Enhanced Recovery After Cleft Lip Repair: Protocol Development and Implementation in Outreach Settings

Abstract

Introduction Clefts of the lip are of the most common congenital craniofacial anomalies. The development and implementation of an enhanced recovery after surgery (ERAS) protocol among patients undergoing cleft lip repair may decrease postoperative complications, accelerate recovery, and result in earlier postoperative discharge. Methods A modified ERAS program was developed and applied through Global Smile Foundation outreach craniofacial programs. The main components of this protocol include: (1) preoperative patient education, (2) nutrition screening, (3) smoking cessation when applicable, (4) use of topical anesthetic adjuncts, (5) facial nerve blocks, (6) postoperative analgesia, (7) preferential use of short-acting narcotics, (8) antibiotic administration, (9) use of elbow restraints, (10) early postoperative oral feeding and hydration, and (11) discharge planning. Results Between April 2019 and March 2020, GSF operated on 126 patients with cleft lip from different age groups and 58.8% of them were less than 1 year of age. Three patients (2.4%) had delayed wound healing and one (0.8%) had postoperative bleeding. There were no cases of mortality, length of hospital stay did not exceed 1 postoperative day, and patients were able to tolerate fluids intake at discharge. Conclusion The implementation of an ERAS protocol among patients undergoing cleft lip repair has shown to be highly effective in minimizing postoperative discomfort while reducing opioids use, decreasing the length of stay in hospital, and leading to early oral feeding resumption. The ERAS principles described carry increased relevance in the context of the ongoing COVID-19 pandemic and opioid crisis and can be safely applied in resource-constrained settings.

Opioid Sparing by ERAS Protocol in Cleft Lip and Palate Craniofacial Surgery

“…This finding aligns with the ERAS goal of reducing postoperative pain by multimodal, non-opioid management. 14 Findings were also consistent among procedure types that we examined. Despite ERAS implementation, patients still required a comparable amount of morphine in both cohorts across the whole study timeframe, although the average is down trending.…”

“…2 More recently, ERAS protocols for cleft lip repair have been proven to reduce opioid use, leading to shortened time to feeding resumption and return to function. 14,16,22 Our study sought to identify the benefits that an ERAS protocol with oral acetaminophen had in the immediate 2 years following its implementation compared to the 2 years prior. By implementing ERAS, an expected rise in both IV and PO NSAID utilization for pain management was witnessed during the patient's hospital course.…”

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

“…10 GSF and Smile Train have developed quality assurance and anesthetic guidelines to prioritize and ensure patient safety in international surgical endeavors. [34][35][36] In a similar way, protocols can be developed that outline best practices for maximizing follow-up. This protocol could outline the way future appointments are discussed during initial visits, recommend ways for the local providers to maintain continuity with patients throughout the year, and detail what information is given to patients.…”

Current trends in unilateral cleft lip repair

“…However, there is no proven benefit to longer courses of postoperative antibiotics in ‘clean contaminated’ surgeries such as UCLR [8]. In a 2022 ERAS protocol implemented in outreach settings through the Global Smile Foundation, intravenous antibiotics were administered at the time of incision usually with a first- or second-generation cephalosporin [9 ▪ ]. This was followed by 5 days of an equivalent oral antibiotic along with topical antibiotic ointment application [9 ▪ ].…”

“…In a 2022 ERAS protocol implemented in outreach settings through the Global Smile Foundation, intravenous antibiotics were administered at the time of incision usually with a first- or second-generation cephalosporin [9 ▪ ]. This was followed by 5 days of an equivalent oral antibiotic along with topical antibiotic ointment application [9 ▪ ]. Of the 126 patients operated on in the study, there were no reported immediate postoperative complications, including infection or wound dehiscence, however the authors reported three patients had delayed wound healing [9 ▪ ].…”