b.Cleft palate


There is currently no pain management guide in patients with cleft lip and palate; each institution must, based on its experience and population needs, establish a protocol based on multimodal analgesia. This consists of the infiltration of local anesthetics, nerve blocks, opioid analgesics and non-opioid analgesics, providing sufficient analgesia with a lower risk of postoperative agitation [29]:


Other recommended drugs are those that reduce the risk of respiratory depression such as dexmedetomidine and ketamine [3].

The premise is to provide a state of complete patient well-being through multimodal analgesia; this technique emerged in 1997 and is based on the impact of several drugs at minimum doses on the different nociception mechanisms, with a lower risk of adverse effects. Management must be individualized considering factors such as age and degree of airway commitment [3, 10, 28, 29]

### **5.2 Management of postoperative agitation**

The incidence of agitation during emersion or in the postanesthetic is high (12–13%), with references up to 67%. The mechanism that originates it is not clear and has been related to factors such as psychological vulnerability of the patient (separation anxiety, fear of the unknown), anesthetic technique with halogenates, and surgical stimulation such as the subsequent narrowing of the nasopharyngeal cavity due to closure of the palate; other possible causes are postsurgical stimulation such as pain, hypoxemia, hyponatremia, hypoglycemia, CO2 retention, urinary retention, postural discomfort, and/or a very rapid awakening.

Clinically it is characterized by alterations in the state of consciousness or behavior, inconsolable crying, bedwetting, nightmares, anxiety, irritability, uncontrollable movements of limbs, and inability to identify objects or people. Drugs with evidence in reducing agitation are fentanyl, midazolam, and dexmedetomidine infusion [31].
