To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.
Design
Retrospective cohort study.
Setting
Hospitals participating in the Pediatric Health Information System.
Patients
Primary cleft lip repairs performed in the United States from 2010 to 2020.
Interventions
Local anesthesia injected—treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.
Outcome Measures
Perioperative narcotic administration.
Results
During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.
In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%).
Conclusions
In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.
BennettKGHarbaughCMHuHMVerclerCJBuchmanSRBrummettCMWaljeeJF. Persistent opioid use among children, adolescents, and young adults after common cleft operations. J Craniofac Surg. 2018;29(7):1697-1701. doi:10.1097/SCS.0000000000004762
2.
BouwmeesterNJAndersonBJTibboelDHolfordNH. Developmental pharmacokinetics of morphine and its metabolites in neonates, infants and young children. Br J Anaesth. 2004;92(2):208-217. doi:10.1093/bja/aeh042
3.
HatchDJ. Analgesia in the neonate. Br Med J (Clin Res Ed). 1987;294(6577):920. doi:10.1136/bmj.294.6577.920
4.
LynnAMSlatteryJT. Morphine pharmacokinetics in early infancy. Anesthesiology. 1987;66(2):136-139. doi:10.1097/00000542-198702000-00005
5.
SadhasivamSMyerCM. 3rd. Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012;13(7):982-983; author reply 984. doi:10.1111/j.1526-4637.2012.01419.x
US Food and Drug Administration. FDA Drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm
9.
FalolaRABloughJTAbrahamJTBrookeSM. Opioid prescribing practices in cleft lip and cleft palate reconstruction. Cleft Palate Craniofac J. 2021;58(12):1500-1507.
BenzingACBellCDerazinMMackRMacIntoshT. Disparities in opioid pain management for long bone fractures. J Racial Ethn Health Disparities. 2020;7(4):740-745. doi:10.1007/s40615-020-00701-1
12.
BuonoraMPerezHRHeoMCunninghamCOStarrelsJL. Race and gender are associated with opioid dose reduction among patients on chronic opioid therapy. Pain Med. 2019;20(8):1519-1527. doi:10.1093/pm/pny137
13.
EhwerhemuephaLDonaldsonCDKainZNLuongVFortierMAFeasterWWeissMTomaszewskiDYangSPhanM, et al. Race, ethnicity, and insurance: the association with opioid use in a pediatric hospital setting. J Racial Ethn Health Disparities. 2021;8(5):1232-1241. doi:10.1007/s40615-020-00882-9
14.
GroenewaldCBRabbittsJAHansenEEPalermoTM. Racial differences in opioid prescribing for children in the United States. Pain. 2018;159(10):2050-2057. doi:10.1097/j.pain.0000000000001290
15.
HorvatCMMartinBWuLFabioAEmpeyPEHagosFBigelowSKantawalaSAuAKKochanekPM,et al.Opioid e-prescribing trends at discharge in a large pediatric health system. J Opioid Manag. 2019;15(2):119-127. doi:10.5055/jom.2019.0493
16.
TomaszewskiDMArbuckleCYangSLinsteadE. Trends in opioid use in pediatric patients in US emergency departments from 2006 to 2015. JAMA Netw Open. 2018;1(8):e186161. doi:10.1001/jamanetworkopen.2018.6161
17.
WingESaadatSBhargavaRYunHChakravarthyB. Racial disparities in opioid prescriptions for fractures in the pediatric population. Am J Emerg Med. 2022;51:210-213.
18.
KrederHJGrossoPWilliamsJIJaglalSAxcellTWalEKStephenDJ. Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario. Can J Surg. 2003;46(1):15-22.
19.
D’RummoKATenNapelMJShenX. The impact of radiotherapy facility volume on the survival and guideline concordance of patients with muscle-invasive bladder cancer receiving bladder-preservation therapy. Am J Clin Oncol. 2019;42(9):705-710. doi:10.1097/COC.0000000000000582
20.
KrederHJWilliamsJIJaglalSHuRAxcellTStephenD. Are complication rates for elective primary total hip arthroplasty in Ontario related to surgeon and hospital volumes? A preliminary investigation. Can J Surg. 1998;41(6):431-437.
21.
