Enhanced Recovery After Surgery in Patients With Cleft Lip and Palate Undergoing Alveolar Bone Grafting: A Review

IntroductionEnhanced Recovery After Surgery (ERAS) protocols are evidence-based perioperative management pathways designed to optimize surgical outcomes. The American Society of Craniofacial Surgeons (ASCFS) Presidential Task Force has developed a series of ERAS protocols for patients with cleft and craniofacial anomalies. We outline an ERAS protocol for secondary alveolar bone grafting using cancellous bone graft from the iliac crest for patients with cleft lip and palate.Design and settingThe authors extracted information from existing peer-reviewed literature and our institutional experience at a large, tertiary pediatric hospital through retrospective chart review to guide surgeons in the pre-hospitalization, preoperative, intraoperative, and postoperative phases of care of alveolar bone grafting.ResultsIn the pre-hospitalization phase, our ERAS protocol emphasizes family education and expectation management, as well as minimization of preoperative fasting. In the preoperative phase, oral midazolam is recommended to reduce patient anxiety. In the intraoperative phase, we emphasize multimodal pain control with regional nerve blocks, bupivacaine-soaked absorbable sponge in the iliac crest, and ketorolac to minimize postoperative narcotic use. To prevent postoperative nausea and vomiting, we emphasize the use of an oropharyngeal pack prior to incision and nasogastric tube evacuation of the gastric contents at the completion of surgery, as well as a combination of ondansetron with dexamethasone intraoperatively. In the postoperative phase, we recommend dexmedetomidine, early postoperative oral feeding and hydration, and early ambulation with Physical Therapy consultation.ConclusionsThe present study sought to outline an ERAS protocol for secondary alveolar bone grafting in pediatric patients with cleft lip and/or palate to optimize surgical outcomes.