167. Comparing Pain Management Techniques in Children Undergoing Primary Palatoplasty: A Prospective Study

PURPOSE: Administering opioids to infants raises concerns regarding postoperative sedation, respiratory depression, and consequent airway compromise. While the use of nerve-block techniques during palatoplasty is gaining popularity and local anesthetic is the conventional method, there remains no clear consensus on the most effective mode of analgesia in primary palatoplasty. This study aims to evaluate whether local palatal infiltration is as effective as suprazygomatic maxillary nerve block (SMB) in minimizing postoperative pain, optimizing postoperative feeding, and expediting discharge from the hospital. METHODS: All patients between the ages of 2 months and 7 years undergoing primary cleft palate repair at our institution were eligible for the study. Participants who consented to the study were randomly assigned to receive either local palatal infiltration of the palate or ultrasound-guided bilateral SMB. Participants in the local cohort received a local injection of 0.125% bupivacaine with 1:400,000 epinephrine at a dose of 2 mL/kg prior to incision. For participants in the SMB cohort, an ultrasound-guided bilateral SMB, using 0.15 ml/kg of 0.2% ropivacaine per side, was administered by the anesthesia team for a total of 0.3 ml/kg. Participants in the SMB cohort received local palatal injection of 0.9% saline with 1:400,000 epinephrine at 2 ml/kg prior to incision, equivalent to the dose of epinephrine administered to the local infiltration cohort. Hospital staff monitored pain levels every 4 hours using the Face, Legs, Activity, Cry, Consolability (FLACC) score. Participants were assessed for the following: amount of opioids and pain medication consumed, FLACC score, time to first postoperative oral intake, and length of stay. Chi squared tests and unpaired t-tests were used to assess for differences in outcomes between the treatment groups. Opioid administration, reported as oral morphine equivalents (OME), was separately analyzed for postoperative administration (administered after leaving the operating room and prior to discharge) and perioperative administration (administered while in operating room and during the defined postoperative period). RESULTS: Forty-two patients were enrolled, with twenty-one patients enrolled in the local infiltration group and twenty-one patients enrolled in the SMB group. Patients in the local infiltration group received significantly more perioperative opioid medication than the SMB group (13.06 vs. 9.68 OME, p = 0.03). There was no statistically significant difference in the quantity of postoperative opioids, Tylenol, Hycet, Ketorolac, and Motrin given between the two groups. There were no statistically significant differences in the total anesthesia time, length of stay, and time to first postoperative oral intake between the cohorts. CONCLUSIONS: This study demonstrates that both local infiltration and SMB are safe analgesic modalities in primary palatoplasty. SMB notably reduced perioperative opioid requirements compared to local infiltration, resulting in decreased total opioid administration. However, our other findings suggest that either technique provides effective pain management for this patient population. Based on these findings, we recommend that SMB be prioritized in hospitals with the appropriate resources to administer this.