventions Classification Taxonomies were used. Data underwent descriptive statistical analysis.

RESULTS

The sample consisted of 126 children. Psychobiological needs such as oxygenation, hydration, nutrition, elimination, cutaneous-mucosal and physical integrity, pain and environmental perception predominated. Based on them, nine nursing diagnoses, with four focusing on the problem and five on risk, as well as 17 interventions, were identified.

CONCLUSION

The use of standardized languages to identify affected human needs and, based on them, diagnoses and interventions, favored clinical reasoning for the construction and organization of clinical nursing practice.

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua

BACKGROUND

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country.

DESIGN

Prospective outcomes study.

SETTING

Comprehensive Cleft Care Center.

PATIENTS

Candidate patients presenting for cleft lip or palate repair or revision.

INTERVENTIONS

Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals.

MAIN OUTCOME MEASURES

Complication was defined as fistula, dehiscence and/or infection.

RESULTS

Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery.

CONCLUSIONS

Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

A Challenging Period After Repair: Etiology and Follow-Up Rates of the Patients With Cleft Lip and Palate in Intensive Care Unit

ABSTRACT

The perioperative period is quite challenging because of the featured anatomical and clinical properties of the babies with cleft lip and palate (CLP). Therefore follow-up in the intensive care unit (ICU) is a crucial parameter for managing these patients. Although various studies in cleft literature, limited studies have analyzed the ICU admission rate and its etiology in the cleft population. At this point, the present study aims to reveal the etiology and rate of ICU admission of babies with an orofacial cleft to contribute to taking preventive precautions.The rate of primary CLP patients was 69.5% (937 of 1348 patients). Intensive care unit admission rate of primary CLP patients was 6.2% (n = 58). The expected and unexpected ICU admission rate was 4.8% and 1.4%, respectively. Of the patients admitted to the ICU, 53.4% (n = 31) were boys and 46.6% (n = 27) were girls. There was no statistically significant association between gender and ICU admission (P = 0.896). However, the association between cleft type and ICU follow-up was statistically significant (P < 0.001).The findings of the present study reveal the high ICU admission rate of cleft patients within all patients admitted to ICU. Due to many unique statuses of cleft babies, attentive assessment in the preoperative period and determining the postoperative need for ICU follow-up would contribute to preventing postoperative complications.

Effect of bilateral infraorbital nerve block on intraoperative anesthetic requirements, hemodynamics, glycemic levels, and extubation in infants undergoing cheiloplasty under general anesthesia

Background

Inappropriate use of intravenous and inhaled anesthetics may be dangerous in infants undergoing facial cleft surgeries. This study primarily aimed to compare the effect of infraorbital nerve block on sevoflurane requirement in infants undergoing cheiloplasty. Intraoperative opioid consumption, hemodynamics, blood glucose levels, extubation time, and delirium were also compared.

Methods

This prospective, randomized, double-blinded study was conducted in 34 infants undergoing cheiloplasty under general anesthesia. After induction, group A received bilateral infraorbital nerve block with 0.5 mL of 0.5% bupivacaine and group B 0.5 mL saline. An increase in heart rate or blood pressure > 20% was managed by increasing sevoflurane by 2-2.5%, followed by fentanyl 0.5 µg/kg bolus. The chi-square test and independent-sample t-test were used where applicable.

Results

Demographics, duration of surgery, and intravenous fluids used were comparable between the groups. Compared to group A, patients in group B had significantly higher consumption of fentanyl (14.2 ± 4.4 µg vs. 22.1 ± 6.2 µg) and sevoflurane (14.2 ± 4.8 mL vs. 26.8 ± 15.6 mL). Intraoperative hemodynamic parameters were significantly lower in group A, the number of times increases in hemodynamic parameters occurred, and fentanyl supplemental bolus was required remained significantly lower in group A than in group B. Intraoperative glycemic levels remained higher in group B, and the extubation time was significantly shorter in group A than in group B (4.40 ± 1.60 min vs. 9.2 ± 2.18 min). Group A had a lesser occurrence of postoperative delirium.

Conclusion

Supplemental infraorbital block in infants undergoing cheiloplasty under general anesthesia resulted in significantly decreased anesthetic requirements and optimal hemodynamic and glycemic levels with faster extubation and lesser delirium.

