ANESTHESIA MANAGEMENT CASE SCENARIO PROVISIONAL DIAGNOSIS ANESTHETIC MANAGEMENT DISCUSSION ANESTHETIC CONSIDERATIONS PERIOPERATIVE MANAGEMENT CONCLUSION

1. Presenter: DR.M.MADHU CHAITANYA, 2nd year PG
Moderator: DR.JAYA CHANDRA , Assistant Professor
DEPARTMENT OF ANAESTHESIOLOGY
ANESTHESIA MANAGEMENT OF
CLEFT LIP & PALATE

2. CONTENTS
1. CASE SCENARIO
2. PROVISIONAL DIAGNOSIS
3. ANESTHETIC MANAGEMENT
4. DISCUSSION
5. ANESTHETIC CONSIDERATIONS
6. PERIOPERATIVE MANAGEMENT
7. CONCLUSION

3. A 1 ½ year old boy, dixit, hails from srikakulam was brought by his mother who is reliable
informant comes with complaints of
1. Abnormality In lip since birth
2. Difficulty with feeding / suckling
3. Difficulty In swallowing with potential for liquids
CASE SCENARIO

4. HISTORY OF PRESENTING ILLNESS
 According to mother, baby was born at term gestation.
 Baby cried immediately after birth .
 But after 30 minute of birth when mother tries for feeding she observed
difficulty In sucking from baby’s mouth
 Flow of milk through nasal passages during feeding
 C/o feeding problem& Difficulty In swallowing with potential for liquids,
what ever was fed to him regurgitated through his nose
 h/o URTI/LRTI on /off, intermittent, relieved by medications
 No h/o diarrhoea, chronic ear infections,No h/o cough, Fever

5. PAST HISTORY
No H/o any significant medical/ surgery illness, No dental approach, h/o OG feeds
FAMILY HISTORY:
First order
No hereditary disorders in the family
No history of TB, HTN, DM or other chronic illness in the family
No Family history of similar or congenital anomaly
PERSONAL HISTORY
 Milestones achieved normally within time limits.
 Sleep- adequate
 Bowel & Bladder- Regular

6. Obstetric and birth history
Antenatal: Maternal illness during pregnancy not significant
Natal:
• No H/O birth trauma.
• Normal vaginal delivery
• Baby cried well after birth.
• No H/O breathing difficulty.
• Weight of baby at birth was 2.7 Kg.
Immunization history
•Immunized according to national immunization schedule till date

7. GENERAL EXAMINATION
A. Child is conscious, active ,stable ,cooperative and smiling all the time ,
he was healthy according to age. .
B. Length: 80cm
C. Wt - 10kgs
D. BMI – 15.6kg/m2
E. No Pallor, icterus, cyanosis, lymphadenopathy and pedal edema
F. Cleft lip right side present,
G. Oral examination – palpation with little finger - cleft palate

8. VITALS
I. Temperature- 98.4
II. PR- 102/min, rt. radial ,normal volume, regular, no radioradial & radiofemoral
delay
III. BP – 90/60mmhg,right arm, supine position
IV. CVS Examination: S1 and S2 heard, No murmurs
V. RESPIRATORY SYSTEM : Bilateral air entry-present, No adventitious sounds
VI. CNS :Activity- good, No abnormality detected

9. INVESTIGATIONS
1. Hb-12gm%
2. Blood Group/ Typing- B+ve
3. T.W.B.C-7200cells/cumm
4. Platelet count- 2 lakhs/cumm
5. RBS-110mg/dl
6. Screening – negative
7. Serum electrolytes - normal
8. 2D ECHO normal
9. BT-1min 20 seconds ,CT-3min 30 seconds

10. SUMMARY/PROVISIONAL DIAGNOSIS
 A 1 ½ year old boy with h/o abnormality In lip since birth, Difficulty with
feedings & swallowing with clinical findings of lip/cleft deformity & with
investigations normal, based on above findings this is most probably a
case of unilateral cleft lip /cleftpalate, incomplete, right side not
associated with other congenital anomalies .,posted for lip repair &
palatoplasty

11. PLAN
• Patient was admitted
• Consent was taken
• Lip Repair & Palatoplasty was planned
• Anaesthesia: General anaesthesia

12. ANESTHETIC TECHNIQUE
1. GA with endotracheal intubation with spontaneous /controlled
ventilation
2. Total intravenous anesthesia
3. Local anesthesia

13. PRE OPERATIVE PREPARATION
• Pre-anaesthetic evaluation done
• All Preoperative investigations sent and reports reviewed.
• Consent & Npo orders
• Achieve IV access,24 G iv cannula
• Arrange Cross match Blood and blood products ,
• The pre-anesthetic evaluation of a child coming for procedure include a rapid
assessment to determine the risk of difficult airway, hemorrhage and risk of
aspiration.

