Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Abstract

Background: Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study’s purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair. Methods: A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated. Results: Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores (p < 0.001) and time to analgesia failure (p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure (p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed. Conclusions: The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

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

“…By comparison, in cleft lip repair bilateral infraorbital nerve blocks resulted in increased latency to first analgesia and decreased opioid consumption (P < 0.00001). Pfaff et al 28 reported significant improvements in pain control (P < 0.001) and time to analgesia failure (P < 0.001) using intraoperative nerve block compared with placebo in cleft lip studies. The authors similarly found improved time to analgesia failure (P < 0.005) using maxillary and palatal nerve blocks in palatoplasty studies.…”

“…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.…”

“…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. One found that when clonidine (3 μg/kg) was included with bupivacaine as an adjuvant in suprazygomatic maxillary nerve block for cleft lip and palate repair, emergence agitation was significantly reduced.…”

Current trends in unilateral cleft lip repair

“…Preoperative optimization with a special focus on pain management has been a topic of interest of late. A recent review looked at 23 studies focusing mainly on the efficacy of intraoperative nerve blocks [6 ▪ ]. They found that infraorbital blocks with nasal blocks for concomitant cleft rhinoplasty led to less postoperative narcotic use and decreased hospital stay [6 ▪ ].…”

“…A recent review looked at 23 studies focusing mainly on the efficacy of intraoperative nerve blocks [6 ▪ ]. They found that infraorbital blocks with nasal blocks for concomitant cleft rhinoplasty led to less postoperative narcotic use and decreased hospital stay [6 ▪ ]. To further explore perioperative pain control and narcotic minimization, an enhanced recovery after surgery (ERAS) protocol was implemented in 2020 in one Atlanta-based study.…”