Is the Use of Opioids Safe after Primary Cleft Palate Repair? A Systematic Review

Pharmacologic treatment of postoperative pain after cleft palate repair includes opioids and nonopioid analgesics, nerve blocks, and local anesthetic infiltration. Use of opioids in infants has concerns regarding sedation, risk of aspiration, respiratory depression, and respiratory distress. The main objective of this review was to analyze information available on the safety of the use of opioids during perioperative management of pain related to primary cleft palate repair in published studies.

Methods

A systematic review of the literature for studies published until March 2020 was performed to evaluate the safety of opioid drugs during primary cleft palate repair pain management. The authors chose the following MesH terms for this systematic review: cleft lip and palate AND opioids AND pain management. The investigators performed a systematic literature search using the Pubmed/MEDLINE, Embase, Web of Science, and Cochrane Library databases.

Results

After a literature search resulting in 70 identified studies, 9 were qualified for the final analysis, which included 772 patients. There was a high level of evidence in the selected studies according to the Oxford CEBM Level of Evidence classification and GRADE scale. The most common adverse event reported was postoperative nausea and vomiting (from 5% to 25%). Episodes of oxygen desaturation have been reported from 2.5% to 7.4% of the studied patients.

Conclusion

s: Definitive conclusions about the safety of opioid drugs during primary cleft palate repair pain management cannot be drawn. Vomiting and oxygen desaturation have been associated with the use of opioids in the studied population.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Lip: An Analysis of 2126 Patients

ABSTRACT

Congenital cardiac comorbidities represent a potentially elevated risk for complications in patients undergoing cleft lip repair. National databases, such as the National Surgical Quality Improvement Program Pediatric (NSQIP-P) allow for analysis of large national datasets to assess these risks and potential complications. The aim of this study is to assess the risk of complications in patients undergoing cleft lip repair with congenital cardiac co-morbidities using the NSQIP-P.The 2012 to 2014 NSQIP-P databases were queried for patients undergoing cleft lip repair. Data abstracted for analysis included demographic, clinical, and outcomes data. Patients with cleft lip were stratified based on the presence or absence of congenital cardiac comorbidities. Univariate analysis and step-wise, forward logistic regression were performed to compare these groups.Nationally, between 2012 and 2014, 2126 patients underwent cleft lip repair, 227 with cardiac disease, and 1899 without cardiac disease. Weights were similar between the groups at the time of surgery, though patients with cardiac comorbidities were older. Postoperatively, cardiac disease patients were more likely to experience an adverse event. Specifically, they were more likely to experience reintubation, reoperation, longer length of stay, and death. Rates of surgical site infection and dehiscence were not different between the groups.This study demonstrates that cleft lip repair in patients with congenital heart defects is safe. However, patients undergoing cleft lip repair with comorbid congenital cardiac disease were more likely to experience adverse events. Cardiac patients require special preoperative evaluation before repair of their cleft lip, but do not appear to experience worse wound-related outcomes.

Optimal Timing of Palatoplasty in Infants With Comorbidities

Objective:

Ideal timing of palatoplasty continues to be debated given that early repair is thought to improve speech and hearing, whereas delayed repair is associated with less midface growth disruption. The purpose of this study is to elucidate optimal timing of palatoplasty in patients with comorbidities to mitigate perioperative complications.

Design:

Retrospective cohort study.

Setting:

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Pediatric.

Patients:

Palatoplasty performed for children younger than the age of 2 years with comorbidities.

Outcomes:

Medical/surgical complications, reoperations, readmissions within 30 days postoperatively.

Results:

Patients with comorbidities having Veau I or II cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 125 days of age ( P < .001). Patients with comorbidities having Veau III cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 225 days of age ( P = .010). Patients with comorbidities having Veau IV cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 250 days of age ( P = .045).

Conclusions:

Infants with comorbidities having progressively increasing Veau classification demonstrate unique age-dependent perioperative thresholds, such that more extensive phenotypes are associated with better perioperative outcomes with older age at time of cleft palate repair.

Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized, Prospective, Double-Blind Study

OBJECTIVES

Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery?

DESIGN

Randomized, controlled, and double-blind study.

SETTING

Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India).

PARTICIPANTS

A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders.

INTERVENTIONS

Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG.

