Implementation of a Modified Enhanced Recovery Protocol in the Surgical Management of Pediatric Velopharyngeal Insufficiency

Abstract

Background: We have recently shown that the use of a modified enhanced recovery after surgery (ERAS) protocol in primary cleft palatoplasty decreases perioperative narcotic utilization and length of stay (LOS) while allowing quicker return to oral intake. In an effort to broaden the application of ERAS protocols within pediatric craniofacial surgery, we have applied our modified ERAS protocol to patients undergoing surgery for velopharyngeal insufficiency (VPI). Methods: A modified ERAS program was implemented in a multidisciplinary manner. The primary components of the protocol included: (1) administration of gabapentinoids, (2) minimal perioperative narcotic use, and (3) post-operative pain control using nonnarcotic firstline agents. One hundred twenty-nine patients were collected prospectively, assigned to the modified ERAS protocol, and compared to historic controls. Patients with a diagnosis of VPI undergoing sphincter pharyngoplasty, pharyngeal flap, or furlow palatoplasty were included. We reviewed patient demographics, narcotic use, length of stay (LOS), and complication rates. Results: Between October 2017 and December 2020, 129 patients underwent speech surgery under the modified ERAS protocol and were compared to 57 historic patient controls. The mean age (control: 7.79 ± 5.27 years, ERAS: 8.00 ± 4.69 years), weight (29.28 ± 19.37 kg, 29.71 ± 18.40 kg), and comorbidities did not differ between groups. Total narcotic usage, reported in mg morphine equivalents/kg (MME/kg), across all phases of care was greater in the controls than in ERAS, respectively (Intraop: 0.30 vs 0.079 MME/kg, PACU: 0.071 vs 0.012 MME/kg, Postop: 0.22 vs 0.0026 MME/kg, P < .0001). Implementation of the ERAS protocol also led to a 29.1% decrease in LOS (1.51 days vs 1.07 days) without an increase in return to service or perioperative complications. Conclusion: Implementation of a modified ERAS protocol in patients undergoing reconstruction for VPI provided effective perioperative pain control allowing for narcotic minimization and a shorter LOS without an increased complication rate.