Maxillary nerve block may reduce perioperative opioid consumption in pediatric primary clefts

Maxillary nerve block may reduce perioperative opioid consumption in pediatric primary clefts

In infants undergoing cleft palate surgery, injection of a local anesthetic that targets the maxillary nerve in the face may reduce or eliminate the need for opioid medications to control postoperative pain, a study inThe Journal of Craniofacial Surgery.The journal is published in the Lippincott portfolio of Wolters Kluwer.

“Our study presents preliminary but promising results suggesting that suprazygomatic maxillary nerve block [SMNB] may reduce perioperative opioid consumption in pediatric primary clefts, particularly in cleft palate closure.”

Rutger M. Schols, MD, PhD, senior author, MosaKids Children's Hospital, Maastricht, The Netherlands

Nerve block during cleft palate surgery: technique and results

Cleft palate is a common congenital condition occurring in 0.3 to 0.4% of infants. Early surgery – typically performed between six and twelve months of age – is essential for normal speech, swallowing and breathing function.

Postoperative pain control remains a major challenge in infants undergoing cleft palate surgery. Although opioid medications like morphine are effective, they carry significant risks such as nausea and vomiting, constipation, and shortness of breath. Regional anesthesia techniques have been evaluated to control postoperative pain and potentially reduce the need for opioids.

Dr. Schols and colleagues evaluate their experiences with SMNB in ​​ten infants, average age seven months, undergoing cleft palate surgery. After induction of general anesthesia, a small dose of local anesthetic is injected to block the transmission of pain signals from the maxillary nerve, which triggers sensations in the center of the face, including the upper jaw (maxilla) and upper lip.

The article provides a detailed, illustrated explanation of the injection technique, including the use of ultrasound guidance to ensure precise injection of local anesthetic around the maxillary nerve. The authors' SMNB technique involves the use of a mild sedative (dexmedetomidine), which may help prolong the effect of the nerve block.

Focusing on the need for opioid medications, researchers compared postoperative pain control in infants who underwent SMNB with ten patients who had previously undergone cleft palate surgery without a nerve block. Use of other pain control measures, including non-opioid pain medications, was similar between groups.

Overall, infants who received SMNB had significantly lower opioid consumption after cleft palate surgery. The mean total morphine dose was 0.1 milligrams in the SMNB group, compared with 0.75 mg in infants who did not undergo a nerve block. Seven out of ten children in the SMNB group did not require morphine for pain control, compared to only two out of ten children without SMNB.

Use of other painkillers, including a weaker opioid called tramadol, was similar in both groups. Infants who received SMNB spent less time in the hospital after surgery: 2.0 days, compared to 2.5 days for infants who did not receive a nerve block. However, this difference was not statistically significant.

The researchers note several limitations of their small, exploratory study, including the fact that patients were not randomly assigned to SMNB or standard pain control alone. The authors emphasize the need for larger, controlled studies to confirm their results.

Although the SMNB technique is not new, previous studies on its use in cleft palate surgery differed significantly, particularly with regard to the injection techniques used. Dr. Schols and co-authors emphasize the use of real-time ultrasound guidance to ensure proper injection of local anesthetic. They conclude: "By evaluating this targeted approach, we aim to contribute to the development of standardized perioperative pain management protocols to ultimately optimize recovery and shorten the length of hospital stay in this vulnerable patient population."

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