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A survey on Enhanced Recovery After Surgery (ERAS) elements in cleft palate repair
Christina Grabar1, Jennifer Fligor1, Melissa Kanack1, Raj Vyas1 1 University of California, Irvine, Orange, CA

Background: Enhanced Recovery After Surgery (ERAS) protocols have been associated with beneficial outcomes in adult populations, but reports evaluating such protocols in the pediatric population is more limited in the literature. While the potential benefits of enhanced recovery protocols represent worthwhile goals in any surgical procedure, the very integrity of a cleft palate repair may stand to benefit from a protocol which limits patient discomfort and crying (and, by extension, strain on the muscular repair of the soft palate). For this reason, cleft palate repair may represent a particularly valuable context for implementation of enhanced recovery protocols. This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons.

Methods: Academic craniofacial surgeons (n=102) were provided with electronic surveys. Respondents rated their current use of, knowledge about, and willingness to implement preoperative, intraoperative, and postoperative interventions modeled after adult ERAS protocols.

Results: Of the 102 cleft palate surgeons surveyed, 31 completed the survey (30.4%). 74.2% (n=23) of respondents' primary practice is pediatric craniofacial surgery and 51.6% (n=16) perform more than 20 cleft palate repairs per year. A majority (n=21, 67.7%) rated that they were "very knowledgeable about," "knowledgeable about," or "somewhat knowledgeable about" ERAS. However, 61.3% "never use" a standardized ERAS protocol for cleft palate surgery. The majority indicated three ERAS elements are currently used for all patients: avoiding prolonged perioperative fasting (n=21, 67.7%), using hypothermia prevention measures (n=23, 74.2%), and minimizing use of opioids for postoperative pain control (n=18, 62.5%). A majority of respondents noted that they never administer a bolus of tranexamic acid (n=22, 71.0%) nor administer infusion dosing of tranexamic acid (n=25, 80.6%), and more than half do not audit information on patient outcomes (n=20, 64.5%). Of the elements that were never used by most respondents, 67.7% and 71.0% indicated that administering a bolus of tranexamic acid and infusion dosing of tranexamic acid, respectively, "would not be a valuable addition to [their] practice." 83.9% rated that conducting audits on patient outcomes would be a "valuable addition to their practice." For short-acting anesthetics such as PrecedexTM, 12.9% (n=4) use it with all patients for extubation and 16.1% (n=5) use it with all patients for postoperative recovery; while 22.6% (n=7) never use it for extubation and 48.4% (n=15) never use it for postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repairs.

Conclusion: Many respondents report using interventions which are compatible with an ERAS approach to peri-operative care, and the majority would be willing to implement an ERAS protocol for cleft palate repairs. Use of tranexamic acid, either as a bolus and an infusion, was not found to be common among those surveyed. Gaining additional insight into optimization of perioperative care for these patients could help to improve post-operative outcomes for children undergoing cleft palate repair in the future.

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