Massachusetts Chapter of the American College of Surgeons

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Perioperative Pain Management after Primary Palate Repair; A Three Surgeon Retrospective Study
Ingrid M. Ganske, MD MPA1; Olivia Langa, BA1; Nancy DiTullio, NP1; Zoe Fullerton, MD2; Walid Alrayashi, MD3; John G. Meara, MD DMD MBA1; John B. Mulliken MD1; Carolyn R. Rogers-Vizena MD1
1Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Boston MA 2 Department of Otolaryngology Head & Neck Surgery, Stanford University School of Medicine, Stanford CA 3 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston MA

Background: Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. This study aims to define analgesic variables that affect post-operative narcotic use and time to resumption of oral intake.
Methods: Retrospective review of non-syndromic patients undergoing primary palate repair. Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/hour) administered. Analgesic variables were analyzed with the Mann-Whitney U test and the impact of age and weight were assessed with regression analysis.
Results: Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and post-operative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P>0.05, all). Post-operative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized p0.05, both).
Conclusion: Several perioperative analgesic strategies lead to comparable post-operative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.


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