ANAESTHETIC CONSIDERATIONS FOR CLEFT LIP AND CLEFT PALATE REPAIR:
Dr. S. Lakshmi. M.D., D.A., - HOD Dept. of Anaesthesia
Dr. D. Kannan. D.A., DNB., - Dept. of Anaesthesia
Providing anaesthesia for children who need special care and dedication is main goal for us. It needs precise and efficient contribution from every member involved in the team, which includes coordination from medical & paramedical staff to make the experience of painless surgery.
The aspects of providing anaesthesia for children with cleft lip and palate corrective procedures are given below.
Pre Operative Considerations:
It is a well known fact that children are not ‘small adults’ as there are essential differences between adults, children and infants in the aspects of anatomical and physiological status. They act differently in the pharmacological aspects too.
As these children are born with these defects they are prone to develop certain problems during the developmental period.
Feeding problems:
Due to the inability of a child with cleft palate creates a negative pressure during feeding which is usually not adequate and will result in malnutrition.
Frequent infection:
Because of frequent regurgitations these children will develop respiratory infections than normal children.
Airway anomalies:
Some babies will have other associated airway anomalies like micrognathia, large tongue, inadequate mouth opening owing to some congenital anomalies. Babies with bilateral cleft lip and wide cleft on the left side pose difficult during laryngostopy.
Psychological aspect:
As these babies are disfigured and have difficulties in speech are depressed and this aspect should also be looked into.
Preoperative evaluation:
The main goals are;
- To assess the status of the child to know whether he / she is in optimal condition.
- To look for any associated problems which many require preoperative treatment.
- To plan for anaesthetic protocol.
- To develop good rapport with the child, family and to allay anxiety.
Pre anaesthetic assessment:
After obtaining the elaborate history (from parents), the examination will include all systems including airway and looking for presence of any infection (URI, LRI, Middle ear) or other associated anomalies like Pierre – Robin syndrome, Treacher – Collins syndrome, Congenital heart diseases etc. Investigations include hemoglobin, TC, DC and urine routine, ELISA for HIV and other investigations are conducted if needed.
Preoperative fasting: 6 hrs for solids, 4 hrs for breast feeds and 2 hours for clear fluids.
Premidication: Syp. Trichlofos, Oral midazalam or Oral ketamine.
Management of anaesthesia:
Monitoring: Apart from the use of routine monitors like ECG SpO2, NIBP, we employ special monitors like Et CO2, Temperature and End tidal concentration of anaesthetic agents like N2O, Halathane and Sevoflurane.
Induction: Most of the children receive intravenous induction with Thiopentane at a dose of 6-7 mg/kg. Inhalation induction (Sevoflurane) is reserved for children with anticipated difficulty airway.
Intubation: Once in deep plane they are inhibited with RAE tubes after adequate relaxation with either Atracurrium or suxamethonium (in special situations) is obtained.
Maintenance: Intra operatively anaesthetic plane is maintained with N2O&O2 with sevoflurane Halothane as an inhalational agent. Relaxation is achieved with Atracurium or Vacuranium. Analgesia is usually achieved with narcotics like fentanyl, pethidine etc.
Intra operative considerations: The most important anaesthetic consideration is maintaining a patent airway throughout the procedure. Since the surgeon shares the airway there is every possibility of the endotracheal tube getting misplaced or kinked. Fluid balance is maintained according to the weight and blood loss.
Recovery and extubation: At the end of the surgery muscle paralysis is reversed with Neostigmine and glycopyrrolate. After making sure of removal of pack, complete hemostasis and adequate return of muscle power, patient is extubated. After extubation, patient is placed in lateral position, receiving oxygen either through hood or mask. After cleft lip repair some children may require a nasopharyngeal airway (Tip of the suction catheter or cut ET tubes) in the immediate postoperative period to keep the nares patient.
Post operative considerations:
Analgesia: We routinely employ infra orbital nerve block for post op pain relief with good results. Subsequent analgesia is achieved with rectal paracetamol or diclofenac (older children) according to the age.
Monitoring: Closure monitoring of ECG, respiratory pattern and saturation will be continued in the post operative period as these patients are prone to develop laryngospasm, respiratory depression more frequently than others.
Conclusion:
With proper preoperative assessment, vigilant monitoring and with high standard an aesthetic techniques and equipments makes paediatric anaesthesia for cleft surgeries relatively safe and easy. But not the lease with excellent job of our surgeons and paramedical staff.