K. V. Gillespie, R. Goel, L. Bubb, J. Keough

Alder Hey Children's Hospital, UK

Introduction and Aims

Opioid-free anaesthesia is gaining popularity as it is thought to offer advantages by avoiding their unwanted side effects alongside reducing post-operative complications (1,2). Other systemic analgesic options include using a combination of: ketamine, alpha-2 agonists, magnesium, paracetamol and non-steroidal anti-inflammatory drugs (3). Anaesthetic techniques vary not only between anaesthetists, but also centres and regions (4). Whilst reviewing the anaesthetic management of cleft surgery patients at our tertiary centre, we sought to see if there was a benefit in outcomes for those patients who had opioid-free anaesthesia in comparison to those who had intra-operative opioids.


During January to November 2023, there were 120 cleft surgery patients who underwent either: cleft palate repair, cleft lip and anterior palate repair, isolated cleft lip repair, pharyngoplasty, or an alveolar bone graft. Their electronic records were audited, and we subsequently excluded 8 cases due to incomplete records. A retrospective analysis of their demographics, peri-operative management and outcomes were recorded with a focus on the time to first oral intake, peri-operative doses of opioids, post-operative pain scores and length of stay.


There were limited numbers of patients receiving opioid-free anaesthesia, the vast majority were cleft palate patients. Therefore, subgroup analysis was performed on patients who had either cleft palate repair or cleft lip and palate repair.

The average intra-operative morphine dose was 0.1mg/kg. There was no statistically significant difference in major outcomes between the 2 groups using a two-tailed t-test. The results suggest a reduction in the average time to first oral intake in the opioid-free group: 146 minutes versus 202 minutes (p=0.069), Table 1.

Discussion and Conclusions

This small subgroup analysis suggests that opioid-free anaesthesia for cleft surgery patients may be non-inferior to those receiving intra-operative opioids. There is a demonstrable reduction in the average time to first oral intake in those that receive opioid-free anaesthesia for patients undergoing cleft lip and anterior palate or cleft palate repair, however this was not statistically significant. All other outcome measures were similar between groups.

Other factors that may have contributed to the reduced time to first intake are total intravenous anaesthetic (TIVA), or the use of non-opioid adjuvant therapy such as dexmedetomidine in the opioid-free group.

We do recognise that there are several limitations of our study. It was a retrospective study performed in a single centre, with a small sample size, and a small proportion of those received opioid-free anaesthesia. However, the results do suggest some benefit with reduced time to first oral intake, alongside a general non-inferiority to a more traditional technique with intra-operative opioids. The results suggest it may be beneficial to carry out a larger study, such as a multi-centre randomised control trial to evaluate the results further.


(1)              Lee A, Chang BL, Yan C, Fox JP, Magee L, Scott M, et al. The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery. Plastic and Reconstructive Surgery. 2020; 145(2):507-516.

(2)              Frauenknecht J, Kirkham KR, Jacot-Guillarmod A, Albrecht E. Analgesic impact of intra-operative opioids vs. opioid-free anaesthesia: a systematic review and meta-analysis. Anaesthesia. 2019;74(5):651-662

(3)              Sultana A, Torres D, Schumann R. Special indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best Practice & Research Clinical Anaesthesiology. 2017; 31(4):547-560

(4)              Vittinghoff M, Lonnqvist P-A, Mossetti V, Heschl S, Simic D, Colovic V, et al. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Pediatric Anaesthesia. 2018; 28(6):493-506

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