Quality Improvement Protocol to Reduce Excessive Postoperative Recovery Following Cleft Palate Repair
Pediatric Anesthesia
Submitted January 2026 by Dr Tom Walker
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Summary
This Australian single-centre quality improvement (QI) study focussed on the anaesthetic management of children undergoing cleft palate repair with the primary aim of reducing PACU length of stay.
Methods
Participants were infants <36 months undergoing primary cleft palate repair (excluding cleft lip/anterior palate repairs, revisions, and pharyngoplasty). The primary outcome measure was mean PACU length of stay. Secondary outcomes were the incidence of pain or distress, airway obstruction, hypoxaemia, or unplanned intensive care admission.
The multidisciplinary QI team included anaesthetists, plastic surgeons, and PACU nurses.
The study consisted of four non randomised sequential phases:
- A retrospective baseline phase (May 2016 – September 2020)
- Introduction of a standardised anaesthetic protocol, including paracetamol 20mg/kg, parecoxib 1mg/kg and clonidine 1- 2mcg/kg (October 2020 – January 2022)
- Introduction of selective (rather than universal) above-elbow arm splints (February 2022 – November 2023)
- Introduction of an intraoperative dexmedetomidine infusion (1 mcg/kg/hr) instead of clonidine (December 2023 – December 2024)
Results:
In total, 434 patients were studied (mean age 14.7 months; 10.1 kg), including 205 in the retrospective group, 71 in phase 2, 82 in phase 3, and 76 in phase 4. Compared with the retrospective group, all three interventions resulted in a reduction in mean PACU length of stay, achieving the project’s predefined goal of at least a 10% reduction.
Standardisation of the anaesthetic approach resulted in 15% reduction (mean difference 23.6 minutes) in PACU length of stay, selective arm splint use result in 15% reduction (mean difference ~30.7 min) compared with phase 1, and dexmedetomidine infusion resulted in a 11% reduction (mean difference ~16.4 min) compared with phase 1
In terms of secondary outcomes, pain or distress requiring opioid rescue was 33% in the retrospective phase and was not significantly reduced in phase 2 (32%), phase 3 (32%) and phase 4 (26%). Postoperative respiratory events requiring intervention occurred in 30% in the retrospective phase and were reduced in phase 2 (18% p = 0.06), phase 3 (21%) and phase 4 (12%). The incidence of postoperative paediatric intensive care involvement reduced from 7.3% in the retrospective phase to 1.2% and 1.3% in phase 3 and 4 respectively.
The standardised anaesthetic protocol did not increase costs and was readily accepted by anaesthetic staff. The more selective use of arm splints was not associated with an increased incidence of bleeding or wound damage.
Commentary
This study demonstrates that standardised intraoperative analgesia can reduce PACU length of stay following cleft palate repair. Substantial reductions in total PACU time were compromised by prolonged wait times between being ready for PACU discharge and ward admission. Interestingly, pain outcomes did not improve significantly with the different interventions, possibly reflecting limitations of FLACC scoring in distinguishing pain from distress, agitation, and hunger in this patient group.
The authors acknowledge that regional anaesthetic techniques such as suprazygomatic maxillary nerve blocks may represent an opportunity for prolonging time to first rescue analgesia. However, they were not incorporated into the study due to infrequent use at the study institution. Balancing measures were reassuring, with no observed increase in bleeding or wound complications.
Take home message
Standardised anaesthetic intraoperative analgesia, including paracetamol, parecoxib and clonidine was shown to be associated with a reduction in PACU length of stay and post operative respiratory events following cleft palate repair. The addition of selective use of arm splints and replacement of clonidine with dexmedetomidine infusion was not associated with a further reduction in PACU length of stay.
This paper provides a practical and transferable framework for centres seeking to optimise postoperative recovery in this population.
Given the sequential quality improvement design, the observed improvements should be interpreted as associations rather than evidence of direct causality. The findings are most appropriately viewed as reflecting the cumulative effect of pathway standardisation and evolving practice over time, rather than the isolated impact of individual interventions.
