The Use of Postoperative Restraints in Children after Cleft Lip or Cleft Palate Repair: A Preliminary Report

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.

Section: Elbow Restraintsmentioning

confidence: 92%

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

Melhem

Ramly

Abyad

et al. 2022

“…Huth et al performed a prospective study (with unclear randomization) of restraints versus no restraints in a total of 47 postoperative cleft lip repairs. They found no differences in lip repair outcomes (Huth et al, 2013).…”

Section: Resultsmentioning

confidence: 97%

Perioperative Management of Cleft Lip Repair: A Meta-Analysis and Clinical Practice Guideline

Ranzer

Daniele

Purnell

2021

Objective: Few studies have focused on perioperative management of cleft lip repair. We sought to evaluate the available data on this topic to create evidence-based clinical guidelines. Design: Systematic review, meta-analysis. Methods: A PubMed search was performed focusing on perioperative management of cleft lip repair. Studies were included if they included comparative data. A systematic review and meta-analysis was performed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Main Outcome Measures: Systematic review of literature regarding wound closure, postoperative arm restraints, perioperative antibiotics, outpatient or ambulatory surgery, or feeding restrictions postoperatively. Results: Twenty-three articles met inclusion criteria after initial screening of 3103 articles. This included 8 articles on wound closure, 2 on postoperative restraints, one on perioperative antibiotics, 6 on outpatient surgery, and 6 on postoperative feeding. Meta-analysis could be performed on dehiscence rates with postoperative feeding regimen and readmission rates after outpatient versus inpatient lip repair. There were few studies with low risk of bias. Outpatient cleft lip repair does not increase readmission (odds ratio [OR]: 0.92, 95% CI: 0.28-3.07). Allowing postoperative breastfeeding or bottle-feeding does not increase dehiscence (OR: 0.61, 95% CI: 0.19-1.95). There was no evidence of publication bias. Conclusion: Within the limitations of available data, there is no evidence of a clearly superior closure material. The evidence does not support use of postoperative arm restraints. The evidence does not support the use of preoperative nasal swabs for antibiotic guidance. With careful patient selection, outpatient cleft lip repair appears safe. The evidence supports immediate breastfeeding or bottle-feeding after cleft lip repair.

“…Arm splinting to prevent injury after cleft surgery has had common support, with routine use in as many as half the cleft surgeons in North America (Petersen & Lehman, 2008). However; more recent studies have found no significant difference in the rate of wound disruption in children who received arm splints after cleft lip or palate repair and those who did not (Michelotti et al, 2012;Huth et al, 2013;Shaye et al, 2015). Furthermore, the lack of significant difference held, even when parents of patients undergoing cleft surgery reported thumb-sucking behavior or pacifier use by patients in the postoperative period.…”

Section: Discussionmentioning

confidence: 99%

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction

Falola

Blough

Abraham

et al. 2021

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.