Intraoperative Administration of Intravenous Dexmedetomidine and Acetaminophen for Improved Postoperative Pain Management in Primary Palatoplasty

Abstract

BACKGROUND: Effective pain management for primary palatoplasty (PP) is critical to minimizing risk for postoperative complications including hemorrhage and airway loss. Administration of intravenous (IV) dexmedetomidine and IV acetaminophen is a successful intraoperative analgesic with the additional benefit of being an opioid-sparing technique. The current study assesses the efficacy of intraoperative use of these medications in managing pain after PP. METHODS: We reviewed our ongoing prospective database of patients undergoing PP from April 2009 to July 2018. We excluded patients who did not receive both medications or received additional intraoperative ketorolac. Patients were divided into those who received intraoperative IV dexmedetomidine and IV acetaminophen (Group 1) and those who did not (Group 2). Outcome variables included postoperative narcotic use by morphine milligram equivalents (MME), time to oral intake, need for supplemental oxygen, length of stay (LOS), and rate of complications (eg, bleeding requiring exploration or readmission) within the 30-day postoperative period. Baseline characteristics were compared in both groups. Continuous variables were compared using t test for normally distributed data and Mann-Whitney U test for skewed data, whereas categorical variables were compared using chi-square test or Fisher’s exact test. Multivariable linear regression was used to analyze continuous outcomes, and multivariable Poisson regression with robust variance estimation was used to analyze binary outcomes. RESULTS: One hundred ninety-three patients met inclusion criteria (Group 1, N = 54; Group 2, N = 139). Median age at PP was 11.7 (interquartile range, 10.4–15.5) months for Group 1 and 11.3 (interquartile range, 9.8–14.2) months for Group 2 (P = 0.13). Baseline characteristics such as weight, gender, type of palatoplasty, Veau classification, syndromic diagnosis, and prior use of Latham device were consistent between groups. ASA scores were found significantly different (ASA 1: 11.1% versus 29.7%, ASA 2: 75.9% versus 61.6%, ASA 3: 13.0% versus 8.7%, for Groups 1 and 2, respectively; P = 0.02). Group 1 required significantly lower doses of postoperative acetaminophen (mean dose: 71.0 mg/kg, 95% CI: 57.8–84.3 versus 90.9 mg/kg, 95% CI: 82.7–99.1; P = 0.01), as well as lower fentanyl requirements in the recovery room (mean dose: 0.68 µg/kg, 95% CI: 0.48–0.88 versus 1.18 µg/kg, 95% CI: 1.06–1.31; P < 0.001). Although Group 1 patients had shorter LOS, shorter duration to oral intake, lower pain scores, less narcotic requirements for breakthrough pain, and less 30-day complication rates (1.8% versus 5.0%; P = 0.45), these differences did not reach statistical significance. CONCLUSION: The addition of intraoperative IV dexmedetomidine and IV acetaminophen during PP provides effective perioperative pain control, resulting in statistically significant decreased need for postoperative pain medication. Our study also documents an overall trend for decrease in LOS, time to oral intake, pain scores, total narcotic requirements, and postoperative complications. These results warrant larger studies to confirm the statistical significance of some variables.