Predicting Risk For Adverse Perioperative Events In Patients Undergoing Furlow Cleft Palate Repair
Marten N. Basta, MD1, John E. Fiadjoe, MD2, Albert S. Woo, MD1, Kenneth N. Peeples, BS2, Oksana A. Jackson, MD2.
1Brown University, Rhode Island Hospital, Providence, RI, USA, 2Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Adverse perioperative events (A.P.E.) complicate 5-30% of cleft palatoplasties. Identifying patients at highest risk for A.P.E. may reduce morbidity, parental distress, and healthcare costs. This study aimed to identify risk factors for A.P.E. after cleft palatoplasty to develop an assessment tool quantifying individual risk.
Patients under 2 years having primary Furlow palatoplasty were reviewed for medical history and perioperative data. A.P.E. included laryngobronchospasm, accidental extubation, reintubation, obstruction, hypoxia, and unplanned ICU admission. Multivariate regression modeling, risk factor stratification, and model performance were assessed.
300 patients averaging 12.3 months were included. Cleft distribution included: Submucosal-1%, Veau 1-17.3%, Veau 2-38.3%, Veau 3-30.3%, Veau 4-13.0%. Pierre Robin (N=43) was the most prevalent syndrome/anomaly. 83% of patients received paralytic reversal and total narcotic dose averaged 0.19 mg/kg. 69 patients (23.0%) had an A.P.E., most frequently hypoventilation (10%) and airway obstruction (8%). Major A.P.E. included reintubation (4.7%) and laryngobronchospasm (3.3%).
A.P.E. was associated with difficult intubation (OR=7.2), abnormal airway anatomy (OR=3.8), operation>160 minutes (OR=2.4), narcotic dose>0.3 mg/kg (OR=2.2), and inexperienced provider (OR=2.0), while paralytic reversal was protective (OR=0.5). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (A.P.E. 2.5%-70.4%) with excellent risk discrimination (C-statistic=0.79).
A.P.E. incidence was 23.0% after palatoplasty with 30-fold higher incidence in extreme risk patients. Individualized risk assessment tools may enhance perioperative clinical decision-making to mitigate complications.
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