anaesthetic considerations for cleft surgeries

8/3/2019 Anaesthetic Considerations for Cleft Surgeries

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ANAESTHETIC CONSIDERATIONS

FOR CLEFT SURGERIES

SNIGDHA PADDALWAR

JNMC,DMIMS

WARDHA



INTRODUCTION

Ever since John Snow published in the lancet 1847, thefirst report of giving ether to a 7 year old boy for cleft liprepair, anesthesiologist's have been striving to perfectthe safety of anaesthesia in craniofacial surgeries.

Cleft lip and palate - commonest craniofacialabnormalities.

Facial disfigurement - Huge impact on life of an

individual/family Surgery-Anatomically corrects deformity

Augments dento-alveolar growth

Restores normal palatal function and self confidence



INTRODUCTION (CONTD)

Safe surgical repair

R equires a team approach.

µthe difference to thesurgeon, between doing acleft palate operation witha thoroughly experienced anaesthetist and aninexperienced one, is the

difference between pleasure and pain! ¶

-Quoted by a surgeon in 1912

ANAESTHETIST

PAEDIATRICIAN

SURGEON




The optimum anaesthetic management depends

on

1.Age of the patient

2.Associated abnormalities

3.Availability of

Intraoperative monitoring equipment

Anaesthetic drugs

Expertise Level of postoperative care

Availability of equipments/devices for difficult airway




The majority of anaesthetic morbidity relates to

Establishment of difficult airway

Protection and maintenance of airway

Co morbidities

Associated syndromes

Sharing area of intervention with the surgeon

Non availability of nasal route

Paediatric age group Postoperative complications



INCIDENCE

CLEFT LIP

Asians- 1.61/1000 births

African/American- 0.3/1000 births

Whites- 0.9/1000 births

CLEFT PALATE

Asian-0.2/1000 births

African/American-0.5/1000 births

Whites- 0.4/1000 births



INCIDENCE

Cleft palate more in females than males

Combination of cleft lip/palate-more in males

Cleft lip more in males

Left sided common as compared to right

Many complex classifications have been devised

cleft can involve the lip, alveolus, hard palateand / or soft palate

Complete or Incomplete,

Unilateral or Bilateral.



ANATOMY

Embryologically, clefts arise - failure of fusion or

breakdown of fusion between the nasal and

maxillary processes and the palatine shelves

that form these structures around 8 weeks of life.



³ Anatomy dictates physiology´

Cleft Lip and palate

problems

Failure to

Gain weight

Poor speech

development

Malalignment

of teeth

Difficulty infeeding

Ear infections

Recurrent upper

Respiratory

tract infections

GrowthretardationAspiration

Obstructive

sleep apnoea

Psychological/

Behavioural

problems



TIMING OF SURGICAL REPAIR

Surgical repair of a cleft lip - 3 months onwards

of age for cosmetic reasons

Trend to operate in the neonatal period in

Western countries. (lip adhesion)

Correcting the defect early ± popular with

parents as it facilitates bonding and feeding.

Late repair- Anaesthesia relatively safe Drawbacks- Negative impact on growth and

development

Speech, hearing, psychology and performance

at school



TIMING OF SURGICAL REPAIR

Cleft palate repair - Balance between poor facial growth with an early repair/ poor speechdevelopment with a repair after the age of 1

year. Usually done ± after 6 months of age in

developed countries.