HaqueWVermaVButlerEBTehBS. Trimodality therapy for esophageal cancer at high volume facilities is associated with improved postoperative outcomes and overall survival. Dis Esophagus. 2019;32(4):1-8. 10.1093/dote/doy067
22.
WangHHTejwaniRZhangHWienerJSRouthJC. Hospital surgical volume and associated postoperative complications of pediatric urological surgery in the United States. J Urol. 2015b;194(2):506-511. doi:10.1016/j.juro.2015.01.096
23.
HammoudehJAImahiyeroboTALiangFFahradyanAUrbinelliLLauJMatarMMageeW3rdUrataM. Early cleft lip repair revisited: a safe and effective approach utilizing a multidisciplinary protocol. Plast Reconstr Surg Glob Open. 2017;5(6):e1340. doi:10.1097/GOX.0000000000001340
24.
KalmarCLPatelVAHumphriesLSVuGHZimmermanCESwansonJWTaylorJA. Thresholds for safety of cleft lip surgery in premature infants. Plast Reconstr Surg. 2020;146(4):859-862. doi:10.1097/PRS.0000000000007159
25.
LeeMKYenSLAllareddyV. Hospitalization outcomes of cleft lip repair in neonates across the United States. Cleft Palate Craniofac J. 2018;55(4):528-535. doi:10.1177/1055665617726531
26.
LeslieFMTsoSHurlbutDE. Differential appearance of opiate receptor subtypes in neonatal rat brain. Life Sci. 1982;31(12–13):1393-1396. doi:10.1016/0024-3205(82)90389-7
27.
PasternakGWZhangATecottL. Developmental differences between high and low affinity opiate binding sites: their relationship to analgesia and respiratory depression. Life Sci. 1980;27(13):1185-1190. doi:10.1016/0024-3205(80)90470-1
28.
MileradJLarsonOHagbergCIdebergM. Associated malformations in infants with cleft lip and palate: a prospective, population-based study. Pediatrics. 1997;100(2 Pt 1):180-186.
29.
ShprintzenRJSiegel-SadewitzVLAmatoJGoldbergRB. Anomalies associated with cleft lip, cleft palate, or both. Am J Med Genet. 1985;20(4):585-595. doi:10.1002/ajmg.1320200404
GuyGPJr.ZhangKBohmMKLosbyJLewisBYoungRMurphyLBDowellD. Vital signs: changes in opioid prescribing in the United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4
32.
LawRCde KlerkC. Anaesthsia for cleft lip and palate surgery. Update in Anaesthesia. 2002;14(9):27-30.
33.
KokkiH. Nonsteroidal anti-inflammatory drugs for postoperative pain: a focus on children. Paediatr Drugs. 2003;5(2):103-123. doi:10.2165/00128072-200305020-00004
34.
VinycombTISahharLJ. Comparison of local anesthetics for digital nerve blocks: a systematic review. J Hand Surg Am. 2014;39(4):744-751. e5. doi:10.1016/j.jhsa.2014.01.017
35.
YilmazAHZiypakEZiypakTAksoyMAdanurSKocakgolHDemirdogenSOPolatO. Comparison of the effect of lidocaine versus a lidocaine-bupivacaine combination in a periprostatic nerve block undergoing transrectal ultrasound-guided prostate biopsy: a double-blind randomized controlled trial. Curr Urol. 2016;9(3):153-158. doi:10.1159/000447132
36.
Lee-ElliottCEDundasDPatelU. Randomized trial of lidocaine vs lidocaine/bupivacaine periprostatic injection on longitudinal pain scores after prostate biopsy. J Urol. 2004;171(1):247-250. doi:10.1097/01.ju.0000098688.12631.a0
37.
FahradyanAGaldynIAzadgoliBTsuhaMUrataMMFrancisSH. To admit or not to admit: that is the cleft lip question. Confirming the safety of outpatient cleft lip repair. Plast Reconstr Surg. 2018;142(1):159-168. doi:10.1097/PRS.0000000000004473
38.
DoyleEHudsonI. Anaesthesia for primary repair of cleft lip and cleft palate: a review of 244 procedures. Pediatr Anesth. 1992;2(2):139-145. doi:10.1111/j.1460-9592.1992.tb00189.x
39.
