It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate.

INTRODUCTION: Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established. METHODS: A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined. RESULTS: Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery. CONCLUSION: The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.

Anesthetic Complications in Children Undergoing Mehta Spine Casting: A Case Series.

Elongation-derotation flexion casting, commonly referred to as Mehta casting, is a relatively new treatment for infantile idiopathic scoliosis. Surgeons have noted remarkable, sustained improvement in scoliosis following treatment with serial Mehta plaster casts. There is scant literature regarding anesthetic complications during Mehta cast placement. This case series examines 4 children who underwent Mehta casting at a single tertiary institution. Complications included endotracheal tube obstruction, hypothermia, pressure point injuries, and prolonged exposure to general anesthesia (GA) that potentially increases the risk of long-term neurodevelopmental delay.

Factors Associated with Prolonged Exposure to General Anesthesia During Dental Rehabilitation Under General Anesthesia In Patients Under Age Three Years.

Purpose: The purpose of this study was to determine the risk of prolonged general anesthesia (GA) for pediatric dental patients and understand factors that contribute to prolonged GA in patients under age three years in an academic hospital. Methods: A retrospective chart review for pediatric dental patients treated using GA collected data for patient age, treatment provided, other services involved in patient management, and case GA length. Further chart analysis was completed by a multidisciplinary team for cases of prolonged general anesthesia. Results: A total of 114 cases were evaluated. The incidence of prolonged GA exposure was 21.9 percent (N equals 25). Cohort data of cases younger than three years show that cases of prolonged GA exposure were more likely to be closer to age three, require longer non-throat pack time, require more restorative procedures, require longer procedure times, and utilize additional surgical services more often (P<0.05). Four common themes for prolonged exposure were identified (significant restorative needs, provider-level training, anesthesia complications, and utilization of other services), with most cases (88 percent) experiencing multiple themes as contributing factors. Few adverse effects were noted, and none had long-lasting effects. Conclusions: Dental rehabilitation cases in very young patients are at risk for prolonged exposure to GA. Providers should be aware of total anesthesia time while completing dental rehabilitation using GA and proactively attempt to reduce the risk of prolonged exposure.

Enhanced Recovery After Surgery Protocol for Primary Cleft Palate Repair: Improving Transition of Care.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 ±â€Š0.49) and even higher satisfaction levels for understanding (5.0 ±â€Š0) and management of pain at home (4.92 ±â€Š0.29). 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). CONCLUSION: 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.

How Should Trainees' Influences on Postoperative Outcomes Be Disclosed?

Conflict arises when surgeons and anesthesiologists disagree about goals of care in perioperative settings. Collaboration is essential for safe, efficient, and effective care. Drawing on 2 pediatric cases that highlight risks of anesthetic exposure, this article examines the influence of surgical training on outcomes, barriers to collaboration, and anesthesiologists' ethical obligations to educate surgeons and parents about anesthesia-induced neurotoxicity risks. The article also discusses how to align surgical and anesthetic practice during surgeries with prolonged anesthetic use.

Traumatic Tracheobronchial Laceration Causing Complete Tracheal Resection: Challenges of Anesthetic Management.

We report the case of a 9-year-old girl who sustained blunt trauma to the chest and presented for emergent repair of a complete tracheobronchial laceration. Tracheobronchial laceration is potentially life threatening. While conservative management has been described for simple tears, more complex injuries require surgical repair. We discuss the anesthetic challenges, airway management, and ventilation options for surgical repair in a child with a complex laceration involving the tracheobronchial tree.

Behavioral Disturbance Causing Sudden Respiratory Distress in a 3-Year-Old After Tracheocutaneous Fistula Closure: A Case Report.

A 3-year-old boy underwent tracheostomy at age 5 months for respiratory failure. The tracheostomy tube was removed a year later but a tracheocutaneous fistula developed requiring fistulectomy and primary skin closure. After an initial uneventful course in the postanesthesia care unit, the patient became agitated, began to scream, and suddenly developed rapidly progressing subcutaneous emphysema over his chest, face, and abdomen. Orotracheal intubation was emergently performed and chest radiograph revealed pneumothorax and pneumomediastinum. The child was taken to the operating room for placement of a tracheostomy tube.

Challenging Airway Secondary to Purpura Fulminans With Face and Neck Bullae in a Premature Infant: A Case Report.

A former 25-week-old neonate presented at 34 weeks postconceptual age with necrotizing fasciitis and purpura fulminans because of Group B Streptococcus infection. He was septic and coagulopathic when he was intubated, and the endotracheal tube was secured with adhesives. When he subsequently developed large purpuric, bullous lesions on the face and neck, he presented to the operating room for excision and debridement of his facial lesions. No change was made in how the endotracheal tube was secured. Midprocedure, an unintentional extubation occurred. We describe how we subsequently secured the airway and make recommendations on how to avoid this problem in the future and for rescue preparation before the procedure.