AIC Kijabe Hospital Anesthesia Protocol for Cleft Palate Surgery

Aim: To optimize perioperative care for patients undergoing cleft palate reconstruction at AIC Kijabe Hospital

Included Procedures

  • Cleft palate repair
  • Combined cleft lip and palate repair
  • Cleft palate revision

Key Points

Cleft lip and palate is one of the most common congenital abnormalities and may cause speech and feeding problems throughout childhood. Repair of cleft lip and palate has important clinical and social advantages. Airway complications are the most significant postoperative concerns. Patients with significant comorbidities are at increased risk of complications.

Elements

Preoperative assessment

a. Consider delaying lip surgery past 3 months of age, and palate surgery past 6 months of age

b. Evaluation: should include birth history including gestational age, patient and family anesthetic history, and presence of any comorbidities

  • Abnormal facial features (small chin, craniosynostoses), heart murmur, or pulmonary abnormalities may indicate significant comorbidities that require further evaluation

  • All patients should receive CBC with minimum preoperative Hgb of 10g/dL

  • Chest x-ray, ECG or echocardiogram may be obtained if history or physical exam suggests cardiac or pulmonary abnormalities

c. URI: A patient with active lower respiratory tract (infection rales or wheezes on exam, pulmonary symptoms), or upper respiratory tract infection with systemic symptoms (fever, malaise) must have surgery delayed by 4-6 weeks. Patients with mild upper respiratory tract infections or symptoms may proceed on a case by case basis.

d. Airway: The presence of cleft lip or palate does not necessarily indicate difficult airway management; however, evidence of mandible hypoplasia, bilateral cleft palate, and craniosynostosis may indicate increased airway risk.

e. Nutritional status: should be assessed by checking weight appropriateness for age and growth rate, with patients who are undernourished advised on supplemental feeding plans for 2-4 weeks prior to operation

Preoperative preparation

a. Theatre set-up: should include all appropriately sized pediatric anesthesia equipment (circuit, facemasks, ETT, oropharyngeal airways, laryngoscope and blades, bougie, stylet, self-inflating resuscitation bag). Theatre should be warmed for younger patients or forced-air warmer used.

b. Postoperative admission plan: should be determined in advance especially if ICU bed is anticipated. Any patient with significant airway obstruction at baseline (e.g., Pierre-Robin sequence) or comorbidities should be monitored in an ICU postoperatively for 12-24 hours.

c. Patient NPO status: should be minimized with intake of clear liquids surgery encouraged. Breast feeding up to 3 hours before surgery. If a PIV is placed, then maintenance fluid may be administered prior to surgery.

Intraoperative management

a. Access: should include 1 PIV

b. Monitoring: should include all standard monitors (ECG, pulse oximeter, non-invasive BP with appropriately sized cuff, etCO2) and temperature monitoring, if available

c. Airway: If available, a pre-formed oral RAE endotracheal tube is preferred and should be well-secured (using pink tape if possible) below the lower lip. A cuffed ETT is preferred to reduce leak, and the cuff should not be over-inflated (check leak for less than 20 cmH2O).

d. Induction: may proceed with inhalation or IV induction. For patients where airway management is a concern, a spontaneously breathing technique (volatile or ketamine) is required. Some lip abnormalities may make mask seal difficult, and oropharyngeal airway may be required. As long as mask ventilation is adequate, intubation with muscle relaxants may make improve first time success.

e. Fluids: should replace fluid deficits with isotonic fluids (Ringer’s lactate or Hartmann’s preferred) and avoid excessive fluid administration by using standard maintenance and surgical formulas.

f. Antibiotic dosing with standard antibiotic of choice should be given before incision.

g. Local anesthetic infiltration: by the surgeon is recommended with 1% lidocaine with 1:200,000 adrenaline. The toxic dose of lidocaine with adrenaline is 7mg/kg, and the dose of adrenaline should be less than 5mcg/kg (or 1cc/kg) when halothane is used. Infraorbital nerve blocks can also provide excellent analgesia.

h. Positioning: usually requires a head ring and roll under the patient’s shoulders. Special attention to the ETT should take place and bilateral breath sounds assured. A throat gag will be placed and removal prior to emergence must be confirmed.

i. Anesthetic maintenance: may be used with volatile agent. Analgesia should be provided with rectal or IV paracetamol. Cleft lip repairs may also receive fentanyl 1-2 mcg/kg, and more painful cleft palate repairs may receive longer acting opioids such as morphine 50-100mcg/kg. The stomach should be suctioned prior to emergence, and any additional suctioning of the mouth should be done cautiously to avoid disturbing the wound. Dexamethasone 0.2-0.5mg/kg should be given, when available, to reduce airway swelling.

Critical events

a. As with other shared airway cases, ETT disconnection, obstruction by kinking, or extubation can occur. This requires close communication with the surgeon, secure ETT placement, and attention to changes in positioning.

b. Airway fires can occur any time there is cautery in the airway. Review airway fire procedures, and if a fire occurs then stop gas flow, flood the field with saline, remove the ETT, re-establish ventilation and reintubate the patient. Close monitoring for airway swelling or prolonged intubation may be required.

c. Airway obstruction can occur postoperatively from airway swelling. For cases longer than 2 hours, the surgical suspension should be relaxed for 5-10 minutes every hour to reduce the risk of tongue ischemia and swelling. If obstruction occurs, discuss placement of a nasal airway with the surgeon. Nasal airway may also be place prior to emergence by the surgeon if obstruction is likely. Oral airway placement has a high risk of disrupting the surgical repair. Tongue suture placed by the surgeon is another option for patients with predicted severe airway obstruction postoperatively.

Postoperative management

a. Patients should arrive to PACU awake and breathing spontaneously without additional support. They must remain under supervision in PACU until they are fully awake, pain is controlled and there is no evidence of nausea, vomiting or postoperative bleeding.

b. Respiratory monitoring is vital and postoperative airway obstruction may occur with patients who have preoperative airway problems. Prone or lateral positioning may improve ventilation for patients with airway swelling. A patient with desaturation that does not improve with any of the above measures is an emergency and should return to theatre for management.

c. IV fluids should be continued until patients are able to tolerate adequate oral intake.

d. Analgesia should include scheduled paracetamol every 6 hours, NSAIDs for patients over 6 months, and intermittent opioids if necessary.

Resources

SmileTrain Best Practice Resources

Rawlinson, E. “Postoperative Airway Complications After Cleft Palate Repair.”. Anesthesia Tutorial of the Week. 2011.