Cleft lips and palates - often done much later in

developing countries due to non availability of atrained anesthesiologist



PREOPERATIVE EVALUATION

In collaboration with a paediatrician Standard preoperative history

Thorough examination

Special care to assess A detailed family history

Birth history

Allergy to drugs Previous exposure to

anaesthesia



PREOPERATIVE EVALUATION

(CONTD)

Peculiarity of the defect

Previous repairs done

Associated anomalies and problems Associated complications

Psychological issues

DETAILED AND THOROUGHEVALUATION OF AIRWAY



ASSOCIATED CONGENITAL ANOMALIES

Pierre Robin Sequence

80% associated with cleft palate

Micrognathia

Glossoptosis

Underlying syndrome/anomalies

Usually easier to intubate with age

Treacher Collins Syndrome

28% associated with cleft palate

Micrognathia and maxillary

hypoplasia

Choanal atresia

Eye and ear malformationsIntubation may become

more difficult with age



PIERRE ROBIN SYNDROME



TREACHER COLLINS SYNDROME



ASSOCIATED SYNDROMES(CONTD)

Hemifacial Microsomia

Hemifacial

and mandibular hypoplasia

Cervical spine abnormalities

Ear and eye abnormalities

Intubation may become

more difficult with age

Velocardiofacial Syndrome

Microcephalymicrostomia

Flat nasal bridge

small ears

short stature

Immune deficiency

congenital cardiac disease

Laryngeal anomalies

tracheal anomalies




Stickler Syndrome

Progressive connective

tissue disorder

Micrognathia and

flat face

Eye, ear and joint

abnormalitiesCongenital cardiac disease

Down Syndrome

Microstomia

relative macroglossia

Epicanthic folds

simian crease

Congenital cardiac

disease Atlantoaxial subluxation

and instability




Fetal Alcohol Syndrome

Smooth philtrum

Thin vermillion

Small palpebral fissures

Growth deficit

CNS abnormalities

Klippel-Feil syndrome

5% with cleft palate

Short, webbed neck

fused cervical vertebrae

Congenital cardiac disease



PAEDIATRIC AGE-GROUP

Different airway anatomy

Obligate nose breathers

Immature organ functions

Less organ reserve

Reduced cardiac calcium stores

Meticulous fluid balance Immature temperature regulation

Susceptibility to depressant effects of anaesthetic drugs



CHRONIC RHINORRHOEA

.

Common in children with cleft palate

Reflux into the nose during feeds.

Distinguish from active infection - surgery can bepostponed

Preoperative antibiotics - low grade nasal infections

1) Reduces - frequency of postoperative pyrexial illnesses.

2) Reduces - post op respiratory complications

3) Prevents spread of infection intracranially-handling of tissues in the vicinity of cranium



UPPER RESPIRATORY TRACT

INFECTION

ALWAYS INFORM THE SURGEON OF INCREASED

RISKS

Decision to proceed with surgery/anaesthesia-depends

on various factors Can be a prodrome of a serious illness/simple viral

infection

Child with URI-increased risk of Atelectasis

Laryngospasm

Bronchospasm

Postintubation croup

Pneumonia

Episodes of Desaturation



CHRONIC UPPER AIRWAY

OBSTRUCTION

Parents will give H/O

Snoring or obvious airway obstruction during

sleep.

Apnoea during feeds

Prolonged feeding time

Failure to thrive due to an inability to coordinate

feeding and breathing at the same time. Afraid of letting the child sleep alone

Child sleeps comfortably when prone



OBSTRUCTIVE SLEEP APNOEA SYNDROME

Disorder of breathing during sleep

Chronic upper airway obstruction/intermittent

complete obstruction

Abnormality of central respiratory control.

Risk factors-craniofacial abnormalities,

neuromuscular abnormality, adenotonsillar

hypertrophy

Sensitive to respiratory depressant effects of anaesthetic agents, benzodiazepines, opioids

Prone for cor pulmonale, post operative apnoea



RIGHT VENTRICULAR HYPERTROPHY

COR PULMONALE

Results from recurrent hypoxia due to airway

obstruction

Highly sensitive to fluid load

Avoid hypoxia, hypercarbia, acidosis and

hypothermia

Keep ionotropes ready Avoid causes increasing sympathetic activity



NUTRITION AND HYDRATION

Potential difficulty with feeding ± Assess

State of hydration

Overall growth

Nutritional anemia

³Haemoglobin concentration-as a guide´

Physiological anaemia - between 3 and 6

months of age. Ideally Hb >10g/dl.

