**3. Consideration of anesthesia management**

During surgical repair, a general anesthetic is required to allow for optimal surgical conditions. Control of ventilation through endotracheal intubation is necessary. Given the abnormalities of the face, concern may exist regarding the difficulty of mask ventilation and endotracheal intubation. Both ease of ventilation and intubation might have significant effects on the management of the induction of anesthesia as well as the equipment that should be present prior to induction of general anesthesia. Unlike the adult population, there are not any objective exam criteria that can help identify a difficult airway. Young children will not participate in the normal airway exam. A difficult airway, defined as a difficult laryngoscopy, intubation or mask ventilation, is less common in pediatric patients [15–20]. However, young age (less than 1 year of age) and craniofacial abnormalities increase the risk of a difficult airway [15].

• Non-pathologic background related with nutritional state and development

and other anesthetic procedures in the past and the patient's reactions to them.

b) Evaluate the anesthetic risk and decide on the anesthetic technique to be used.

separation anxiety before taking the children into the operating room.

airway.

X-rays or echocardiogram [25].

• Complete physical examination, including the possibility of difficult venous access and

• Lab work: complete blood count, prothrombin time, partial thrombin time, bleeding and coagulation times, and any other studies for cardiovascular assessment such as EKG, chest

c) Inform the parents about the anesthetic technique to be used and the possibility of adverse events as well as the amount of time the patient needs to be NPO before the surgery depending on the age of the patient: 2 hours of clear liquids in all ages, to age less than 6 months 4 hours for maternal milk, and 6 hours for non-maternal milk. For patients 6 to 36 months old; 6 hours to solid food and non-maternal milk including formula [26, 14]. d) Preoperative medications: intranasal dexmedetomidine is great for patients older than 6 months because it diminishes secretions that are produced by crying. It must be administered and be continuously monitored in any setting. Midazolam PO is used to treat

No matter the setting where the cleft surgery is going to take place, the anesthetic procedure must have the basic monitoring like continuous evaluation of electrocardiography, noninvasive blood pressure, arterial oxygen saturation, temperature, end-tidal carbon dioxide, with capnography. The objective is to obtain a safe management of the patient and to minimize the complications [9, 27]. When the surgical outreach trips for clefts in children occur in a general hospital not a pediatric hospital, it is important to provide that institution with the appropri-

There is no standard anesthetic that has been shown to be superior in the care of children for repair of CL and CP. Typically, CL are repaired at 2–3 months of age to improve feeding and repair the muscular of the mouth. CP is repaired between 9 and 12 months of age. The goal is to optimize speech development. However, earlier repair could increase the likelihood of midface hypoplasia in the future. No premedication is required for children of these ages undergoing CL and CP repair. At this stage in life, separation anxiety is not yet a major concern. Most children present for surgery from home and have no established intravenous access. Most anesthesiologists utilize an inhalational induction with volatile

ate monitors and equipment for the adequate management and safety for the patient.

• Review of systems: pulmonary abnormalities including recent respiratory infections, craniofacial deformities that will make airway and respiratory management more difficult [8], cardiac abnormalities and their treatment and cardiovascular evaluation required latest respiratory infection due to the high incidence of fistula formation or palate wound dehiscence [8], or increasing the incidence of complications of the anesthetic procedure (23%). It has been recommended a period of 4 to 6 weeks between the relief of respiratory infection and the surgical and anesthetic event to avoid such complications [25–26]. Another important issue is allergies to medications, food and toys. Kind of malformations the patient has

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Although there are not set criteria that is useful to identify a child with a CP who will be a difficult laryngoscopy, examination for retrognathia should occur in each child. Viewing the face from the side is an easy way to identify retrognathia. If retrognathia is present, a potentially difficult intubation should be anticipated, and additional precautions should be undertaken. In the United States, a laryngeal mask airway, video laryngoscope and a fiber optic bronchoscope are tools that could be used to aid with a difficult intubation. If providing surgical care in a resource limited location these tools may not be available. An honest, but thorough evaluation of the facility's capabilities should be performed to ensure that the primary goal of doing no harm to the patient is followed.

Pre-operative history should also focus on determining if the infant has an upper respiratory infection (URI). Patients with a URI are at increased risk for perioperative respiratory events such as bronchospasm, laryngospasms, desaturations, breath holding and postintubation croup [21]. Presence of copious sputum and secretions, nasal congestion, recent URI (less than 2 weeks), and history of reactive airway disease increased the risk of perioperative adverse respiratory events [22]. Patients with CL and/or CP with a recent URI are at an increased risk of perioperative respiratory events compared to children without CL and/or CP who have had a recent URI. To minimize the risk of perioperative respiratory events, it is recommended that surgery be postponed for 4–6 weeks after the URI has resolved and that an experienced pediatric anesthesiologist performs the anesthetic [19]. Despite these perioperative events, in the experienced hands of a pediatric anesthesiologist there is not a risk for substantial morbidity or mortality in these patients. Nonetheless, if these symptoms are present it is prudent to postpone surgery for repair of the CL or CP until the child is no longer ill. Gunawardana and Arteau-Gauthier et al. [23, 24] studied risk factors for difficult laryngoscopy in children with CP. These children did not have any identified syndrome. 5–7% of patients in these studies had difficult laryngoscopy, a higher incidence than in other pediatric patients. Large or bilateral clefts, micrognathia and age less than 6 months were associated with increased incidence of difficult laryngoscopy. Large and bilateral clefts can be difficult because the blade of the laryngoscope can fall into the cleft. Should this occur, one can pack the cleft with gauze to improve the laryngoscopy. No patients in these studies were associated with difficult mask ventilation. Since mask ventilation is not difficult in most of these patients, an inhaled induction with volatile anesthetic with control of ventilation is appropriate in most of these patients in experienced hands.