MAIN OUTCOME MEASURE

The primary end point was the incidence of emergence agitation.

RESULTS

There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed.

CONCLUSIONS

The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.

Sustainable Cleft Care: A Comprehensive Model Based on the Global Smile Foundation Experience

INTRODUCTION

Clefts of the lip and palate are leading congenital facial anomalies. Underserved patients with these facial differences lack access to medical care, surgical expertise, prenatal care, or psychological support. Moreover, the disease results in significant economic strains on patients and their families. While surgical outreach programs have attempted to fill this void, significant challenges facing international comprehensive cleft care persist.

OBJECTIVE

Propose a path toward international sustainable cleft care based on the Global Smile Foundation experience.

RESULTS

International sustainable comprehensive cleft care can be achieved by regulating surgical outreach programs. Regulation of these missions would ensure standardized care and encourage stakeholders to cooperate and adequately allocate funding and resources. Capacity building can be achieved through "diagonal" cleft care delivery models, multidisciplinary workshops, fellowship programs, research and quality assurance, as well as leveraging emerging technologies such as Augmented Reality.

CONCLUSION

International comprehensive cleft care requires continuous collaborative efforts between visiting and local teams as well as international and national organizations. Standardizing and regulating current practices as well as promoting capacity building initiatives can contribute to sustainable cleft care.

Cleft Lip and Palate in Ectodermal Dysplasia

OBJECTIVE

Ectodermal dysplasia (ED) comprises multiple syndromes that affect skin, hair, nails, and teeth, and sometimes are associated with orofacial clefting. The purpose of this study is to (1) identify the prevalence and characteristics of cleft lip and/or palate (CL/P) in patients with ED and (2) describe the management and outcomes.

DESIGN

Retrospective review from 1990 to 2019.

PATIENTS

All patients with ED treated at Boston Children's Hospital.

MAIN OUTCOMES MEASURES

Prevalence of CL/P was calculated and clinical details recorded: phenotypic anomalies, cleft type, operative treatment, and results of repair.

RESULTS

Of 170 patients with a purported diagnosis of ED, 24 (14%) had CL/P. Anatomic categories were bilateral CL/P (67%), unilateral CL/P (8%), and cleft palate only (25%). The most common ED syndrome (37%) was ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC). Pathogenic variants in TP63 were the most frequent finding in the 11 patients who had genetic testing. Aberrations from a typical clinical course included failure of presurgical dentofacial orthopedics, dehiscence of nasolabial adhesion, and total palatal absence requiring free-flap construction. Two patients had prolonged postoperative admission for respiratory infection. High fistula (8%) and velopharyngeal insufficiency (33%) rates reflected the predominance of bilateral complete forms.

CONCLUSIONS

As in other types of syndromic CL/P, cleft phenotypic expression in ED is more severe than the general cleft population. Further studies are needed to correlate genotype and phenotype for the distinct syndromes included in the ED spectrum.

Cleft Palate Repair: A New Maxillary Nerve Block Approach

OBJECTIVE

To introduce a different approach for maxillary nerve block (MNB), in cleft palate repair. To reduce the use of opioids during surgery and to prevent frequent respiratory complications by means of an adequate intra and postoperative pain relief.

PATIENTS AND METHODS

A prospective clinical trial was planned, to collect scientific evidences between 2 groups of patients with primary cleft palate, receiving surgery in 2 Pediatric centers of Buenos Aires, utilizing a different protocol.Sixty patients undergoing primary cleft palate repair in both hospitals, from January 2017 to July 2018, by senior surgeons and the same expert anesthesiologists' team, were included.Syndromic and secondary cases, and patients whose parents rejected to participate of this study were excluded. The first group called Hospital A included 45 children, the second group identified as Hospital B was formed by 15 patients.A combination of general whit local anesthesia and a bilateral regional MNB, was used in all the patients of the Hospital A. Utilizing an aspirating syringe, children received 0.15 ml/kg of lidocaine clorhidrate 2% with epinephrine 1:50.000, under direct vision through the spheno palatine holes, just before surgery. A traditional general anesthesia procedure plus local anesthesia, was utilized in all the patients treated at the Hospital B Medial blood pressure and cardiac frequency parameters were tested during induction, along the surgical procedure and in the immediate post op, to detect any sign of pain (12). After surgery, patient reactivity, airway depression symptoms, time of initial feeding and discharge time, were also monitored (13).This study was approved by the Hospitals Ethics Committees of both hospitals, and is in accordance with the 1975 Helsinki Declaration, as amended in 1983. The parents have signed an informed consent form for all the patients included.