14. GENERAL ANESTHESIA- PRE OPERATIVE
1. Fast pre-op assessment
2. Essential equipment to be carefully checked and laid out before induction
3. Suction devices with wide bore tubing, turned on
4. Laryngoscopes with the correct size of blade – check they are working and ready
5. Endotracheal tubes with a range of sizes,3.5mm.4mm ,4.5mm- RAE south pole
6. Malleable introducer, pediatric Gum elastic bougie
7. Laryngeal mask airway (LMA) size1,1 1/2 and ProSeal laryngeal mask
8. Cricothyroidotomy set

15. PREMEDICATION
1. Inj Ketamine30mg Inj midazolam 1mg, Inj Atropine 20mcg/kg IM-30min
2. Antisialogauge: IV Atropine 0.02mg/kg,
3. Inj. Ondansetron 0.1mg/kg - 1mg
4. Antibiotics 50 mg/kg ; INJ Ceftriaxone 500mg

16. INTRA OPERATIVE MONITORING
1. ECG
2. NIBP
3. Pulse oximeter
4. ETCO2
5. Temp probe - operating room was adjusted within 23-25°C along with
warm blankets and caps to cover the baby
6. Precordial stethoscope
alarm limits should be adjusted prior to case shifting machine check

17. INDUCTION/ INTUBATION
1. Preoxygenate - O2 5 l/min for 3 mins
2. Inj Ketamine ( 2mg/kg) ie; 20mg / Propofol 2mg/kg 20mg
3. IV Opioid ( Fentanyl 2mcg/kg)ie;20mcg
4. Laryngoscope blade can slip into the cleft. However, packing the cleft
with gauze may prevent this from occurring.
5. Intubation with a smaller ETT size 4.0mm unCuff inflated and found to be
leak free. Throat –Pack placed.
6. CHECK POSITION OF ENDOTRACHEAL TUBE (ETT)

18. Maintenance
1. 70% nitrous oxide + 30% oxygen + volatile agent sevo
2. NDMR- Atrac – 0.5mg/kg ie 5mg / Vec 0.1mg/kg ie 1mg
3. Fluids 4ml/kg/hr plus pre volume deficit 4 hours- 160ml
4. The child may become cold ,should be kept well covered to maintain body
temperature, warming blanket used with temperature monitoring.
Recovery
1. Residual NM blockade reversal 0.5mg neostigmine + 0.1 mg glycopyrrolate
2. Extubate only once awake awake in the left lateral, head down position
3. IV dexamethasone 1.5mg & humidified O2

19. POST OPERATIVE
 Shifted in SICU for observation
 Vital signs monitored and quick examination
 NBM- Clear water after 5 hours & Semi-Solid after 12 hours
 The hemoglobin should be measured and coagulation screen sent .
 Inj. Paracetamol IV 200mg for pain management.
 Discharged after 7 day

20. DISCUSSION
 Cleft lip and palate are the commonest craniofacial abnormalities.
 A cleft lip, with or without a cleft palate, occurs in 1 in 600 live births.
 A cleft palate alone, is a separate entity and occurs in 1 in 2000 live births.

21. Embryology
1. Development of facial structures starts at the end of 4th week
2. Clefts arise because of failure of fusion or breakdown of fusion between the
nasal and maxillary processes and the palatine shelves that form these
structures at around 8 weeks of life
Formation of clefts
1. Failure of fusion of maxillary and medial nasal processes – anterior to
incisive foramen
2. Failure of fusion of palatine shelves – posterior to incisive foramen
3. Cleft lip – failure of proliferation of mesodermal cells in midline

22. ANESTHETIC CONSIDERATIONS
1. Difficulty with intubation
2. Inadvertent extubation during the procedure
3. Postoperative airway obstruction.
4. Age of the patient
5. The availability of intraoperative monitoring equipment
6. Anaesthetic drugs and expertise
7. Share airway
8. The level of postoperative care.
9. Rule of ten- WT 10lbs, HB 10 gr and 10 wk age.

23. Airway Challenges
1. Difficult Mask Seal
2. Distorted Airway Anatomy
3. Difficult airway resources
4. Risk of aspiration
5. Difficulty Swallowing-uncoordinated Reflexes Prone to OSA
6. Nasal Obstruction

24. PREOPERATIVE EVALUATION
In addition to the standard preoperative history and examination special care
needs to be taken in assessing the following:
1. Associated congenital abnormalities
2. Congenital heart disease
3. Chronic rhinorhoea
4. Chronic airway obstruction/sleep apnoea
5. Right ventricular hypertrophy and cor pulmonale
6. Anticipated difficult intubation
7. Nutrition/hydration
8. Need for premedication

25. INTRAOPERATIVE MANAGEMENT
Induction of anaesthesia is most safely performed by inhalational anaesthesia
with halothane or sevoflurane
Intravenous access is gained when an adequate depth of anaesthesia is
achieved and endotracheal intubation performed either under deep volatile
anaesthesia or facilitated by suxamethonium or a non-depolarising
neuromuscular blocking agent.
No neuromuscular blocking agents should be given until one is sure that the
lungs can be ventilated with a mask.

