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

Abstract

Objective: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. Design: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). Patients: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. Interventions: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. Main Outcome Measures: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. Results: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 μg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. Conclusions: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

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

“…Studies investigating the topic of pain and analgesia were the most common (n=31; Supplemental Table 5, Supplemental Digital Content 5, http://links.lww.com/SCS/E642)12,13. Many of the included studies investigated the use of various analgesia techniques that aimed at reducing postoperative opioid consumption 2,14–29. Seven of the included studies investigated the effectiveness of bupivacaine for use in nerve block in cleft lip and/or palate repair 1,4,28,30–33.…”

“…Many of the included studies investigated the use of various analgesia techniques that aimed at reducing postoperative opioid consumption. 2,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] Seven of the included studies investigated the effectiveness of bupivacaine for use in nerve block in cleft lip and/ or palate repair. 1,4,28,[30][31][32][33] All but 1 1 focused on infraorbital nerve block placement in cleft lip surgery patients.…”

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

“…Due to the potential adverse effects of increased IV opioid use, reducing narcotic administration in infants is crucial. In addition, optimization of perioperative analgesia and opioid use has been associated with earlier feeding and, therefore, shorter lengths of hospital stay 3,9 . Prior studies have concluded that the use of intraoperative US-guided SMBs can potentially reduce postoperative pain and adverse outcomes during hospital stays.…”

“…Limiting postoperative pain is particularly important in pediatric cleft palate repair procedures. However, achieving adequate analgesic control through IV opioids can be challenging in young infants 9 . Due to the potential adverse effects of increased IV opioid use, reducing narcotic administration in infants is crucial.…”

Enhanced Recovery After Surgery for Pediatric Cleft Repair: A Systematic Review and Meta-Analysis

“…1). Following screening, 18 articles underwent full-text review and 5 studies [14][15][16][17][18] met final inclusion criteria. Upon initial review, 1 study was found to deliberately compare outcomes between controls and an ERAS group that was distinctly different with regards to demographics and medical history.…”