Malnutrition and anaemia-delay wound healing



RULE OF µTEN¶

A patient with

1) Hb- 10gm%

2) WBC count </= 10,000/cumm3) Weight > 10 pounds

4) Age > 10 weeks



INVESTIGATIONS

Laboratory work - CBC, platelets, PT/PTT (for cleftpalate repair), KFT, LFT

CXR/ECG not necessary if the history and heart/lung

exam - normal

Consider bank blood availability - large cleftpalate repairs

Complete cardiac evaluation ± associated cardiacdefects

Relevant radiographs ± evaluation of airway



PREOPERATIVE PREPARATION

Desired goals

Afebrile

Optimal cardio respiratory condition

URI resolved as much as possible Banked blood arranged - if required

NPO status as per protocol

Informed consent for the surgical procedure obtained bysurgeon

Discussion of general anesthesia, including potentialrisks and complications, by the anesthesiologist withpatient's parents



PREOPERATIVE PREPARATION(CONTD)

NPO status for elective cases

2 hours - clear liquids (water, apple juice)

for all ages

4 hours - solids and milk/formula up to 6

months old

6 hours for solids, non-clear liquids for all

children 6 months or older



PREFERRED SCHEDULE

Youngest and smallest patients - early in theday.

Cleft palates, revisions, and other difficultcases earlier than others

Avoid being overenthusiastic while postingcases-per day/surgeon/2-3 cases

Remember-Anaesthetic morbidity increases asduration of period under anaesthesiaincreases



PREMEDICATION

Oral midazolam 0.25-0.5 mg/kg 1/2 hour prior to

induction if >8 kg; otherwise, no premedication.

Recognize that premedication may cause the

patient to be drowsy

To be given in preanaesthesia care unit

preferably with child in mothers lap

Should be avoided in patients comingfor secondary repairs like Abbe flap,

pharyngoplasty, tongue flap etc



PREPARATION OF ANESTHETIC

EQUIPMENT

Full vaporizer

Functioning suction machine/

catheters Full oxygen tanks

ECG and pulse oximetry

Capnography (end-tidal co2) if available

Temperature-monitoring device Appropriate circuit to give positive pressure

ventilation (circle or Jackson-Rees)



PREANAESTHETIC PREPARATION(CONTD)

Appropriate sizes of blood pressure cuffs, ETT(RAE) south pole, largyngoscope blades,masks, Oral/Nasal airways, LMA.

Secure 22 / 20G IV catheters 60 drop/cc IV tubing buretrol chamber drip

(Paediatric)

Lactated Ringers or Normal Saline IV solutions

Warm blankets Anesthetic record with continuous recording of

vital signs (every 5 minutes or less)



INTRAOPERATIVE MEDICATIONS

Inhalational agent

Sevoflurane

HalothaneIsoflurane

Muscle relaxants

Succinyl choline

Vecuronium

Atracurium

RocuroniumIV induction agent

Propofol

Thiopental

Ketamine

Antisialogogue, vagolytic

Atropine

Glycopyrrolate

AntibioticAnalgesics

Fentanyl

morphine

Reversal agents

Edrophonium

NeostigmineNaloxone



INTRAOPERATIVE MEDICATIONS

Rectal acetaminophen

Steroids

(1 or 2 doses only)

Bronchodilators

Aminophylline

Terbutaline

Albuterol inhaler

Resuscitation medications

Epinephrine

AtropineCalcium

Bicarbonate

Glucose

Banked blood



INDUCTION OF ANAESTHESIA

VARIOUS METHODS

FOR

INDUCTION OF

ANAESTHESIA

Inhalational mask

inductionwith spontaneous

ventilation and IV after

Loss of

consciousness

IV induction if child is older

and cooperative

IM induction if child uncooperative

and apprehensive

INHALATION

INDUCTIONWITH

IV SECURED, IN

DIFFICULT AIRWAY



INTUBATION AND MAINTENANCE

Assure ability to ventilate by mask withoutmuscle relaxants

Intubation after Preoxygenation with 100% O2

ETT size - air leak at 15-30 cm H2O pressure Observe and auscultate

Equal bilateral chest movement

Presence of end-tidal CO2

Secure ET tube properly

Maintenance-O2/N2O/inahlational agent



INTRAOPERATIVE MAINTENANCE

Beware of ETT movement during

patient's head is being positioned

retractors are being placed.