The preanesthetic assessment is very important and should contain the patient's information: age, height and weight and its main goals are:


• Non-pathologic background related with nutritional state and development

exam criteria that can help identify a difficult airway. Young children will not participate in the normal airway exam. A difficult airway, defined as a difficult laryngoscopy, intubation or mask ventilation, is less common in pediatric patients [15–20]. However, young age (less than 1 year of age) and craniofacial abnormalities increase the risk of a difficult airway [15].

Although there are not set criteria that is useful to identify a child with a CP who will be a difficult laryngoscopy, examination for retrognathia should occur in each child. Viewing the face from the side is an easy way to identify retrognathia. If retrognathia is present, a potentially difficult intubation should be anticipated, and additional precautions should be undertaken. In the United States, a laryngeal mask airway, video laryngoscope and a fiber optic bronchoscope are tools that could be used to aid with a difficult intubation. If providing surgical care in a resource limited location these tools may not be available. An honest, but thorough evaluation of the facility's capabilities should be performed to ensure that the primary goal of

Pre-operative history should also focus on determining if the infant has an upper respiratory infection (URI). Patients with a URI are at increased risk for perioperative respiratory events such as bronchospasm, laryngospasms, desaturations, breath holding and postintubation croup [21]. Presence of copious sputum and secretions, nasal congestion, recent URI (less than 2 weeks), and history of reactive airway disease increased the risk of perioperative adverse respiratory events [22]. Patients with CL and/or CP with a recent URI are at an increased risk of perioperative respiratory events compared to children without CL and/or CP who have had a recent URI. To minimize the risk of perioperative respiratory events, it is recommended that surgery be postponed for 4–6 weeks after the URI has resolved and that an experienced pediatric anesthesiologist performs the anesthetic [19]. Despite these perioperative events, in the experienced hands of a pediatric anesthesiologist there is not a risk for substantial morbidity or mortality in these patients. Nonetheless, if these symptoms are present it is prudent to postpone surgery for repair of the CL or CP until the child is no longer ill. Gunawardana and Arteau-Gauthier et al. [23, 24] studied risk factors for difficult laryngoscopy in children with CP. These children did not have any identified syndrome. 5–7% of patients in these studies had difficult laryngoscopy, a higher incidence than in other pediatric patients. Large or bilateral clefts, micrognathia and age less than 6 months were associated with increased incidence of difficult laryngoscopy. Large and bilateral clefts can be difficult because the blade of the laryngoscope can fall into the cleft. Should this occur, one can pack the cleft with gauze to improve the laryngoscopy. No patients in these studies were associated with difficult mask ventilation. Since mask ventilation is not difficult in most of these patients, an inhaled induction with volatile anesthetic with con-

trol of ventilation is appropriate in most of these patients in experienced hands.

delivery, need of special care after birth, prolonged hospitalization [9].

a) To obtain the medical and surgical background of the patient:

age, height and weight and its main goals are:

• Family background of anesthetic problems

The preanesthetic assessment is very important and should contain the patient's information:

• Perinatal background such as pregnancy evolution, kind of delivery, complications during

doing no harm to the patient is followed.

58 Anesthesia Topics for Plastic and Reconstructive Surgery


No matter the setting where the cleft surgery is going to take place, the anesthetic procedure must have the basic monitoring like continuous evaluation of electrocardiography, noninvasive blood pressure, arterial oxygen saturation, temperature, end-tidal carbon dioxide, with capnography. The objective is to obtain a safe management of the patient and to minimize the complications [9, 27]. When the surgical outreach trips for clefts in children occur in a general hospital not a pediatric hospital, it is important to provide that institution with the appropriate monitors and equipment for the adequate management and safety for the patient.

There is no standard anesthetic that has been shown to be superior in the care of children for repair of CL and CP. Typically, CL are repaired at 2–3 months of age to improve feeding and repair the muscular of the mouth. CP is repaired between 9 and 12 months of age. The goal is to optimize speech development. However, earlier repair could increase the likelihood of midface hypoplasia in the future. No premedication is required for children of these ages undergoing CL and CP repair. At this stage in life, separation anxiety is not yet a major concern. Most children present for surgery from home and have no established intravenous access. Most anesthesiologists utilize an inhalational induction with volatile 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 used with similar anesthetic results [30].

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

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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

surgical field. Typically, only 0.5–1 mL of local anesthetic is utilized.

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

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 moment of extubation.
