**5. Postoperative care**

Postoperatively, there is not a concern for respiratory compromise with CL repair. CP repair differs as obstruction is possible following extubation. The surgical repair itself reduces the size of the airway and excessive sedation from anesthesia and opioids can cause the tongue to lose muscle tone causing obstruction. If the Digman retractor is up for long periods of time, the tongue itself can have some swelling. Obstruction is problematic as blind placement of an oral airway can result in disruption of the fresh surgical repair. Therefore, a plan should be formulated intraoperatively to avoid obstruction in the postoperative period. Dexamethasone is frequently given early during the surgical repair to reduce any swelling. A tongue stich or nasal trumpets can also be placed by the surgeon following CP repair to relieve obstruction should it result. These techniques are not uniformly used by cleft teams in the United States [42] and there is no increase in reintubation rates when tongue stitch is avoided [43], but it is our practice to place a tongue stitch on all our CP patients. The tongue stitch remains in place while the patient is in the PACU, but is removed before transfer to a medical floor for monitoring overnight.

During the postoperative stage, the main care is based on continuous monitoring the supplementary oxygen depending on the needs of the patient. The bleeding assessment is the proper management of pain and the start of oral intake of clear liquids before allowing the patient to be discharged. It is important to establish which patients are candidates for ambulatory management, which ones have a higher risk to present adverse events like bronchospasm, laryngospasm, desaturation and respiratory difficulty. High risk patients with palate repair could end up having to stay in the hospital or intensive care unit longer than expected and this should be a consideration [28]. It's recommended that the stay at the PACU is 1 hour at least [26]. In the Instituto Nacional de Pediatría in Mexico City, the management of pain after surgery is based on paracetamol at 15 mg/kg or an AINE like ketorolac at 1 mg/kg, and other

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.

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

Postoperatively, there is not a concern for respiratory compromise with CL repair. CP repair differs as obstruction is possible following extubation. The surgical repair itself reduces the size of the airway and excessive sedation from anesthesia and opioids can cause the tongue to lose muscle tone causing obstruction. If the Digman retractor is up for long periods of time, the tongue itself can have some swelling. Obstruction is problematic as blind placement of an oral airway can result in disruption of the fresh surgical repair. Therefore, a plan should be formulated intraoperatively to avoid obstruction in the postoperative period. Dexamethasone is frequently given early during the surgical repair to reduce any swelling. A tongue stich or nasal trumpets can also be placed by the surgeon following CP repair to relieve obstruction should it result. These techniques are not uniformly used by cleft teams in the United States [42] and there is no increase in reintubation rates when tongue stitch is avoided [43], but it is our practice to place a tongue stitch on all our CP patients. The tongue stitch remains in place while the patient is in the PACU, but is removed before transfer to a medical floor for monitoring overnight.

During the postoperative stage, the main care is based on continuous monitoring the supplementary oxygen depending on the needs of the patient. The bleeding assessment is the proper management of pain and the start of oral intake of clear liquids before allowing the patient to be discharged. It is important to establish which patients are candidates for ambulatory management, which ones have a higher risk to present adverse events like bronchospasm, laryngospasm, desaturation and respiratory difficulty. High risk patients with palate repair could end up having to stay in the hospital or intensive care unit longer than expected and this should be a consideration [28]. It's recommended that the stay at the PACU is 1 hour at least [26]. In the Instituto Nacional de Pediatría in Mexico City, the management of pain after surgery is based on paracetamol at 15 mg/kg or an AINE like ketorolac at 1 mg/kg, and other

Typically, narcotics are used in the United States to supplement the residual discomfort.

also decrease postoperative pain [41].

62 Anesthesia Topics for Plastic and Reconstructive Surgery

**5. Postoperative care**

**Figure 2.** Edited from Lewis CW, Jacob LS, Lehmann CU, AAP SECTION ON ORAL HEALTH. The primary care pediatrician and the care of children with cleft lip and/or cleft palate [44].

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

Following the primary repair of CL and CP, children with CP with or without CL have multiple future treatments and potential additional surgical interventions (**Figure 2**).

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 if possible.
