**6. The international team of cleft lip and palate**

Internationally, there is a need for surgical teams to help aid in surgical repairs of CL and CP. A full discussion of the techniques of establishing sites for these surgical services is beyond the scope of this chapter. However, it is important for the anesthesiologists to recognize differences occur when surgical teams go to other countries. When resources are limited, the choices one makes may differ from the choices made in one's home country. Similarly, a different environment may affect outcomes [45]. Before proceeding with any medical procedures, it is helpful to understand local culture and medical practices. For example, in the United States it is very common that patients receive opioid medications for recovery on the hospital medical floor following surgery. In some countries, the infrastructure and the comfort with postoperative narcotics is not present. Thus, an adapted anesthetic plan should be implemented to ensure that the ultimate goal of adequate pain relief is met with non-narcotic medications. In these countries reliance in nerve blocks and other non-opioid pain medication becomes valuable (**Table 1**).

improve the quality of care provided. All facilities should meet the basic standards to care for all patients, if these standards are not met by the facility, the visiting team is required to bring with them the supplies and equipment necessary to meet these basic standards such as:

Pediatric Anesthesia for Patients with Cleft Lip and Palate

http://dx.doi.org/10.5772/intechopen.74926

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**5.** Working suction should be present at each operating room table and in the recovery area.

Every team should include a surgeon who is familiar with the planned procedures, preferably a board certified surgeon, a board certified anesthesiologist experienced in the care for children undergoing same or similar procedures, who should be supervising no more than two procedures at any given time, certified nurse anesthetists with experience in the care of children undergoing the same or similar procedures, a board certified pediatrician, operating

The visiting team should always bring the airway equipment including appropriate laryngoscopes and blades, laryngeal mask airways, self-inflating bag-valve-mask in all care areas, emergency cricothyroidotomy kit and fiber-optic bronchoscope. Emergency medications, emergency vascular access kits, defibrillator, portable pulse oximetry, Stat laboratory and portable oxygen supply must be included among the supplies and equipment needed during

Anesthesia in cleft patients should be performed in a setting with the proper equipment, medications and supplies to provide the safest procedure by experienced anesthesiologists since these patients have high risk for respiratory complications such as difficult intubation, laryngospasm, bronchospasm, or if they have had an upper respiratory infection within the month preceding the surgery, then they may suffer complications like pneumonia or bronchopneumonia. If any other complication may arise from the surgical or anesthetic procedure, the anesthesiologist should be able to diagnose it and manage it and the patient should be transferred to a post anesthetic care unit or intensive care unit, depending on the severity of the complication. Favorable outcomes are directly related to carefully selecting the patient that will undergo cleft surgery, anesthesiologists properly trained to manage this kind of cases and having all the human and material resources to provide the best care during and after the surgical procedure.

**1.** Electrical power that is dependable and continuous.

**4.** Full-functioning monitoring for each patient in the operating rooms.

**6.** Basic laboratory and radiology services should be immediately available.

room, recovery area and ward nurses experienced in the care of children.

**2.** Working modern anesthesia machines.

**3.** Dependable oxygen supply.

cleft surgical outreach trip [46].

**7. Conclusions**

**7.** Blood banking.

The most important idea when surgically treating patients in other countries is to remember to *"first do no harm."* The pre-operative evaluation becomes vital to ensuring safety in these kids. It is unlikely that an extensive cardiac evaluation may have been done. A murmur on exam or a history consistent with heart failure warrants further workup before proceeding to surgery. Similarly, a difficult airway should not be underestimated when in a resource limited location. If a potential difficult airway is identified, with known risk factors such as retrognathia, young age and a syndrome associated with a difficult airway, an assessment of resources is important. A plan should be made prior to proceeding in case extubation is not possible following the procedure. Finally, a history and physical should thoroughly inquire about the possibility of a current or recent upper respiratory infection. If risk factors for perioperative respiratory complications from the upper respiratory infection are identified, surgical repairs should be postponed.

In general, once appropriate surgical patients are identified, anesthetic care is similar regardless of the location. The medications available and local customs for postoperative care will help shape the anesthetic designed and the plan for postoperative care.

