1. Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics Ph D physiology. Mahatma gandhi medical college and research institute, puducherry, India

2. Incidence  one child in every 700 is born with a cleft.  For India, this translates into over 35,000 babies born each year with this condition

3. Variations  CLP is more common in males  cleft lips are usually left-sided.  Unilateral cleft lip 25%  Unilateral cleft lip and palate 25%  Bilateral cleft lip and palate 10%  Cleft palate alone 40%

4. Causes  “multi-factorial”  genetic predisposition  environmental issues such as drug and alcohol use, smoking,  maternal illness, infections  and lack of vitamin B folic acid

5. Why it happens ??  clefts arise because of failure of fusion or  breakdown of fusion between the nasal and maxillary processes and the palatine shelves that form these structures at around 8 weeks of life.

6. Incomplete, complete, bilateral

7.  CL may be reliably diagnosed at the 18- 20 week scan.  CP is harder to see and can only be excluded on examination after delivery.

8. In 1912 – a surgeon wrote  the difference to the surgeon, between doing a cleft palate operation with a thoroughly experienced anaesthetist and an inexperienced one, is the difference between pleasure and pain!

9.  Cleft lip cosmetic – tube fixing  Turnbul connection – invention of Bains

10. Preanaesthetic check up  standard preoperative history and examination  Special :  Associated congenital abnormalities  Pierre robin  Treacher collins  Goldenhar Syndrome

11. Preanaesthetic check up Pierre robin Treacher collins

12. This is not golden hair syndrome

13. Anaesthesia  Surgery is usually performed at 3 months for cleft lip repair 6 months for cleft palate  It may be delayed by the investigation of other problems or on-going airway difficulties – discussion

14.  Waiting until 3 months of age gives time to detect most congenital abnormalities, and allows anatomical and physiological maturation.

15. Rule of 10- for cleft lip repair  10 weeks of age  10 gm% of Hb  TC < 10000  10 pounds weight

16. Preanaesthetic check up  Congenital heart disease occurs in 5 - 10% of these patients  Chronic rhinorhoea.  This is common in children presenting for cleft palate closure and is due to reflux into the nose during feeds

17. Preanaesthetic check up  a history of snoring or obvious airway obstruction during sleep.  Anticipated difficult intubation.  Right ventricular hypertrophy and cor pulmonale may result from recurrent hypoxia due to airway obstruction

18.  Upper respiratory tract infections are particularly common at this age and carry an increased risk of airway complications and impaired wound healing  Appropriate antibiotics  Explanation to mother  nutrition

19. Haberman nipple

20. If not repaired  Feeding  Speech  Secretory otitis media  Cosmetic

21. Premed  Sedative premedication – NO  the risk of airway obstruction  Atropine if necessary  Antibiotics  Oral paracetamol – 20 mg/kg

22. Induction  Inh. Halo or sevo  Iv access  Agent/ suxa / NDPs for intubation  No relaxants if mask ventilation is inadequate  Mask easy but tube difficult?

23. Difficult laryngoscopy  Difficult laryngoscopy (Cormack and Lehane views grade III or IV) occurs in up to 10% of ASA I patients for CLP repair.  Large alveolar defects may hamper laryngoscopy, a tendency for the laryngoscope to fall into the cleft; Packing with gauze, use of a straight blade may prevent this

24. Equipment  RAE tube  Armoured tube  Well fixed  JRMATP  ETCO2 monitoring must to detect accidental extubation

25. Other options  LMA has been successfully used to allow CLP repair in a child in whom intubation had proved impossible  more bulky, less secure than an endotracheal tube and its routine use is not advised.  Armoured LMA  Fibreoptic intubation - skilled personnel

26. Dingman retractor check again

27. Anaesthesia - tricks  oral pack to absorb blood and secretions.  A head ring and a roll under the shoulders is frequently used  local anaesthetic and adrenaline into the surgical field to reduce blood loss and improve the surgical field. It also provides some intraoperative analgesia

28. Controlled Vs spont  Spont  Ok if extubates  But small infants ??  Controlled better

29. Periop pain relief  Morphine sulphate 0.1-0.2mg/kg intravenously is commonly used and provides good early postoperative analgesia. Fentanyl – choice  The use of opioids results in a smoother emergence and less crying on extubation. This reduces trauma to the airway and decreases the risk of postoperative bleeding.

30. Concerns  IV fluids  Blood for cleft palate repair  Temperature, NMJ  Postop analgesia  Suctioning cautious  No airway  Tongue stitch

31. Logan bow and elbow restraints

32. Regional anaesthesia  Infra orbital block  The infraorbital nerve  supplies sensory  innervation to the  lower eyelid,  the side of the nose,  and the upper lip

34.  Extraoral approach  intraoral approach  Don’t pierce the foramen  Give 2-3 ml of LA

35. No usg guided infraorbital nerve block

36. Post op airway obstruction  Gag induced edema  postoperative airway obstruction include  subglottic edema,  flap edema,  increased oral secretion,  posterior displacement of the tongue, and an overlooked throat pack

37.  In the postoperative period, arm restraints, which prevent elbow flexion, are routinely used to keep the child's hands away from the child's face.  Later naso tracheal tube??, tonsillectomy???

38. Summary  35,000 births in india every year??  3 months & 6 months(speech, feeds, otitis.cometic)  Look for other anomalies and airway  Premed – para  Induction sevo/ thio--- intubate/ LMA  Fixing, positioning ETT  No suction, airway, smooth ext.  Regional for analgesia 

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