Enhanced recovery after cleft palate repair: A quality improvement project. Issue 10 (11th August 2022)

• Record Type: Journal Article
• Authors: Esfahanian, Mohammad; Marcott, Stephen Craig; Hopkins, Elena; Burkart, Brendan; Khosla, Rohit Kumar; Lorenz, H. Peter; Wang, Ellen; De Souza, Elizabeth; Algaze‐Yojay, Claudia; Caruso, Thomas J.
• Is Part Of: Paediatric anaesthesia. Volume 32:Issue 10(2022)
• Page Start: 1104
• Page End: 1112
• Publication Date: 2022-08-11
• Subjects: analgesics—opioid -- cleft palate -- enhanced recovery after surgery -- length of stay -- maxillary nerve -- pain—postoperative; Pediatric anesthesia -- Periodicals; 617.96798
• DOI: 10.1111/pan.14541
• Languages: English
• ISSNs: 1155-5645

Abstract

Abstract: Background: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. Aims: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. Methods: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target‐based care. Interventions included maxillary nerve blockade and enhanced intra‐ and postoperative medication regimens. Outcomes were displayed as statistical process control charts. Results: Pathway compliance was 77.0%. Patients during the intervention period ( n = 39) experienced a 49% reduction in postoperative opioid consumption ( p < .0001) relative to our historical cohort ( n = 63), with a mean difference of −0.33 ± 0.11 mg/kg (95% CI −0.55 to −0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% ( p = .002), with a mean difference of −0.27 ± 0.09 mg/kg (95% CI −0.45 to −0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake ( p = .02) relative to our historical cohort, with a mean difference of −3.81 ± 1.56 h (95% CI −6.9 to −0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. Conclusion: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.