RESULTS

Patients of both groups did not show any significant variant in the monitored parameters to detect signals of pain, along the surgery. The rest of controls during and after surgery showed significant differences in favor of the patients of Hospital A.

CONCLUSIONS

Bilateral regional MNB, under direct vision trough the spheno palatine holes results an effective, easy, and safe method for pain relief during and after primary cleft palate repair surgeries.The combination of slight general anesthesia with local anesthesia and regional blocks, results a good option to reduce opioids utilization, to prevent neurotoxicity, respiratory depression, sickness, and vomiting facilitating early feeding and patient discharge.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes

BACKGROUND

When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes.

METHODS

Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement.

RESULTS

Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair.

CONCLUSIONS

This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.

The History and Mission of Smile Train, a Global Cleft Charity

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.

Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

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.

Cleft lip repair: are outcomes between unilateral and bilateral clefts comparable?

This study sought to compare patient demographics, operative course, and peri-operative outcomes between unilateral and bilateral cleft patients. Primary cleft lip repairs were isolated from the National Surgical Quality Improvement Program Pediatric Database (NSQIP-P). Unilateral and bilateral cases of primary cleft lip were identified by ICD codes. Demographics, comorbidities, and post-operative outcomes were compared between cohorts. Patients were propensity matched to control for differences before repeating the analysis. About 4550 cleft lip repairs were evaluated over the 5-year period. Of the cases where the cleft type was identifiable, 75.5% were unilateral clefts and 24.5% were bilateral clefts. The bilateral cleft population had significantly more comorbidities including higher rates of ventilator dependence (1.0% versus 0.4%, p = 0.02), asthma (1.6% versus 0.7%, p = 0.011), tracheostomy (1.6% versus 0.5%, p < 0.001), gastrointestinal disease (16.9% versus 12.7%, p < 0.001), previous cardiac surgery (3.6% versus 2.2%, p = 0.015), developmental delay (9.9% versus 4.6%, p < 0.001), structural central nervous system abnormalities (5.0% versus 2.5%, p < 0.001), and nutritional support (8.0% versus 3.2%, p < 0.001). Following propensity matching, there were no significant differences in complications, readmissions, or reoperations between the cohorts. Patients with bilateral cleft lip have significantly more comorbidities than unilateral cleft lip patients. However, peri-operative outcomes are comparable between the groups.

The Difficult Route to Glottis in Cleft Patients Simplified

Introduction

Cleft lip with or without palate is one of the most common craniofacial anomalies worldwide. Airway problems in children with cleft lip and palate were well recognized since very early times.

Objective

The aim of this technical note is to describe a unique method of performing direct laryngoscopy in children with cleft lip and palate by using a palatal obturator to cover the alveolar and palatal defect in these patients.

Methods

The palatal obturator was fabricated using cold cure acrylic after making an impression of the defect using putty-type impression material.

Results

The use of the palatal obturator facilitated the placement of the laryngoscope's blade by providing adequate leverage to it during the process of direct laryngoscopy prior to intubating children with cleft lip and palate defect.

Conclusion

A discontinuous alveolar arch and palatal defect contribute to lack of effective leverage of the laryngoscope blade while attempting visualization of the glottis. This difficulty can be overcome by use of an obturator to cover the alveolar and palatal defect in order to provide adequate leverage while using a laryngoscope for visualizing the glottis.

The Incidence of Sleep Disordered Breathing One Week After Primary Palatoplasty: Evaluation With Overnight Pulse Oximetry

BACKGROUND

Sleep disordered breathing (SDB) is defined as a series of disorders including snoring, obstructive sleep apnea, and hypopnea. Few studies investigated the incidence of SDB following primary palatoplasty with objective testing. The aims of this study were to elucidate the prevalence and degree of SDB approximately 1 week following primary palatoplasty with objective testing and to clarify the risk factors.

