**4. Perioperative and postsurgery analgesia**

Pain control during the entire perioperative procedure is especially important in CL and palate surgeries. Multi-modal pain therapy with narcotic, non-narcotic and regional anesthesia can help ensure optimal pain control. In the United States, the surgeon will typically inject local anesthetic and epinephrine prior to the repair of both CL as well as CP. The main goal of this injection is to provide vasoconstriction in surgical field. However, when local anesthetic is utilized the patient will benefit from some additional pain control. The duration of which is dependent on the type of local anesthetic used. Opioids can be used intraoperatively to smooth the hemodynamic response to surgical pain. Some anesthesiologists in the United States are increasingly using the short acting narcotic remifentanil. Remifentanil is potent and quick acting, but is metabolized quickly allowing its effects to dissipate quickly. Remifentanil can also be used to facilitate a smooth emergence and extubation in these patients. However, remifentanil may not be available in all facilities throughout the world, making it difficult to utilize in resource limited locations.

Regional anesthesia can provide excellent analgesia in children undergoing surgical repair of CL. The infraorbital nerve provides sensory innervation to the skin on the unilateral skin and mucous membranes from the upper lip through the check and to the lower eyelid. Sensory innervation for the nasal alae is also provided (**Figure 1**). Blockade of the infraorbital nerve should provide pain relief for most of the tissue affected by a CL repair. A 2016 Cochrane Review of infraorbital nerve blocks during CL repair demonstrated that bilateral infraorbital nerve blocks result in lower opioid consumption during the surgical procedure as well as lower pain scores in the Post-Anesthesia Care Unite (PACU) [32]. The pain relief was superior to fentanyl [33], placebo [34], and local infiltration [35]. Nicodemus et al. [36] demonstrated that pain relief lasted 19 hours when a mixture of bupivacaine with epinephrine was used for the block. Infraorbital nerve blocks can be easily placed via two approaches; intraoral or extra-oral. The intraoral approach directs a 25 g needle in the mouth and until the gingivalabial fold near the canine toward the infraorbital notch. The infraorbital nerve emerges from the infra-orbital foramen below the eye which is easily palpated in most patients. Care must be taken to avoid advancing the needle past the foramen into the eye in neonates and infants. Given the small size of these patients, the toxic dose of local anesthesia should be calculated when the surgeon also utilizes local anesthetic with epinephrine for vasoconstriction in the surgical field. Typically, only 0.5–1 mL of local anesthetic is utilized.

The sensory innervation of the palate is more complex than the lip, requiring blockade of the greater palatine, lesser palatine and the nasopalatine. Each of these nerves is branches of the maxillary division of the trigeminal nerve. The suprazygomatic approach to maxillary nerve blockade allows a single injection to provide improved pain control for CP repair [37–38]. Overall, pain was better controlled, and fewer narcotics were required for the first 48 hours following

**Figure 1.** Sensory innervation of the infraorbital nerve.

anesthesia. If a difficult airway is anticipated, then this induction may be changed. The induction stage is the one with the most risk of adverse events. The main adverse event reported in the literature at the Instituto Nacional de Pediatría in Mexico City is laryngospasm which was noted in 77% of the cases [28]. Once intravenous access is obtained intubation with a RAE (Ring, Adiar and Elwyn) endotracheal tube is used. The pre-formed bend in this endotracheal tube lies on the chin, optimizing the surgical exposure for the surgeon. For a CP repair a throat pack may be used and a Digman retractor is typically placed to further improve surgical visualization. Care must be taken to ensure that the endotracheal tube is not moved when these devices are placed, as endobronchial intubation or inadvertent extubation can occur. In addition, the Digman retractor can compress the endotracheal tube when initially raised. Communication with the surgeons is important to ensure optimal oxygenation and ventilation continues throughout the surgical repair. Multiple anesthesia techniques can be used for the children undergoing CL or CP repair. In the United States, use of a volatile anesthetic with or without opioids or regional anesthesia [29–31] is commonly used. Anesthesia with propofol-remifentanil can also be

