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Plastic Surgery Research Council

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Use Of A Novel Monitor To Optimize Management Of Pain Control After Infant Cleft Lip And Palate Repair
Samuel Boas, BS, Brian Paoletti, BS, Carlyann Miller, Ryan Nazemian, MD, Corinne Wee, Anand Kumar, MD, FACS, Peggy Seidman.
Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Purpose:Surgical pediatric patients with respiratory compromise receiving narcotic pain control are at an increased risk of hypercapnic respiratory failure. End-tidal CO2 (EtCO2) remains the gold-standard to approximate of arterial CO2, despite the challenging and unreliable nature of these measurements in pediatric patients1,2,3. This study explores the accuracy of a noninvasive Transcutaneous CO2 monitor (TCOM) in both intra-operative and post-operative settings for pediatric cleft lip and palate repair. We hypothesized that intraoperative TCOM readings already validated in the operating room would allow us to monitor respiratory depression in the post-operative period in an extubated patient receiving narcotics. Methods: This was a case study of two pediatric patients who underwent a primary repair of a congenital cleft lip and palate. After IRB consent, standard monitors and the TCOM were applied prior to induction of general anesthesia. Venous blood gas samples were taken throughout case including hemoglobin, hematocrit, -HCO3 and CO2. After completion of surgery, patients were extubated and transferred to the PICU. Patients retained the TCOM monitor throughout. Standard pain control was delivered via nurse-controlled PCA per acute pain service protocol. The time stamp of each narcotic bolus during the 24-hour post-operative monitoring period was noted and later correlated to TCO2 measurements. Intra-operative VBG, EtCO2, and TCO2 levels were compared. All calculations were performed using the R Statistical Programming environment (R version 3.3.0). Results: In both cases, post-operative CO2 levels measured by TCOM increased following Narcotic Administration. Trends showed transient changes in CO2 levels with return to baseline. Return to baseline followed a variable time course. The absolute change in pCO2 was noted to be of a smaller magnitude when baseline pCO2 was higher. This finding was associated with a higher baseline pCO2 we saw during the nighttime. Conclusion: This case study demonstrates the utility of TCOM TCO2 monitor as a possible adjunct monitor for post-operative CO2 monitoring in pediatric patients receiving narcotics. We believe with routine use of this modality, should improve our ability to safely deliver narcotics to post-operative pediatric patients. Our study is limited by the small sample size. Further studies are warranted to evaluate the efficacy of this monitoring modality.


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