Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs

Abstract

Aims: Enhanced Recovery after Surgery (ERAS) protocols have been shown to improve patient outcomes in numerous adult surgical populations, but there are few known standards for their use in pediatric patients. To assess the effectiveness in pediatric craniofacial surgery, we present our results following the application of a modified ERAS protocol for patients undergoing primary palatoplasty. Methods: A modified ERAS program was developed and implemented in a multidisciplinary manner. The primary components of the protocol included: (1) administration of gabapentinoids, (2) minimal perioperative narcotic use, and (3) post-operative pain control using nonnarcotic first-line agents. Fifty patients were collected prospectively, assigned to the modified ERAS protocol and compared to historic controls. We reviewed patient demographics, narcotic use, length of stay (LOS), oral intake, and complication rates. Results: Between April 2017 and June 2018, 50 patients underwent palatoplasty under the modified ERAS protocol. The mean age (control: 9.7 ± 2.3 months; ERAS: 9.9 ± 1.6 months), weight (8.8 ± 1.3 kg; 8.6 ± 1.3 kg), and comorbidities did not vary between the groups. ERAS patients evidenced an increase in oral intake normalized per LOS (22.3 mL/h vs 15.4 mL/h). Total narcotic usage (morphine equivalents) during each phase of care was greater in the controls compared with ERAS (Intraop: 3.71 mg vs 0.12 mg; PACU: 0.51 mg vs 0.05 mg; Postop: 2.6 mg vs 0.07 mg). The implementation of this protocol led to a 36.6% decrease in LOS (1.83 days vs 1.16 days) without an increase in perioperative complications. Conclusions: Implementation of a modified ERAS protocol provided effective perioperative pain control allowing narcotic minimization, increased post-operative oral intake, and a shorter LOS without an increased complication rate.

Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty

“…For each phase of care, all relevant narcotics (eg, fentanyl, dilaudid, morphine, hydrocodone) were converted in standardized ratios to morphine equivalency for uniform comparison. In our original study, the ERAS group evidenced a significant decrease in the time to resumption of oral intake as well as increase in overall oral intake when normalized over the hospital stay (Hush et al, 2019). The expanded analysis presented here included patients who had a variety of baseline enteral feeding regimens such as those who were partially or entirely tube-fed.…”

“…Once patients were selected for the ERAS protocol, providers and staff followed the established protocol guidelines. These guidelines were explicitly outlined in our POC work but reviewed here for ease of reference (Hush et al, 2019).…”

“…Proof of concept was initially established with a homogenous group of infants undergoing primary palatoplasty. Implementation of the protocol evidenced significant perioperative narcotic minimization, increased postoperative oral intake, and a shorter LOS without an increased complication rate (Hush et al, 2019). The protocol was then expanded to include analysis of its utility in patients of variable age and medical complexity.…”

“…The main components of the anesthetic protocol consisted of administration of dexmedetomidine, dexamethasone, ketorolac, ondansetron, and goal-directed fluid administration. The detailed anesthetic protocol is elucidated in our POC analysis for reference (Hush S, et al, 2019).…”

The Impact of Bilateral Suprazygomatic Maxillary Nerve Blocks on Postoperative Pain Control in Patients Undergoing Orthognathic Surgery

“…Our institution has previously shown the efficacy of a modified Enhanced Recovery After Surgery (ERAS) protocol in pediatric cleft palatoplasty, resulting in perioperative narcotic minimization, increased post-operative oral intake, and a shorter LOS without an increased complication rate. 5 Our institutional protocols were extrapolated from the fundamental concept of ERAS as a multimodal therapy.…”