Beware of tube occlusion if mouth retractor is opened completely.

Beware of throat pack placement and assure removal beforeextubation

Recommend intraoperative suture tag placement on side of patient'scheek and assign OR personnel to remind of throat packplacement/removal



TUBE PLACEMENT



HANDING OVER

Handing over the patient to the surgeon

Crucial step- as anesthesiologist now losesdirect access to the airway

Ensure Correct placement/fixation of ET tube

Access to IV line

Fixation of monitoring leads

Proper and tight connections of breathing circuit

Optimum position of the patient



INTRAOPERATIVE MAINTENANCE(contd)

Prefer inhalational agent and O2/N2O or O2/air

for maintenance

Record vital signs (BP, HR, RR, O2 sat, Temp,

and ET CO2 if avail.) every 5 minutes

Carefully monitor intraoperative blood loss, fluid

administration and urine output for prolongedsurgeries



ADRENALINE INFILTRATION

Local anaesthetic with adrenaline infiltration

Should be done carefully after negative

aspiration

Dose 10microgm/kg

If infiltration causes tachycardia

Hypovolemia/Hypercapnia

Light plane of anaesthesia Inhalational agents sensitize myocardium to

exogenous catecholamines



COMPLICATIONS

General anaesthesia ±can cause life threateningcomplications

Common in infants and neonates

Careful selection of patients

Anticipation of problems

Thorough preparation to handle the difficulties

Early recognition

Prompt treatment Inform and discuss with surgeon

As far as possible follow protocols



INTRAOPERATIVE COMPLICATIONS

Inability to secure airway

Airway trauma

Desaturation

Surgeon and anaesthetist share the area of intervention

Kinking of tube

Tube dislocation/disconnection

Tube block

Accidental extubation



INTRAOPERATIVE COMPLICATIONS(CONTD)

Hypothermia

Excessive bleeding

Hypercapnia

Hypoxia

Equipment failure

Drug allergies

Cardiac Arrythmias

Hypotension



PEDIATRIC INTRAVENOUS FLUID

ADMINISTRATION GUIDELINES

Maintenance Fluids

4 cc/kg/hr - 0-10kg

2cc/kg/hr - next 10 kg

1cc/kg/hr - additional kgs

Balanced salt solution (e.g. LR, plasmalyte) for Deficit

Third space

Blood loss replacement

Deficit: calculate from above then x hours NPOReplace 1/2 first hour

1/4th second hour

1/4th third hour



PEDIATRIC INTRAVENOUS FLUID

ADMINISTRATION GUIDELINES

Third Space Losses

2-4 cc/kg/hr minor procedure (lip scar revision)

4-6 cc/kg/hr moderate procedure (bilateral lip repair)

8-10cc/kg/hr major procedure (large cleft palate repair)

Blood Loss

Replace 3x blood loss with balanced salt solution

10cc/kg/hr PRBCs raises HCT 5%

Estimated Blood Volume

Infant 80 ml/kg1-3 years 75 ml/kg

3-6 years 70 ml/kg

>6 years 65 ml/kg

A well-hydrated patient will have less post operative nausea



EXTUBATION IN OR

Ensure

Throat pack removed

Remove throat pack before surgeon places suture for- Abbe flap,tongue flap

Placement of tongue suture (post-palate/pharyngoplasty) No bleeding

Strong suction available

Patient breathing 100% O2 spontaneously

No residual narcotization/neuromuscular block

Oxygen saturation >97% or better

Surgeon should be present scrubbed and immediately available inOR



EXTUBATION IN OR

Tracheostomy instrument tray available

Gently suction anterior nares, oropharynx if possible-but beware suture lines and wounds

