Anaesthesia for Cleft Lip and Palate Surgery PDF

Anaesthesia for Cleft Lip and Palate surgery Alaye Debas Decmber, 2024 12/31/2024 ada@DMU 1  Introduction Cleft lip and palate are the commonest craniofacial abnormalities....

Anaesthesia for Cleft Lip and Palate surgery Alaye Debas Decmber, 2024 12/31/2024 ada@DMU 1  Introduction Cleft lip and palate are the commonest craniofacial abnormalities. A cleft lip, with or without a cleft palate, occurs in 1 / 600 live births. A cleft palate alone, is a separate entity and occurs in 1 in 2000 live births. The cleft can involve the lip, alveolus (gum), hard palate and / or soft palate and can be – Complete or Incomplete – Unilateral or Bilateral. 12/31/2024 ada@DMU 2  Anatomy Cleft lip (CL) – is a unilateral or bilateral fissure in the upper lip. – Complete CL extends across the whole lip and into the nostrils. – Incomplete CL ranges from small indentations to large defects with little connecting tissue between the two clefts. 12/31/2024 ada@DMU 3  Cleft palate (CP) – is a unilateral or bilateral fissure in the soft palate that may extend into the hard palate. Cleft Palate may occur with Cleft lip when the lip fissure extends beyond the incisive foramen and includes the sutura palatine. 12/31/2024 ada@DMU 4 12/31/2024 ada@DMU 5  Embryology Lip and palate development occurs in the first trimester, the critical period being between weeks 6 and 9 gestation. The upper lip and primary palate are formed from the fusion of the frontonasal and bilateral maxillary prominences CL occurs when this fusion fails on either or both sides. 12/31/2024 ada@DMU 6  The secondary palate is formed from lateral palatal processes arising from the deep portions of the maxillary prominences.  Initially these lie vertically alongside the tongue, but as mandibular development proceeds the tongue moves inferiorly allowing the palatal shelves to assume a horizontal alignment.  Fusion of the two shelves occurs in an anterior to posterior direction – incomplete fusion produces CP. 12/31/2024 ada@DMU 7  Clinical problems : facial disfigurement and potentially social isolation, feeding problems and abnormal speech. 12/31/2024 ada@DMU 8  Anesthetic concerns Majority of anaesthetic morbidity related to these procedures relates to the airway:  Difficulty with intubation  Inadvertent extubation during the procedure  Postoperative airway obstruction. The optimum anaesthetic management will depend on the age of the patient, the availability of intraoperative monitoring equipment, anaesthetic drugs and expertise 12/31/2024 ada@DMU 9  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. associated with about 150 different syndromes Pierre-Robin Syndrome( cleft palate, Micrognathia and upper airway obstruction), Goldenhar Syndrome and Treacher Collins syndrome. Congenital heart disease : occurs in 5 - 10% of these patients. 12/31/2024 ada@DMU 10 2. Chronic rhinorhoea: This is common in children presenting for cleft palate closure and is due to reflux into the nose during feeds. 3. Obstructive sleep apnoea syndrome – very sensitive to any respiratory depressant effects of anaesthetic agents, benzodiazepines or opioid analgesics. – Where available an ECG, echocardiogram and over night saturation monitoring preoperatively will quantify the problem 12/31/2024 ada@DMU 11  Right ventricular hypertrophy and cor pulmonale ; may result from recurrent hypoxia due to airway obstruction 4. Anticipated difficult intubation. – A difficult intubation is especially common in patients less than 6 months of age with either retrognathia (receding lower jaw) or bilateral clefts. 5. Nutrition/Hydration : potential difficulty with feeding, nutritional anaemia. 12/31/2024 ada@DMU 12  Need for premedication:  Risk of air way obstruction: Sedative premedication is not indicated in infants with cleft palates and should be avoided because of the risk of airway obstruction.  Atropine ; for the antisialogue effects 12/31/2024 ada@DMU 13  Techniques of induction Induction of anaesthesia is most safely performed by inhalational anaesthesia with halothane or sevoflurane. Check musk ventilation possible or not ,if possible IV anesthetic + opioids + inhalational + muscle relaxants No neuromuscular blocking agents should be given until one is sure that the lungs can be ventilated with a mask. 12/31/2024 ada@DMU 14  Endotracheal intubation may be difficult, especially in children with a craniofacial syndrome a variety of techniques such as – blind nasal intubation – fibreoptic intubation – the use of bougies or retrograde techniques. – 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. 12/31/2024 ada@DMU 15  Maintenance  Shared airway – well secured ETT and avoid kinking.  Fluid management  Temperature  Homeostasis and hypercapnia : Adrenaline arrhythmia 12/31/2024 ada@DMU 16 – 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 ETT are common. – Endobronchial intubation or inadvertent extubation is common when the head is moved or kinked under the mouth gag. 12/31/2024 ada@DMU 17  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. 12/31/2024 ada@DMU 18 ▓ Maintenance of anaesthesia with an inhalational agent can be with spontaneous ventilation or controlled ventilation. ▓ A spontaneous breathing technique with halothane provides an element of safety in the event of accidental disconnection or extubation but is not suitable in very young infants. ▓ 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. 12/31/2024 ada@DMU 19  Local infiltrations: – to reduce blood loss and improve the surgical field. – It also provides some intraoperative analgesia. – Adrenaline to 5mcg/kg in the presence of normocapnia and halothane. Paractamol (oral /rectal ) , NSAIDS Careful use of intraop opioids / small dose of opioids. 0.5mcg/kg IV fentanyl 12/31/2024 ada@DMU 20  use of short acting opioids : in a smoother emergence and less crying on extubation. Reduces trauma to the airway and decreases the risk of post op bleeding.  Bilateral infraorbital nerve blocks : excellent intra and post op analgesia and no respiratory depression. These nerve blocks are especially useful if a spontaneously breathing technique is used to repair cleft lips in young infants. 12/31/2024 ada@DMU 21  Infraorbital Nerve Block The infraorbital nerve is a terminal branch of the trigeminal nerve. It supplies sensory innervation to the skin and mucous membrane of the upper lip and lower eyelid the skin between them and to the side of the nose. It can easily be blocked as it emerges from the infraorbital foramen, just medial to the buttress of the zygoma (bony prominence immediately lateral to the nose). 12/31/2024 ada@DMU 22 12/31/2024 ada@DMU 23 12/31/2024 ada@DMU 24  The nerve is blocked by inserting a needle perpendicularly to the skin and advancing it until bony resistance is felt. The needle is then withdrawn slightly and 1- 2mls of 0.5% bupivacaine and 1:200,000 adrenaline is injected after performing a negative aspiration 12/31/2024 ada@DMU 25  Extubation Acute airway obstruction is a very real risk following extubation. The surgeon needs to remove the throat packs and ensure that the surgical field is dry. Suctioning should be kept to a minimum to avoid disrupting the surgical repair. Oropharyngeal airways are best avoided, if possible. A tongue stitch will often be placed in patients with preoperative airway obstruction. This pulls the tongue forward away from the posterior pharyngeal wall as a treatment for postoperative airway obstruction. 12/31/2024 ada@DMU 26  Key points A difficult view at laryngoscopy is a more frequent finding than a difficult airway; the anaesthetist should be prepared for either. Patients should be extubated when fully awake with close observation for signs of airway obstruction. Analgesia is an important part of the balanced anaesthetic technique. 12/31/2024 ada@DMU 27 12/31/2024 ada@DMU 28