**3. Transanesthetic management**

#### **3.1 Monitoring**

It is essential to have the basic monitoring for general anesthesia recommended by the current official standards; continuous electrocardiography is included in two leads, noninvasive blood pressure, pulse oximetry, capnography line, and thermal control.

Since hypothermia is one of the most frequently reported adverse events in the literature, thermal control is important throughout the entire transanesthetic [16, 18].

### **3.2 Anesthetic technique used**

In the different bibliographic reviews, there is no consensus on an ideal anesthetic technique or with more preference; the choice will be made based on the characteristics and needs of each patient. There are reports of balanced general anesthesia without neuromuscular relaxation, balanced general anesthesia with neuromuscular relaxation, and intravenous total anesthesia with and without neuromuscular relaxation without significant differences between them [11, 20].

### *3.2.1 Anesthetic induction*

Anesthetic induction is a crucial stage of anesthetic management; through pharmacological measures it provides favorable conditions for airway manipulation, reducing the neurovegetative response to intubation such as hypertension, tachycardia, and increased intraocular or intracranial pressure [21].

Specifically in patients with cleft lip and palate, the use of inhalation induction techniques with sevofluorane or intravenous with propofol is more frequently referred to.

The one made with propofol is characterized by being fast and smooth with the additional advantage of a rapid awakening; in the inhalation with sevofluorane, the advantages lie in halogenated characteristics such as the unpleasant smell, the less irritation of the respiratory tract, the lower solubility in the blood and, in a

**55**

mentioned [22, 23].

*3.2.3 Airway management*

teristics and needs of each patient [3].

when the TET is placed 1.5 cm above the carina [3].

*Anesthesia Considerations in the Perioperative of Patients with Lip and Palate Length*

secondary way, the lower myocardial depression. Other intravenous inducers such as thiopental, midazolam, and ketamine are mentioned in the literature [3, 22]. Within the opioids indicated for the control of the neurovegetative response, fentanyl or remifentanil use is considered without significant differences [21].

Endotracheal intubation is a critical moment in the anesthetic management of the pediatric and adult population, specifically in the presence of difficult airway predictors such as cleft lip and palate facial malformations due to the implicit risk of adverse events; situations of difficult laryngoscopy, difficult or failed intubation,

It is important to use a technique that provides us with rapid and safe favorable intubation conditions in an adequate time. Some authors evaluate the conditions of intubation through the Helbo-Hansen scale that emerged in 1988, which assesses aspects such as jaw relaxation (complete, tone, tense, or rigid), laryngoscopy (easy, good, difficult, or impossible), vocal cords (open, moving, closing, or closing), cough (absent, poor, moderate, or severe), and limb movements (absent, scarce, moderate, or severe); scores of 1–2 indicate favorable conditions, while

There is sufficient evidence that positions propofol as a favorable inducing agent by decreasing airway reflexes and providing adequate conditions for intubation without muscle relaxants; sevofluorane at 8 volume percent facilitates the proper position of the vocal cords in the absence of muscle relaxants, in a period of

The use of neuromuscular blockers is controversial. It is a fact that they provide

Any of the techniques can be effective, the decision will depend on the charac-

Regarding the choice of endotracheal tube (TET), there is no single criterion; the use of RAE (Ring-Adair-Elwyn) U-shaped tubes is recommended for lip surgery and reinforced tubes also known as spiral-shaped spiral wire reinforcement inside and along the tube wall to reduce your occlusion during palate surgery. Other frequently reported are Oxford or "L"-shaped tubes to avoid couplings [24, 25]. A point that should be considered is the lowest risk of accidental extubation

According to different references, the documented incidence of unexpected difficult airway in the pediatric population is low (0.08–1.35%) compared to that of the adult; in children under 1 year of age, it can reach 3.5% and in patients with cleft

favorable conditions for endotracheal intubation, and according to literature reports, there is a lower incidence of respiratory adverse events when they are used; succinylcholine with rapid onset of action and ultra-short effect but with a risk of adverse effects in the pediatric population positions rocuronium and vecuronium non-depolarizing neuromuscular blockers as an alternative with a slower onset, prolonged effect, and great advantage of pharmacological reversal of rocuronium in a situation of unexpected difficult airway [3, 22]. In contrast, some authors recommend avoiding them due to the high incidence of retrognathia, micrognathia, and glossoptosis that make it difficult to approach the airway from ventilation with a facial mask, laryngoscopy, or endotracheal intubation, emphasizing the existence of other alternatives that offer favorable conditions of intubation such as those

*DOI: http://dx.doi.org/10.5772/intechopen.89953*

laryngospasm, and bronchospasm are reported [21].

scores of 3–4 are unacceptable [21, 22].

180 seconds with low incidence of cough [22].

*3.2.2 Endotracheal intubation*

## *Anesthesia Considerations in the Perioperative of Patients with Lip and Palate Length DOI: http://dx.doi.org/10.5772/intechopen.89953*

secondary way, the lower myocardial depression. Other intravenous inducers such as thiopental, midazolam, and ketamine are mentioned in the literature [3, 22].

Within the opioids indicated for the control of the neurovegetative response, fentanyl or remifentanil use is considered without significant differences [21].
