HEAD AND NECK SURGERY Bilateral Extraoral, Infraorbital Nerve Block for Postoperative Pain Relief After Cleft Lip Repair in Pediatric Patients A Randomized, Double-Blind Controlled Study Suna Akin Takmaz, MD,* Hale Yarkan Uysal, MD,* Afsin Uysal, MD,† Ugur Kocer, MD,† Bayazit Dikmen, MD,‡ and Bulent Baltaci, MD* Abstract: The objective of this study was to evaluate the effectiveness of bilateral extraoral infraorbital nerve block with 0.25% bupivacaine admin- istered at the end of surgery in postoperative pain relief after cleft lip repair. Forty ASA I-II children were randomly divided into 2 groups. Group I received 1.5 mL 0.25% bupivacaine and group II received 1.5 mL saline. FLACC scores of the patients in the recovery room in group I were 4 times less than in group II (P = 0.001) and in the first 4 hours postoperatively were apparently less in group I (P = 0.001). Mean time to first paracetamol requirement was longer in group I (P = 0.001). Total paracetamol consump- tion was lower in group I (P = 0.001). None of the patients required rescue tramadol in group I, whereas all patients in group II needed. In group I, parent satisfaction scores were higher (P = 0.001). Vomiting incidence was higher in group II (P = 0.028). Bilateral extraoral, infraorbital nerve block administered at the end of surgery provides satisfactory analgesia with high parental satisfaction and lower complication rates and reduces rescue anal- gesic consumption in patients undergoing repair of cleft lip. Key Words: infraorbital nerve block, postoperative analgesia, cleft lip repair (Ann Plast Surg 2009;63: 59 – 62) A dequate postoperative analgesia in children is a vital part of perioperative care, as postoperative pain may have adverse physiological and psychologic effects. Good pain relief minimizes the oxygen requirement, reduces cardio-respiratory demands, pre- vents delayed wound healing, and promotes early ambulation and recovery. 1 Cleft lip repair procedure is usually performed in infants and requires excellent postoperative analgesia to prevent the agitated child from handling the delicate surgical site postoperatively besides the reasons above mentioned. 2 The effect of different analgesia technique in cleft lip repair surgery has been studied so far. Infiltration of the surgical field with local anesthetic solution has been used. 3–5 Preincisional infiltration tends to distort the margins of the cleft and makes esthetic repair difficult. 6 Therefore postoperative analgesia cannot be satisfactorily performed under local infiltration. Nonsteroidal anti-inflammatory drugs and opioids have been widely used in the management of postoperative pain treatment. But use of these drugs in children is limited, as there is no adequate data about pharmacologic experience and information, besides the side effects. Nonsteroidal anti-inflam- matory drugs have potential risk of postoperative bleeding and therefore should not be given in early postoperative period. Opioids provide good postoperative analgesia but associated with the risks of airway compromise and respiratory depression. A review of anes- thesia for cleft lip repair reported profound respiratory depression after opioid administration. 3 With regard to unpredictable sensitivity and pharmacokinetic responses to opioids in the pediatric popula- tion, 7,8 nerve-blocking techniques have gained interest for postop- erative analgesia as it provides good pain relief and avoids the complications of opioid analgesics. The aim of this study was to evaluate the effectiveness of bilateral extraoral infraorbital nerve block with 0.25% bupivacaine administered at the end of surgery in postoperative pain relief after cleft lip repair. METHODS After approval of the ethics committee and written informed consent from the parents (ASA groups I, II) 40 children aged under 2 years scheduled for cleft lip repair surgery were included in the randomized, double-blind controlled study. Patients with a history of allergy to patients amid local anesthetics, serious renal, hepatic, respiratory, cardiac, neurologic, or neuromuscular disease and who had abnormal coagulation tests were excluded from the study. Children did not receive any premedication before surgery. Following standard monitorization (electrocardiogram, pulse oxim- etry, noninvasive blood pressure) anesthesia was induced with sevoflurane 8% in oxygen. After securing intravenous access, fent- anyl 1 g/kg and vecuronium bromide 0.1 mg/kg were given and the trachea was intubated with an appropriate recoiled tracheal tube (Ru ¨schelit, Germany). Anesthesia was maintained with 1.5% to 2% sevoflurane in 50% nitrous oxide in oxygen. Each of the patients was randomly allocated to 1 of 2 groups using computer-generated random numbers. Group I received 1.5 mL 0.25% bupivacaine and group II received 1.5 mL saline injected in the area of each infraorbital foramen at the end of the surgery, before emergence from anesthesia, and also only in group II rectal paracetamol (20 mg/kg) was administered for postoperative analgesia. Extraoral approach for infraorbital block advocated by Bo ¨senberg and Kimble 6 was used in all patients. The infraorbital foramen was identified by palpation in a sagittal plane passing through midpoint of palpebral fissure and the angle of the mouth, lying at a point approximately 7.5 mm from the alar base. A 25-G needle was introduced perpendicular to the skin and advanced until bony resis- tance was felt. The needle was then withdrawn slightly and after a negative aspiration test for blood, the local anesthetic was injected. Pressure was applied for 3 minutes and the injection point was massaged to prevent hematoma. The procedure was repeated on the other side. The block was regarded as being successful if there were no significant hemodynamic changes during extubation and if there was no excessive cry on recovery. In all patients, the nerve block Received May 27, 2008 and accepted for publication June 29, 2008. From the Departments of *Anesthesiolgy and Reanimation, and †Plastic and Reconstructive Surgery, Ankara Training and Research Hospital, Ministry of Health, Ankara, Turkey; and ‡Anesthesiolgy and Reanimation Department, Numune Training and Research Hospital, Ministry of Health, Ankara, Turkey. None of the authors has a financial and proprietary interest in any material or method mentioned and there is no public or private support. Reprints: Suna Akın Takmaz, MD, 30 cad., 386 sok., Kardelen Sitesi A Blok 7/35 Umitko ¨y Ankara Turkey. E-mail: takmaz@isbank.net.tr. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0148-7043/09/6301-0059 DOI: 10.1097/SAP.0b013e3181851b8e Annals of Plastic Surgery • Volume 63, Number 1, July 2009 www.annalsplasticsurgery.com | 59