*3.2.2 Endotracheal intubation*

*Current Treatment of Cleft Lip and Palate*

22% in cleft palate [13, 19].

mentioned.

**3.1 Monitoring**

thetic [16, 18].

sequence, and velocardiofacial syndrome [2, 13, 15].

of reducing risks of adverse events [3].

**3. Transanesthetic management**

**3.2 Anesthetic technique used**

*3.2.1 Anesthetic induction*

with a cleft lip with bilateral defect, and in cases of cleft palate, the difficulty in laryngoscopy and intubation is related to age, at a younger age difficulty [3, 18]. Patients with CLP can present various malformations without integrating a specific craniofacial syndrome; approximately 70% of cases of CLP and 50% of isolated cleft palate are considered non-syndromatic. A higher ratio of malformations has been found in patients with CLP (32%) than 11% in isolated cleft lip or

There are about 500 craniofacial syndromes related to the pathology that increase the probability of difficult airway (8.4%) and the risk of perioperative adverse events; the most frequent are Treacher Collins, Goldenhar, Pierre Robin

As part of the comorbidities, the literature reports that 5–10% of patients have some congenital heart disease [7, 13]. The possibility of chronic respiratory symptoms such as rhinorrhea, chronic airway obstruction, and sleep apnea [3, 19] is also

Given the history of upper airway infection, it is suggested that surgery be deferred for 2 weeks and in lower airway infections for 4 weeks with the objective

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 transanes-

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].

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,

Specifically in patients with cleft lip and palate, the use of inhalation induction

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

techniques with sevofluorane or intravenous with propofol is more frequently

tachycardia, and increased intraocular or intracranial pressure [21].

**54**

referred to.

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, laryngospasm, and bronchospasm are reported [21].

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

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 180 seconds with low incidence of cough [22].

The use of neuromuscular blockers is controversial. It is a fact that they provide 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 mentioned [22, 23].

Any of the techniques can be effective, the decision will depend on the characteristics and needs of each patient [3].

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

#### *3.2.3 Airway management*

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 lip and palate from 4.7 to 8.4% representing a greater risk of difficulty in airway management and adverse respiratory events [2, 26, 27].

In 2002 Bordet reported an incidence of airway-related complications of 7.87% in children under general anesthesia, varying according to the type of instrumentation used: 7.4% with endotracheal tube and 10.2% with laryngeal mask [3].

The anatomical characteristics of the airway corresponding to the age group and those of the pathology are related to difficulties in the management of the airway at any time during the perioperative period, induction (ventilation, laryngoscopy, intubation), transanesthetic, extubation, or early postanesthetic period with varying severity, requiring pediatric intensive care unit [17].

On the other hand, more than 500 related craniofacial syndromes such as Treacher Collins, Goldenhar, or Pierre Robin sequence increase the probability of difficult airway. Other related syndromes in the literature are Down syndrome, DiGeorge syndrome, and Marfan syndrome [2, 7, 13, 15].

Some researchers have established situations with a higher risk of adverse events during airway management; there is talk of difficult laryngoscopy in the presence of facial deformities such as micrognathia or bilateral complete fissures due to difficulty in positioning the laryngoscope blade altering the line of sight when falling into the left cleft. There is a greater likelihood of risks in patients with cleft lip with bilateral defects, while the difficulty in laryngoscopy and intubation in patients with cleft palate is related to age, being older at a younger age [3, 18].

A larger number of laryngoscopies performed increases the likelihood of adverse events such as trauma and edema of the airway, laryngospasm, and bronchospasm. Airway management in patients with CLP has been studied for more than 70 years, increasing throughout history the indirect devices and techniques for the pediatric population that favor airway manipulation such as laryngeal masks, video laryngoscopes, and fibrobronchoscopies in their different versions; however, direct laryngoscopy without stiletto remains the most widely used method [14].