METHOD

A retrospective review was performed on children who underwent primary palatoplasty between April 2013 and July 2017 at National Center for Child Health and Development, Tokyo, Japan. As a national center, the authors accept many syndromic patients. The authors keep all patients after palatoplasty intubated and observe them overnight in intensive care unit to reduce the risks of respiratory events. Patients were evaluated with overnight pulse oximetry on 5 to 7 days postoperatively.

RESULTS

Forty-four patients were included, and 30% of the patients were associated with congenital anomaly. Thirteen patients (30%) were diagnosed with SDB. None of the patients required additional treatment after the evaluation. Laryngomalacia and postoperative oxygen requirement significantly correlated with postoperative SDB.

CONCLUSION

Approximately one-third of the patients may be at the risk of SDB 1 week after primary palatoplasty. Patients with history of laryngomalacia or those who required oxygen support for prolonged time after primary palatoplasty should be cared for significantly high risk of postoperative SDB.

Recovery with Propofol Anesthesia in Children Undergoing Cleft Palate Repair Compared with Sevoflurane Anesthesia

Background

Nowadays, propofol total intravenous anesthesia (propofol TIVA) is a very attractive choice for routine pediatric anesthesia practice.

Objectives

To compare propofol- vs. sevoflurane-based anesthesia for pediatrics undergoing cleft palate repair in emergence characteristics and respiratory adverse effects.

Methods

Eighty infants, aged from six months to one year, scheduled for cleft palate repair surgery, were randomly divided into two groups (40 patients each). The group I received general anesthesia induced with intravenous propofol 2.5 mg/kg, 0.1 mg/kg of lidocaine, fentanyl one µg/kg and cisatracurium 0.15 mg/kg, and maintained by a continuous infusion of propofol 9 mg/kg/hr and cisatracurium 3 µg/kg/hr. While in the group II, general anesthesia induced by O₂/sevoflurane, intravenous fentanyl one µg/kg and cisatracurium 0.15 mg/kg then the maintenance was carried out by O₂/air, sevoflurane 2 MAC, and cisatracurium three µg/kg/hr. Postoperative FLACC behavioral pain assessment Scale, modified Hannallah score, postoperative laryngeal spasm incidence, the recovery time, time to extubation, and postoperative complication were recorded.

Results

The quality of emergence was assessed by modified Hannallah score, there was a significant decrease in the number of patients developed agitation after propofol TIVA in comparison to sevoflurane anesthesia (P < 0.001) with a significant decrease in the number of patients developed postoperative laryngeal spasm (P < 0.047). On the other hand, a significantly prolonged time of extubation was observed in the propofol TIVA group (P < 0.001).

Conclusions

Propofol TIVA regimen was the more peaceful recovery approach with less perioperative respiratory complications than sevoflurane-based anesthesia in infants undergoing cleft palate repair surgery.

Anaesthesia for cleft lip surgeries in a resource poor setting: techniques, outcome and safety

Introduction

Cleft lip and palate is one of the more common congenital malformation and the most common craniofacial anomalies in children. The treatment is expensive and requires specialised care. Access to this care in middle and low income countries is compounded by socioeconomic status of patients and their relation and also the inadequacy of expertise in medical personnel and infrastructure. Objective: the study aimed to review the techniques of anaesthesia used in a low resource setting in terms of the techniques, outcome, and safety.

Methods

This is a retrospective review of 79 cases done in a resource poor setting. Information regarding the patients, surgeries and modes of anaesthesia were retrieved from the case notes.

Results

A total of 62 patients were operated with incomplete cleft accounting for 37 (59.7%), complete 23(37.1%), and 2 (3.2%) as bilateral. Forty-six (74.2%) of patients had their surgery done with ketamine anaesthesia without endotracheal intubation, 14 (22.6%) had regional anaesthesia and 2 patients (3.2%) had general anaesthesia with endotracheal intubation.

Conclusion

This study demonstrates that with careful planning and expertise, cleft lip repair can be done safely in resource poor setting.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database

Objective:

To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort.

Design:

Retrospective review.

Patients/Setting:

Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted.

Main Outcome Measures:

It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease.

Results:

Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different.

Conclusions:

Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Feeding obturator as an airway adjunct during complete unilateral cleft palate repair

Background and Aims:

The palatal defect and abnormal dentition in cleft palate make mask ventilation and laryngoscopy difficult. This study aimed to assess the effect of feeding obturator on laryngeal view in unilateral complete cleft palate.