As far as possible-surgeon should perform suctioning

Patient should be

awake

opening eyes

spontaneous purposeful movement

able to open mouth and/or cough Retain ability to give 100% O2 by positive pressure mask

Instrument table remains set up



EXTUBATION

Consider delayed extubation

Suspecting airway edema

Pulmonary edema Severe Bronchospasm

Impossible to re-intubate e.g abbe flap,

pharyngeal flap, tongue flap Hemodynamic instability



COMPLICATIONS DURING EXTUBATION

Laryngospasm

Bronchospasm

Hypoxia

Arrythmias Bleeding

Airway obstruction

Hypothermia

Residual anaesthetic drug effects

Need to reintubate



TRANSPORT OF PATIENTS

Patient fully conscious

Responding well to verbal commands

Hemodynamically stable

Ensure haemostasis Spontaneously breathing well

Maintaining SpO2>97% on

room air

Transport in lateral position

Accompanied by anaesthetist



TRANSPORT TO

PACU

Handing over to ICU personnel

with detailed intraop information

Clear and detailed post operativeinstructions

Attach to monitors immediately

O2 by mask Parents to be involved in post op care



POST OP OBSERVATION

Nurse in lateral position with head low

Vital signs ± stable

Strict vigilance for airway and breathing

No evidence of bleeding.

Vital signs and wound check- every hour or more frequently for the first twelve

hours.

Adequate pain relief Treat nausea/vomiting



POST OPERATIVE CARE

Clear liquids PO to be offered initially

Increase oral intake as per tolerance

Intravenous fluids - continue until the patient is takingliquids well orally.

Recommend high visibility bed

Patient: nurse ratio at least 3:1

Established Emergency protocol

Monitor and treat problems as they arise

Chain of communication and command clearlydelineated



POST OPERATIVE PAIN CONTROL

Intravenous opioids

Oral analgesics-NSAIDS

Rectal suppositories

Infraorbital nerve block

Local anaesthetic with adrenaline infiltration

locally



POST OPERATIVE MANAGEMENT

Ability to access anesthesiologist andsurgeon for airway management postoperatively if needed

Surgeon immediately available to answer and address questions regardingpostoperative wound care and drainage

Family of patient to be fully informed of allperioperative events, including success or failure of procedure performed.



POST OPERATIVE CARE

TRAINED

NURSE

ANAESTHETIST

PARENTS

SURGEON

PATIENT



POST OPERATIVE COMPLICATIONS

Airway obstruction ± blood/secretions/tongue fall/airwayedema

Periodic suctioning

Ensure proper position

Ensure tongue suture in place

Nebulisation and hydration

Post operative apnoea-commonly seen in infants

Keep equipment for mask ventilation ready Avoid opioids

Strict SpO2 monitoring (sleeping pulse oximetry)



POST OPERATIVE COMPLICATIONS(CONTD)

Desaturation- Easy respiratory fatigability

Nose block

Hypoventilation residual effects of

anaesthetic drugs Bleeding

Hyper/hypothermia

Pulmonary edema

Accidental extubation

Aspiration



CONCLUSION

Anaesthesia for cleft lip and palate repair with hospital-based cleft care team is relatively safe

Recommend general anaesthesia for most cases

Local anaesthesia for smaller defects in older

children/adults

Anaesthetist should be

Trained in Paediatric anaesthesia and PALS

Able to manage difficult airway

Able to manage post operative complications Able to understand pathophysiology of clefts, associated

complications, disorders especially syndromic patients



CONCLUSION (CONTD)

A well trained, skilled and coordinated team with good

communication and with implementation of

recommended protocols can provide safe

anaesthesia/surgery to this subset of children, making

and engraving this experience as a smooth sail not onlyfor the patients but also for the parents

anaesthetic considerations for cleft surgeries

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