26. An oral, preformed RAE tube is usually chosen and is taped in the midline.
For palatal surgery, a mouth gag that fits over the tube is used to keep the
mouth open and the tongue out of the way.
The surgeon or anesthetist will insert an oral pack to absorb blood and
secretions and will extend the neck and tip the head down.
A head ring and a roll under the shoulders is frequently used.
Problems with the endotracheal tube are common.
It may be pulled out, pushed into the right main bronchus when the head is
moved or kinked under the mouth gag.
After the patient has been finally positioned for surgery, check the patency and
position of the endotracheal tube by auscultation and by gentle positive pressure
ventilation to assess airway resistance.

27. MAINTENANCE OF ANAESTHESIA
Inhalational agent can be with spontaneous ventilation or controlled ventilation
Controlled ventilation with muscle paralysis allows for a lighter plane of
anaesthesia and more rapid awakening with recovery of reflexes and the lower
PaCO2 probably causes less bleeding.
Appropriate intravenous fluids should be given, taking into account the period
of preoperative starvation, intraoperative and postoperative maintenance
requirements and blood loss.
The use of opioids results in a smoother emergence and less crying on
extubation

28. It is usual for the surgeon to inject local anaesthetic and adrenaline into the
surgical field to reduce blood loss and improve the surgical field.
 Local anaesthetic infiltration provides useful intraoperative analgesia but
cleft palates benefit from careful use of intraoperative opioids.
 Limiting the dose of adrenaline to 5mcg/kg in the presence of normocapnia
Both palates and lips should either receive paracetamol 20mg/kg orally as
premedication or rectal paracetamol post induction (40mg/kg) so that
adequate paracetamol levels are attained by the end of surgery

29. INFRAORBITAL NERVE BLOCK
•The bilateral may be used as an adjunct or as the sole analgesic technique
for cleft lip repair.
•The infraorbital nerve is a sensory nerve that is derived from the 2nd maxillary
division of the trigeminal nerve and exits from the infraorbital foramen to
enter the pterygopalatine fossa.
•There are two approaches to the infraorbital nerve block:
1. EXTRAORAL (PERCUTANEOUS)
2. INTRAORAL.

30. For the extra oral approach, locate the infraorbital foramen and insert a
27- gauge needle toward, but not into, the foramen in the lateral direction.
The intraoral approach is achieved by advancing a 27-gauge needle along the
inner surface of the lip and cephalad to the infraorbital foramen parallel to the
maxillary premolar.
 First palpate the infraorbital foramen and pull the upper lip superiorly to allow
room for the needle and syringe.
 Keep a finger on the infraorbital foramen during the needle advancement
. A total volume of 0.5-1.5 ml of bupivacaine 0.25%, levobupivacaine 0.25%, or
ropivacaine 0.2% with 1:200,000 epinephrine is injected after negative aspiration
for blood.

31. GREATER PALATINE NERVE
The anterior branch of the greater palatine nerve may also be blocked for
cleft palate repair.
Using a 27-gauge needle, insert the needle approximately 1 cm from the
first and second maxillary molars on the hard palate.
 Palpate with the needle to find the greater palatine foramen, whose depth
is usually less than 10 mm.
A total volume of 0.3-0.5 mL of local anesthesia is injected after negative
aspiration for blood.

32. EXTUBATION
1. Acute airway obstruction is a very real risk at the end of the procedure
following extubation
2. The surgeon needs to remove the throat packs and ensure that the surgical field
is dry.
3. Suctioning should be kept to a minimum to avoid disrupting the surgical repair.
4. Oropharyngeal airways are best avoided, if possible.
5. Extubation should be undertaken only after the return of consciousness with
protective reflexes intact.
6. A tongue stitch will often be placed in patients with preoperative airway
obstruction.
7. This pulls the tongue forward away from the posterior pharyngeal wall as a
treatment for postoperative airway obstruction

33. Postoperative Management
I. These patients need to be closely observed in recovery for evidence of
blood loss or airway obstruction
II. Avoid using nipple of bottle for feeding instead used spoon for feeding
III. Supplemental oxygen should be given until the child is fully awake
IV. Cleft lips (especially those who received infraorbital nerve blocks) will
only require rectal or oral preparations of paracetamol or NSAID’s.
V. Cleft palates should receive adequate doses of paracetamol and possibly
oral codeine or NSAID’s after twelve hours.
VI. Ideally these patients should be returned to a high dependency area
with experienced staff and oxygen saturation monitoring

34. ‘The Difference To The Surgeon, Between Doing A
Cleft Palate Operation With A Thoroughly
Experienced Anaesthetist And An Inexperienced One
, Is The Difference Between Pleasure And Pain!’