Methods:

Ninety non-syndromic infants scheduled for the first stage correction of complete unilateral cleft palate were randomised to Group A (no feeding obturator) or Group B (obturator used for induction and intubation). The primary objective was to assess effect of the feeding obturator on the Cormack–Lehane grade on laryngoscopy. Effects on face mask ventilation, easiness of laryngoscopy and intubation and the side effects were also measured.

Results:

Ninety patients completed the study. There was no statistically significant difference between the two groups regarding the CL grade (P < 0.1). However duration for intubation was significantly longer in Group A than Group B (31.4 ± 12.8 vs. 23.4 ± 40.7 sec, P < 0.001). The degree of difficulty of face mask ventilation was significantly greater in Group A than Group B (P < 0.008). Attempts for successful intubation and manoeuvres for successful intubation were significantly more in Group A than B (P < 0.05). Trauma occurred in ten patients in Group A relative to no patients in Group B.

Conclusion:

Use of a pre-sized obturator in infants with complete unilateral cleft palate does not improve the laryngoscopic view. However, it results in better face mask ventilation and easier and faster laryngoscopy and intubation.

Risk factors and comorbidities in Brazilian patients with orofacial clefts

Considering that environmental risk factors substantially contribute to the etiology of orofacial clefts and that knowledge about the characteristics and comorbidities associated with oral clefts is fundamental to promoting better quality of life, this study aimed to describe the risk factors, main characteristics, and comorbidities of a group of patients with cleft lip and/or cleft palate (CL/P) from Rio Grande do Norte (RN), Brazil. Data were obtained from 173 patients with CL/P using a form from the Brazilian database on Orofacial Clefts. Most patients were male with cleft lip and palate and had a normal size and weight at birth; presented few neonatal intercurrent events; and had anemia and respiratory and cardiovascular diseases as main associated comorbidities. They also required timely surgical rehabilitation and multidisciplinary care to stimulate their neuropsychomotor development. In addition, a high frequency of familial recurrence and of parental consanguinity was evidenced in the studied population, especially for the cleft lip and cleft palate type. Other relevant findings were the considerable maternal exposure to alcohol, infections, smoking, and hypertension, as well as low supplementation with vitamins and minerals and deliberate consumption of analgesics, antibiotics, and antihypertensives during pregnancy. Characterization of the CL/P patient profile is essential for the planning of health services and integration among the health professionals involved in the diagnosis and treatment of these malformations. Our results reinforce the need for additional research to confirm the association between environmental factors and the development of orofacial clefts.

Impact of age on the anatomy of the pediatric pterygopalatine fossa and its relationship to the suprazygomatic maxillary nerve block

OBJECTIVES

The suprazygomatic maxillary nerve block is associated with improved post-operative pain management after select craniofacial surgical procedures. This study's objective is to better define the impact of pediatric facial skeletal growth on techniques for accessing the pterygopalatine fossa (PPF).

METHODS

Pediatric patients with prior thin-slice maxillofacial computed tomography imaging were identified in an institutional radiology database. Aquarius image-processing software (Ver. 4.4.11, TeraRecon, Inc., Foster City, CA) was used to measure from the suprazygomatic skin to the greater wing of the sphenoid where the needle is then re-oriented in an anterior and inferior trajectory allowing it to advance into the PPF.

RESULTS

A total of 90 patients ranging from 0 to ≤18 years of age were included in the study. The mean distance from the suprazygomatic skin to the foramen rotundum in patients 0 to ≤12 months of age and >13 to ≤18 years of age was 38.6 (SD ± 4.7) and 47.1 (SD ± 3.2) mm, respectively (p < .0001). The statistical analysis demonstrated a positive correlation between age in years and all of the measured distances (p = .0001). With respect to the plane of the needle entry site, the anterior and inferior angles required for passage into the PPF in the 0 to ≤12 months age group were 11 (SD ± 2.1) and 9.0 (SD ± 2.5) degrees, respectively, compared to those in the >13 to ≤18 years of age group at 12.4 (SD ± 1.9) and 12.1 (SD ± 3.2) degrees, respectively. These data reveal that patients in the oldest compared to the youngest pediatric age groups require significantly greater needle insertion, yet the angles of needle re-orientation are clinically similar between these two pediatric age groups varying by up to only 3°.