VuGHHumphriesLSZimmermanCEKalmarCLBartlettSPSwansonJWTaylorJA. A nationwide analysis of cleft palate repair: impact of local anesthesia on operative outcomes and hospital cost. Plast Reconstr Surg.2021;147(8):978e-989e.
40.
AhujaSDattaAKrishnaABhattacharyaA. Infra-orbital nerve block for relief of postoperative pain following cleft lip surgery in infants. Anaesthesia. 1994;49(5):441-444. doi:10.1111/j.1365-2044.1994.tb03484.x
41.
EipeNChoudhrieAPillaiADChoudhrieR. Regional anesthesia for cleft lip repair: a preliminary study. Cleft Palate Craniofac J. 2006;43(2):138-141. doi:10.1597/05-025.1
42.
GrewalGGargKGrewalA. Bilateral infraorbital nerve block versus intravenous pentazocine: a comparative study on post-operative pain relief following cleft lip surgery. J Clin Diagn Res. 2015;9(5):UC04-UC06.
43.
MalherbeVBosenbergATLizarraga LomeliAKNeserCPienaarCHMadareeA. Regional anaesthesia for cleft lip surgery in a developing world setting. S Afr J Surg. 2014;52(4):108-110. doi:10.7196/sajs.1917
44.
NicodemusHFFerrerMJCristobalVCde CastroL. Bilateral infraorbital block with 0.5% bupivacaine as post-operative analgesia following cheiloplasty in children. Scand J Plast Reconstr Surg Hand Surg. 1991;25(3):253-257. doi:10.3109/02844319109020629
45.
PrabhuKPWigJGrewalS. Bilateral infraorbital nerve block is superior to peri-incisional infiltration for analgesia after repair of cleft lip. Scand J Plast Reconstr Surg Hand Surg. 1999;33(1):83-87. doi:10.1080/02844319950159668
46.
RajamaniAKamatVRajavelVPMurthyJHussainSA. A comparison of bilateral infraorbital nerve block with intravenous fentanyl for analgesia following cleft lip repair in children. Paediatr Anaesth. 2007;17(2):133-139. doi:10.1111/j.1460-9592.2006.02032.x
47.
SalloumMLEberlinKRSethnaNHamdanUS. Combined use of infraorbital and external nasal nerve blocks for effective perioperative pain control during and after cleft lip repair. Cleft Palate Craniofac J. 2009;46(6):629-635. doi:10.1597/08-142.1
48.
TakmazSAUysalHYUysalAKocerUDikmenBBaltaciB. Bilateral extraoral, infraorbital nerve block for postoperative pain relief after cleft lip repair in pediatric patients: a randomized, double-blind controlled study. Ann Plast Surg. 2009;63(1):59-62. doi:10.1097/SAP.0b013e3181851b8e
49.
WangHLiuGFuWLiST. The effect of infraorbital nerve block on emergence agitation in children undergoing cleft lip surgery under general anesthesia with sevoflurane. Paediatr Anaesth. 2015a;25(9):906-910. doi:10.1111/pan.12674
50.
FerianiGHatanakaETorloniMRda SilvaEM. Infraorbital nerve block for postoperative pain following cleft lip repair in children. Cochrane Database Syst Rev. 2016;4(4):CD011131.
51.
MoskowitzGBStoneJChildsA. Implicit stereotyping and medical decisions: unconscious stereotype activation in practitioners’ thoughts about African Americans. Am J Public Health. 2012;102(5):996-1001. doi:10.2105/AJPH.2011.300591
52.
HirshATAnastasTMMillerMMQuinnPDKroenkeK. Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems. Am Psychol. 2020;75(6):784-795. doi:10.1037/amp0000636
53.
KlemtCHarveyMJRobinsonMGEspositoJGYeoIKwonYM. Machine learning algorithms predict extended postoperative opioid use in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2022.
54.
VunikiliRGlicksbergBSJohnsonKWDudleyJTSubramanianLShameerK. Predictive modelling of susceptibility to substance abuse. Mortality and drug-drug interactions in opioid patients. Front Artif Intell. 2021;4:742723. doi:10.3389/frai.2021.742723
55.
ZhaoSBrowningJCuiYWangJ. Using machine learning to classify patients on opioid use. J Pharm Health Serv Res. 2021;12(4):502-508.
