A Prospectively-Validated Risk Stratification Tool for Adverse Perioperative Events in Patients Undergoing Cleft Palate Repair

INTRODUCTION

Adverse perioperative events (APE) complicate 5-30% of cleft palate repairs¹, causing significant morbidity, distress, and prolonged hospitalizations.  While syndromic diagnosis and young age have been implicated as APE risk factors in general anesthesia, individual risk remains difficult to predict.  This study prospectively validates a previously-developed risk assessment tool which estimates individual risk for APEs after cleft palatoplasty.

METHODS

A prospective cohort of patients under 2 years having primary Furlow palatoplasty were reviewed for medical history and perioperative data. APEs were defined as laryngobronchospasm, accidental extubation, reintubation, obstruction, hypoxia, and unplanned ICU admission. Multivariate regression modeling, risk factor stratification, and model performance were assessed.

RESULTS

190 patients averaging 11.7 months were included. Veau Cleft distribution included:  Submucosal-13.9%, I-14.9%, II-31.4%, III-32.0%, IV-7.7%. Pierre Robin (PRS) (N=29) was the most prevalent syndrome/anomaly. 60% of patients received paralytic reversal and total narcotic dose averaged 0.17 mg/kg.  APEs occurred in 31 patients (16.3%): hypoxia (11.6%), airway obstruction (6.3%), unplanned ICU (6.3%), laryngobronchospasm (2.1%) reintubation (1.1%).

Adjusted regression analysis for APEs identified risk factors including higher perioperative narcotic administration (> 0.32 mg/kg OR=11.6, p=0.004), abnormal airway anatomy (OR=4.52, p=0.045), 2+ intubation attempts (OR=4.43, p=0.006), history of reactive airway disease (OR=4.11, p=0.029), and syndrome other than PRS (OR=2.74, p=0.05).  Protective factors included administration of reversal agent (OR=0.37, p=0.05) and use of gelfoam packing (OR=0.25, p=0.04). Patients were risk-stratified according to individual profiles as low (APE: 2.1%), average (APE: 5.7%), high (APE: 37.8%), or extreme risk (APE: 88.9%).  Validation against our prior predictive tool found this prospective risk model was significantly more accurate with C-statistic=0.87 vs. C-statistic=0.74 (p=0.002)².

CONCLUSIONS

APEs occurred in 16.3% of palatoplasties. Higher opioid doses, multiple intubation attempts, and syndromes not including PRS imparted significant perioperative risk while use of paralytic reversal agents was consistently protective.  Validated prospective risk-assessment tools such as this provide discrete strategies³ for reducing risk and may better inform patient selection and perioperative management in an evidence-based manner.

REFERENCES

1. Jackson O, Basta M, Sonnad S, Stricker P, Larossa D, Fiadjoe J. Perioperative risk factors for adverse airway events in patients undergoing cleft palate repair. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association. 2013;50(3):330-336.

2. Basta MN, Fiadjoe JE, Woo AS, Peeples KN, Jackson OA. Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair. The Cleft Palate-Craniofacial Journal. 2018

3. Basta MN, Fiadjoe JE, Peeples KN, Jackson OA. Utility of Tongue Stitch and Nasal Trumpet in the Immediate Postoperative Outcome of Cleft Palatoplasty. Plastic and reconstructive surgery. 2016;138(6):1080e.