CONCLUSION

As expected, the distance from the skin to the foramen rotundum increases significantly with age; however, the angles of re-orientation with respect to the original needle entry site demonstrated up to only 3° of variability between the youngest and oldest age groups evaluated in this pediatric cohort.

A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery

Background

We investigated whether the intraoperative administration of dexmedetomidine would attenuate the profound sympathoadrenal response associated with cleft palate (CP) surgery.

Methods

Sixty children aged 6 months to 12 years undergoing CP surgery under general anesthesia were randomly assigned to the control (C) or dexmedetomidine (D) groups. Group C received benzodiazepine (0.05 mg/kg midazolam followed by infusion of normal saline) fentanyl isoflurane anesthesia, and Group D received dexmedetomidine (loading 1 µg/kg followed by infusion of 0.5 µg/kg/h) fentanyl isoflurane anesthesia. Heart rate (HR), mean blood pressure (MBP), intraoperative fentanyl and isoflurane requirements, recovery scores, emergence agitation, pain scores, time and requirement of rescue analgesic, and surgeon satisfaction were noted.

Results

Intraoperative HR and MBP in Group D were significantly lower than the corresponding values in Group C (P < 0.001). HR decreased up to 16% in Group D. By contrast, HR increased up to 20% in Group C. Group D had comparable MBP to its baseline, whereas Group C had higher MBP until extubation (P = 0.015). Two children in Group D developed bradycardia and hypotension, which was successfully treated. The fentanyl and isoflurane requirements decreased by 43% and 30%, respectively, in Group D patients compared to those in Group C (P < 0.001). Group D had lower pain scores and less emergence agitation (P < 0.001). Time until requirement of first rescue analgesic was longer in Group D than that in Group C (P < 0.001). Surgeon satisfaction was higher in Group D than that in Group C.

Conclusions

Intravenous dexmedetomidine during CP surgery attenuated hemodynamic responses with excellent surgeon satisfaction. Close monitoring of hemodynamics is recommended.

Congenital malformations and medical conditions associated with orofacial clefts in children in Burkina Faso

BACKGROUND

Orofacial clefts are usually isolated cases but can be associated with other congenital malformations that are either recognised or unrecognised syndromes. The reported prevalence and pattern of such associated malformations, however, vary among studies.

OBJECTIVES

To assess the frequencies and aetiologies of congenital malformations and associated medical conditions in children with orofacial clefts in Burkina Faso (Western Africa).

METHODS

A retrospective descriptive study was carried out at the El Fateh-Suka Clinic in Ouagadougou, Burkina Faso. All children who attended surgery for the repair of a cleft lip and/or palate were included in this study.

RESULTS

The frequency of congenital malformations associated with cleft lip and/or palate was 39/185 (21.1%). In the group with multiple congenital malformations of unknown origin (34 patients; 18.4%), 66.7% had cleft lip and palate, followed by isolated cleft lip (27.4%) and isolated cleft palate (5.9%). The digestive system (35.3%), the musculoskeletal system (19.6%), and eye, ear, face, and neck (15.7%) were the most affected systems. In the group of syndromic malformations (five patients; 2.7%), amniotic band syndrome (one patient), Van der Woode syndrome (one patient), Goltz syndrome (one patient), and holoprosencephaly (two patients) were identified. Medical conditions included anaemia (39.4%), infections (9.2%), malnutrition (7.5%), and haemoglobinopathies (4.3%).

CONCLUSIONS

Congenital malformations and medical co-morbidities were frequent in children with OFCs. Further studies and a National Malformations Registry are needed to improve the comprehension of OFCs in Burkina Faso.

An Assessment of 30-Day Complications in Primary Cleft Palate Repair: A Review of the 2012 ACS NSQIP Pediatric

Objective

This study uses the American College of Surgeons Pediatric National Surgical Quality Improvement Program (ACS NSQIP Pediatric), a multicenter database, to identify risk factors for complications after cleft palate repair.

Design

Patients undergoing Current Procedural Terminology (CPT) codes 42200 and 42205 were extracted from the 2012 ACS NSQIP Pediatric. Patients older than 36 months or those who had undergone an additional surgery that altered the risk were excluded. Outcome variables were combined to create a complication variable. Fisher's exact, Pearson chi-square, and Wilcoxon rank-sum tests were used for analysis.

