Moffitt Joseph K, Cepeda Alfredo, Ekeoduru Rhashedah A, Teichgraeber John F, Nguyen Phuong D, Greives Matthew R
Division of Pediatric Plastic Surgery, Department of Pediatric Surgery.
Division of Pediatric Anesthesia, Department of Anesthesia, McGovern School of Medicine at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, TX.
J Craniofac Surg. 2021;32(1):e72-e76. doi: 10.1097/SCS.0000000000006985.
Enhanced recovery after surgery (ERAS) protocols have been adopted for many types of surgery. Postoperative pain following palatoplasty may cause feeding and swallowing difficulty. Our study evaluated the use of ERAS protocols to improve the management of pain following primary palatoplasty as well as in the transition of care from inpatient to outpatient.
An Institutional Review Board approved retrospective analysis was performed for patients who previously underwent primary palatoplasty before ERAS implementation. Separately, an Institutional Review Board approved prospective trial of patients undergoing primary palatoplasty was performed and these patients were managed with ERAS protocols. Data were obtained for length of stay, pain scale scores, milligrams of morphine administered, and inpatient readmissions/emergency department visits. Outpatient medication logs were used to follow pain medicine usage, and a satisfaction survey was administered at the first postoperative visit.
Data were obtained retrospectively for 56 patients and prospectively for 57 patients who underwent primary palatoplasty. Patients in the ERAS protocol received significantly less milligrams of morphine on postoperative day 1 through day 4 than those patients in the usual care group P < 0.05. No significant difference was observed for length of stay, oral intake prior to discharge, or inpatient face, legs, activity, cry, consolability pain scale scores. Outpatient medication logs showed a continued decrease in narcotic usage at home with no spike post discharge day 1. Parents reported high satisfaction levels for inpatient pain management (4.66 ± 0.49) and even higher satisfaction levels for understanding (5.0 ± 0) and management of pain at home (4.92 ± 0.29). Return visits to the hospital for pain management following primary palatoplasty decreased from 7.1% (4) following the previous protocol to 0% with the new ERAS protocol (P = 0.057).
The ERAS protocols provide improved inpatient pain management following primary palatoplasty as evidence by decreased total narcotic pain medication usage. The use of multimodality therapy and increased patient education regarding non-narcotic medications can improve the transition of care from inpatient to outpatient, without sacrificing patient/parent satisfaction. The results of this study merit future study into more restricted use of opioid pain medications with greater emphasis on the use of multimodal therapeutics as primary agents as opposed to adjuncts.
手术加速康复（ERAS）方案已应用于多种类型的手术。腭裂修复术后的疼痛可能导致喂养和吞咽困难。我们的研究评估了ERAS方案在改善初次腭裂修复术后疼痛管理以及从住院到门诊护理过渡方面的应用。
对在实施ERAS之前接受初次腭裂修复术的患者进行了机构审查委员会批准的回顾性分析。另外，对接受初次腭裂修复术的患者进行了机构审查委员会批准的前瞻性试验，这些患者采用ERAS方案进行管理。获取了住院时间、疼痛量表评分、吗啡给药毫克数以及住院再入院/急诊就诊的数据。使用门诊用药记录跟踪止痛药的使用情况，并在术后首次就诊时进行满意度调查。
对56例接受初次腭裂修复术的患者进行了回顾性数据收集，对57例患者进行了前瞻性数据收集。与常规护理组相比，ERAS方案组患者在术后第1天至第4天接受的吗啡毫克数明显更少（P<0.05）。在住院时间、出院前口服摄入量或住院面部、腿部、活动、哭闹、安抚疼痛量表评分方面未观察到显著差异。门诊用药记录显示，在家中麻醉药品的使用持续减少，出院后第1天没有出现峰值。家长对住院疼痛管理的满意度较高（4.66±0.49），对在家中疼痛的理解（5.0±0）和管理的满意度更高（4.92±0.29）。初次腭裂修复术后因疼痛管理返回医院就诊的比例从前一方案的7.1%（4例）降至新ERAS方案的0%（P=0.057）。
ERAS方案通过减少麻醉性止痛药的总使用量，改善了初次腭裂修复术后的住院疼痛管理。使用多模式治疗和增加患者对非麻醉性药物的教育可以改善从住院到门诊的护理过渡，而不影响患者/家长的满意度。本研究结果值得未来进一步研究更严格地使用阿片类止痛药，更加强调使用多模式治疗作为主要药物而非辅助药物。
