C.2. Discuss the induction and management of anesthesia for cleft lip and palate in this nonsyndromic, otherwise healthy infant.
Answer:
After suitable monitors are attached, anesthesia is induced with 100% oxygen and an inhalational agent, most commonly sevoflurane (or halothane in countries where sevoflurane is not available). Once the patient is unresponsive, an intravenous line is established, and appropriate intravenous fluids are started. Spontaneous ventilation should be maintained if any possibility of difficulty with tracheal intubation exists until the glottic opening is visualized. Otherwise, intubation can be facilitated with a nondepolarizing neuromuscular blocking agent.
Laryngoscopy in patients with cleft lip is generally straightforward, but the cleft palate has the capability to trap and immobilize a straight blade. Should this occur, the anesthesiologist must first recognize the problem and then consider inserting a gauze pack or a dental roll in the cleft before laryngoscopy.
To achieve a cosmetic repair, symmetry is essential, so the endotracheal tube (ETT) should exit the mouth in the midline without facial distortion from either the ETT or the securing tape. Some surgeons prefer to suture the ETT to the lower gum.
An orogastric tube should be passed to empty the stomach of gas and secretions, and removed before preparation of the surgical field.
A pharyngeal pack of moistened ribbon gauze is inserted for cleft lip repair; for cleft palate repair, the surgeon inserts the gag before insertion of the pharyngeal pack. Following the gag and pack insertion, ventilation should be reassessed because tube compression may have occurred. To avert eye injury, an ocular lubricant is placed, and the upper eyelids are secured closed with tape.
The recommended maximal dose of lidocaine from surgical infiltration for palate or lip surgery is 5 mg/kg and of epinephrine 10 µg/kg. This epinephrine dose is for hypocarbic or normocarbic patients.
During the surgery, it is necessary to have good communication and cooperation between the surgeon and the anesthesiologist due to the very small yet important shared space.
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