Results

Eligibility criteria were met by 751 patients. Of these, 192 (25.6%) had unilateral clefts, 146 (19.4%) bilateral, and 413 (55.0%) were unspecified. The average age at time of surgery for those without and with complications was 421.1 ± 184.8 and 433.6 ± 168.0 days, respectively ( P = .76). Of the 21 (2.8%) patients with complications, respiratory complications were the most common. Risk factors associated with complications included American Society of Anesthesiologists classification of 3 ( P = .003), nutritional support ( P = .013), esophageal/gastric/intestinal disease ( P = .016), oxygen support ( P = .003), structural pulmonary/airway abnormality ( P = .011), and impaired cognitive status ( P = .009). Patients undergoing concurrent laryngoscopy ( P = .048) or other surgeries ( P = .047) were also found to be associated with increased complications. The 30-day fistula rate was 0.5%, and the readmission rate was 1.9%.

Conclusion

Perioperative complications for primary palatoplasty were 2.8% according to the ACS NSQIP Pediatric. Preoperative patient-related factors as well as concurrent surgeries may affect 30-day complication rates. These results help target those at greater risk for complications and allow for appropriate interventions to mitigate risks.

Cleft Lip and Cleft Palate Surgery: Malpractice Litigation Outcomes

OBJECTIVE

This study examined malpractice claims related to cleft lip and cleft palate surgery to identify common allegations and injuries and reviewed financial outcomes.

DESIGN

The WestlawNext legal database was analyzed for all malpractice lawsuits and settlements related to the surgical repair of cleft lip and palate.

MAIN OUTCOMES MEASURES

Inclusion criteria included patients undergoing surgical repair of a primary cleft lip or palate or revision for complications of previous surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes.

RESULTS

A total of 36 cases were identified, with 12 unique cases from 1981 to 2006 meeting the inclusion criteria. Six cases (50%) were decided by a jury and six by settlement. Five cases involved complications related to the specific surgery, and the other seven were associated with any surgery and perioperative care of children and adults. Cleft palate repair (50%) was the most frequently litigated surgery. Postoperative negligent supervision was the most common allegation (42%) and resulted in a payout in each case (mean = $3,126,032). Death (42%) and brain injury (25%) were the most frequent injuries reported. Financial awards were made in nine cases (after adjusting for inflation, mean = $2,470,552, range = $0 to $7,704,585). The awards were significantly larger for brain injury than other outcomes ($4,675,395 versus $1,368,131 after adjusting for inflation, P = .0101).

CONCLUSION

Malpractice litigation regarding cleft lip and palate surgery is uncommon. However, significant financial awards involving perioperative brain injury have been reported.

An Assessment of 30-Day Complications in Primary Cleft Lip Repair: A Review of the 2012 ACS NSQIP Pediatric

OBJECTIVE

The aim of this study is to identify risk factors associated with complications and readmissions following cleft lip repair using the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric.

DESIGN

Patients undergoing CPT codes 40700, 40701, and 40702 were extracted from the ACS NSQIP Pediatric. Fisher exact, χ(2), and rank-sum tests were used to evaluate risk factors.

RESULTS

Of the 525 patients included, 4.2% had complications, with respiratory complications being the most common. Risk factors included congenital malformations (P = .001), ventilator dependence (P = .002), oxygen support (P = .016), tracheostomy (P = .005), esophageal/gastric/intestinal disease (P = .007), impaired cognitive status (P = .034), acquired central nervous system abnormality (P = .040), nutritional support (P = .001), major and severe cardiac risk factors (P = .011 and P = .005), and an American Society of Anesthesiologists score of 3 (P = .002). In addition, complications were associated with undergoing a one-stage bilateral repair (P = .045) or concomitant ear, nose, and throat procedure (P = .045). The readmission rates for ambulatory patients and inpatients were 2.6% and 4.9% (P = .556), with an overall readmission rate of 4.6%. Ambulatory patients were older (P = .005) and had shorter operative times (P < .001).

CONCLUSIONS

Perioperative complications are low following cleft lip repair, with respiratory complications being the most common. Readmission rates of 4.6% are higher than expected, and insight into predictors of complications will allow surgeons to identify patients who could benefit from additional resources.