D.3. How would you control postoperative pain in patients following a cleft lip and cleft palate repair? Describe a multimodal analgesic plan including regional anesthesia options.
Answer:
Cleft lip and cleft palate repairs are painful procedures that can lead to patient distress and adverse physiologic consequences if not appropriately managed. No child should be discharged from the postanesthesia care unit with uncontrolled pain, and this management continues to the pediatric intensive care unit or ward bed.
Nerve blocks can provide analgesia with less perioperative consumption of opioids and its associated adverse outcomes, such as airway complications (respiratory depression, airway obstruction, and desaturation), postoperative nausea, vomiting, and delayed oral intake.
The infraorbital nerve block can be used for cleft lip repair. This nerve is a branch of the maxillary nerve (pure sensory nerve), which is the second division (V2) of the trigeminal nerve. It exits the infraorbital foramen then supplies sensation to the upper lip, lower eyelid, nasal ala, and the maxillary process. It may be blocked by either the extraoral or intraoral approach, with the latter being more common. The procedure involves everting the upper lip and injecting a small volume (0.5 mL) of local anesthetic into the sulcus of the buccal mucosa opposing the second bicuspid tooth. The needle is directed superiorly and parallel to the second bicuspid until it is palpated externally near the foramen. Several small studies favor the infraorbital nerve block over placebo, local infiltration, and intravenous analgesics due to lower pain scores, time to first rescue analgesic, and shorter time to first feeding without significant adverse events, while others demonstrate conflicting results. Larger, multicenter trials with more rigorous methodology are needed to identify optimal technique and dosing.
For cleft palate repair, nasopalatine and palatine nerve blocks provide palatal hard and soft tissue anesthesia. In infants, the greater palatine foramen is typically located behind the posterior molar. This regional procedure involves a syringe directed into the mouth from the opposite side at a right angle to the target with the needle bevel toward the palatal soft tissue. The greater palatine nerve block anesthetizes the palatal mucosa and hard palate from the first premolar anteriorly to the posterior part of the hard palate. The lesser palatine nerve block is similar and provides analgesia to the soft palate. The nasopalatine nerve block is performed at the incisive foramen. It cannot be performed in complete clefts where the premaxilla is not developed or is malformed.
Suprazygomatic maxillary nerve blocks can also be used for effective pain relief of cleft palate repair by anesthetizing the entire sensory distribution of the maxillary nerve and its terminal branches. The needle is inserted perpendicularly at the angle formed by the superior edge of the zygomatic arch below and the posterior orbital rim forward. The needle is advanced perpendicularly to the skin until it reaches the greater wing of the sphenoid (~2 cm), then withdrawn and reoriented in an anterior/caudal direction (toward the nasolabial fold) and advanced further to 3.5 to 4.5 cm to reach the pterygopalatine fossa. Local anesthetic (0.1-0.15 mL/kg/side) is slowly injected after negative aspiration. Real-time, ultrasound guidance, with the transducer placed in the infrazygomatic area, allows visualization of the pterygopalatine fossa, identification of the maxillary artery, needle tip localization, and visualization of spread within the pterygopalatine fossa.
All these techniques have been shown to have very minimal adverse side effects and can be performed safely in anesthetized patients.
Opioid analgesics that can be used postoperatively are shown in Table 42.2.
Table 42.2: Recommended Opioid Analgesics for Pediatric Patients
| Drugs | Dosage | Form |
|---|---|---|
| Fentanyl | 1 µg/kg | IV |
| Morphine | 0.05-0.1 mg/kg | IV |
| Meperidine | 1 mg/kg | IV |
| Oxycodone | 0.15 mg/kg | PO: 5-mg tablets; syrup 5 mg/mL |
Nonopioid analgesics that can be used postoperatively are shown in Table 42.3. Dexmedetomidine can be used for both analgesic properties and to decrease emergence excitation.
Table 42.3: Recommended Nonopioid Analgesics for Pediatric Patients
| Drug | Dosage | Forms Available |
|---|---|---|
| Acetaminophen (Tylenol) | 10-15 mg/kg PO maximum 2,600 mg/d | Tablets: 80 mg Syrup: 325 mg/5 mL Suppositories: 120, 325, 650 mg |
| Ibuprofen (Motrin) | 10-20 mg/kg PO q6h | Tablets: 300, 400 mg Syrup: 100 mg/5 mL |
| Ketorolac (Toradol) | 0.5 mg/kg IV to load (maximum dose 30 mg) 0.5 mg/kg q8h intramuscularly or intravenously (limit use to 48 h) | Parenteral form used IM/IV |
| Dexmedetomidine | 0.3-1 µg/kg IV | IV |
References
- Chiono J, Raux O, Bringuier S, et al. Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo. Anesthesiology. 2014;120:1362-1369.
- Cho HK, Yoon HY, Jin HJ, Hwang SH. Efficacy of dexmedetomidine for perioperative morbidities in pediatric tonsillectomy: a metaanalysis. Laryngoscope. 2018;128:E184-E193.
- Feriani G, Hatanaka E, Torloni MR, da Silva EMK. Infraorbital nerve block for postoperative pain following cleft lip repair in children. Cochrane Database Syst Rev. 2016;4:CD011131.
- Lonnqvist PA, Morton NS. Paediatric day-case anaesthesia and pain control. Curr Opin Anaesthesiol. 2006;19:617-621.
- Nardi NM, Alvarado AC, Schaefer TJ. Infraorbital Nerve Block. StatPearls Publishing; 2022.