All reconstructive and craniofacial surgeons that oversee cleft care should treat any patient abroad as if they are at their usual surgical facility at home; always following the quality guidelines for their best performance and safety for the patients. There are different protocols for cleft care all over the world, but the visiting surgeon should adapt to the local multidisciplinary team in charge and ensure that there will be the proper follow up for the patients. A complete documentation should be the rule for the entire team working in the operating room. This will simplify preoperative assessment in the future and enable the team to properly evaluate current and future issues that could lead to any adverse outcome and will help


**Table 1.** Shows some syndromes associated with CL and/ or CP and common characteristics.

improve the quality of care provided. All facilities should meet the basic standards to care for all patients, if these standards are not met by the facility, the visiting team is required to bring with them the supplies and equipment necessary to meet these basic standards such as:


implemented to ensure that the ultimate goal of adequate pain relief is met with non-narcotic medications. In these countries reliance in nerve blocks and other non-opioid pain medication

The most important idea when surgically treating patients in other countries is to remember to *"first do no harm."* The pre-operative evaluation becomes vital to ensuring safety in these kids. It is unlikely that an extensive cardiac evaluation may have been done. A murmur on exam or a history consistent with heart failure warrants further workup before proceeding to surgery. Similarly, a difficult airway should not be underestimated when in a resource limited location. If a potential difficult airway is identified, with known risk factors such as retrognathia, young age and a syndrome associated with a difficult airway, an assessment of resources is important. A plan should be made prior to proceeding in case extubation is not possible following the procedure. Finally, a history and physical should thoroughly inquire about the possibility of a current or recent upper respiratory infection. If risk factors for perioperative respiratory complications from the upper respiratory infection are identified, surgical repairs should be postponed.

In general, once appropriate surgical patients are identified, anesthetic care is similar regardless of the location. The medications available and local customs for postoperative care will

All reconstructive and craniofacial surgeons that oversee cleft care should treat any patient abroad as if they are at their usual surgical facility at home; always following the quality guidelines for their best performance and safety for the patients. There are different protocols for cleft care all over the world, but the visiting surgeon should adapt to the local multidisciplinary team in charge and ensure that there will be the proper follow up for the patients. A complete documentation should be the rule for the entire team working in the operating room. This will simplify preoperative assessment in the future and enable the team to properly evaluate current and future issues that could lead to any adverse outcome and will help

help shape the anesthetic designed and the plan for postoperative care.

**Syndromes associate with CL and CP Common features**

Pierre Robin Sequence Micrognathia, glossoptosis

Treacher Collins syndrome Micrognathia, ear defects, congenital heart disease

Fetal alcohol syndrome Congenital heart disease, developmental delay

Klippel-Feil syndrome Fusion of the cervical spine, renal disorders

**Table 1.** Shows some syndromes associated with CL and/ or CP and common characteristics.

Goldenhar's syndrome Unilateral mandibular hypoplasia, unilateral ear deformity Down syndrome Macroglossia, atlantoaxial instability, congenital heart disease

22q deletion syndrome Congenital heart disease, hypocalcemia, thymic hypoplasia

Stickler syndrome Connective tissue disorder, glaucoma and cataracts, hearing loss, joint hypermobility

becomes valuable (**Table 1**).

64 Anesthesia Topics for Plastic and Reconstructive Surgery

Every team should include a surgeon who is familiar with the planned procedures, preferably a board certified surgeon, a board certified anesthesiologist experienced in the care for children undergoing same or similar procedures, who should be supervising no more than two procedures at any given time, certified nurse anesthetists with experience in the care of children undergoing the same or similar procedures, a board certified pediatrician, operating room, recovery area and ward nurses experienced in the care of children.

The visiting team should always bring the airway equipment including appropriate laryngoscopes and blades, laryngeal mask airways, self-inflating bag-valve-mask in all care areas, emergency cricothyroidotomy kit and fiber-optic bronchoscope. Emergency medications, emergency vascular access kits, defibrillator, portable pulse oximetry, Stat laboratory and portable oxygen supply must be included among the supplies and equipment needed during cleft surgical outreach trip [46].

#### **7. Conclusions**

Anesthesia in cleft patients should be performed in a setting with the proper equipment, medications and supplies to provide the safest procedure by experienced anesthesiologists since these patients have high risk for respiratory complications such as difficult intubation, laryngospasm, bronchospasm, or if they have had an upper respiratory infection within the month preceding the surgery, then they may suffer complications like pneumonia or bronchopneumonia. If any other complication may arise from the surgical or anesthetic procedure, the anesthesiologist should be able to diagnose it and manage it and the patient should be transferred to a post anesthetic care unit or intensive care unit, depending on the severity of the complication. Favorable outcomes are directly related to carefully selecting the patient that will undergo cleft surgery, anesthesiologists properly trained to manage this kind of cases and having all the human and material resources to provide the best care during and after the surgical procedure.