There is an important incidence of adverse events during this stage such as accidental extubation and occlusion of the endotracheal tube by surgical instruments or malposition of the patient. It's also important to mention the laryngospasm and bronchospasm during the palate repair. Hypothermia in patients of two months to two years of age is directly proportional to the length of the surgery and the temperature of the surgical room [27]. In the Instituto Nacional de Pediatría, hypothermia was a frequent concern and it is critical to keep the surgical room at an adequate temperature to avoid other adverse events that could alter the behavior or stability of the patient during the moment of the extubation. To avoid the adverse events such as laryngospasm and bronchospasm it is important to set criteria for the best

Pain control during the entire perioperative procedure is especially important in CL and palate surgeries. Multi-modal pain therapy with narcotic, non-narcotic and regional anesthesia can help ensure optimal pain control. In the United States, the surgeon will typically inject local anesthetic and epinephrine prior to the repair of both CL as well as CP. The main goal of this injection is to provide vasoconstriction in surgical field. However, when local anesthetic is utilized the patient will benefit from some additional pain control. The duration of which is dependent on the type of local anesthetic used. Opioids can be used intraoperatively to smooth the hemodynamic response to surgical pain. Some anesthesiologists in the United States are increasingly using the short acting narcotic remifentanil. Remifentanil is potent and quick acting, but is metabolized quickly allowing its effects to dissipate quickly. Remifentanil can also be used to facilitate a smooth emergence and extubation in these patients. However, remifentanil may not be available in all facilities throughout the world, making it difficult to

used with similar anesthetic results [30].

60 Anesthesia Topics for Plastic and Reconstructive Surgery

**4. Perioperative and postsurgery analgesia**

moment of extubation.

utilize in resource limited locations.

surgical repair. Unfortunately, suprazygomatic maxillary nerve block is not frequently used due to lack of familiarity by most anesthesiologists in the United States currently. However, unlike infraorbital nerve blocks the nerve block alone is not sufficient to provide adequate analgesia. Typically, narcotics are used in the United States to supplement the residual discomfort.

Multi-modal pain management incorporates the use of non-narcotic medications. Acetaminophen, non-steroidal anti-inflammatory medications and the alpha-2 agonists, like dexmedetomidine, are commonly used in pediatric patients to reduce the total amount of opioids required following surgical procedures, and to reduce the side effects of opioids such as respiratory depression. In infants undergoing primary CP repair acetaminophen is effective in reducing pain scores and overall opioid consumption [39], with intravenous acetaminophen providing the lowest pain scores and lowest opioid consumption compared to placebo and oral administration. Rectal acetaminophen historically has been used given its ease of administration. However, overall opioid consumption is not decreased when rectal acetaminophen is used; suggesting other routes of administration might be preferred [40]. Alpha-2 agonists, such as dexmedetomidine, and ketamine given intraoperatively can also decrease postoperative pain [41].

options such as a combination of both, or paracetamol with an opioid such as tramadol, or AINE with an opioid. During the surgical outreach trips for clefts, at the surgical setting, there should always be a postanesthetic care unit well equipped to monitor and observe the pediatric patients. The availability of an intensive care unit and a pediatric ventilator should be part

**Figure 2.** Edited from Lewis CW, Jacob LS, Lehmann CU, AAP SECTION ON ORAL HEALTH. The primary care

Pediatric Anesthesia for Patients with Cleft Lip and Palate

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Following the primary repair of CL and CP, children with CP with or without CL have mul-

After multiple surgical procedures, children can be anxious about future procedures. Any past stressful procedure may create lasting difficulty for the future perioperative period. The anesthesiologist should assess for anxiety and create a plan that eases the fears of the patient. In addition, anesthesiologists should be aware of past procedures and what was done. This is especially important following a pharyngoplasty. Nasal intubation following pharyngoplasty can tear or disrupt the past surgical repair. All attempts at nasal intubation should be avoided

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

tiple future treatments and potential additional surgical interventions (**Figure 2**).

of the criteria for any site where one of these trips will take place.

pediatrician and the care of children with cleft lip and/or cleft palate [44].

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

if possible.
