Cleftlip
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This document discusses cleft lip and palate, including the embryology, causes, classifications, genetics, pathophysiology, and anesthetic management for surgeries to repair cleft lip and palate. It notes the multidisciplinary teams involved and describes in detail the considerations and procedures for anesthetizing infants and children undergoing cleft lip and palate surgeries, including airway management, monitoring, induction, maintenance, extubation, and postoperative care.
Cleftlip
- 1. CLEFT LIP / PALATE ANAESTHESIA MANAGEMENT
- 2. Dr.P.NARASIMHA REDDY MD;DA Prof.&HOD. of Anaesthesiology Narayana Medical College Nellore. ANDHRAPRADESH.
- 3. DEFINITIION Defect in the Lip Defect in the Palate Defect in Lip & Palate
- 4. Our problems Anaesthesia for infant / Paediatric patients Due to Clefts & Other associated anomalies
- 5. Incidence More in Asians Lip common in males Palate common in females Genetic influence more common in CLP
- 6. EMBRYOLOGY Face is formed by 5 process which surround stomodium. Frontonasal one Maxillary one + one Mandibular one + one Olfactory pits appear at fifth week of IUL One on either side of midline, inferior aspects of FNP
- 7. EMBRYOLOGY contd.. FNP is divided into Central M.N. process & Lateral nasal processes (two) Olfactory Pits become nares MNP form septum, philtrum & premaxilla LNP forms side of the nose
- 8. EMBRYOLOGY contd.. Maxillary process forms cheek, whole upper lip, upper jaw & part of palate. Mandibular process forms lower jaw. So, UPL is formed by MNP + LNP on each side. Failure to fuse MNP+LNP = Cleft Lip
- 11. EMBRYOLOGY contd.. Palate is formed by 3 components. Premaxilla is developed from MNP 2 + 3 is from palatine process of Maxilla Prepalatal (primary) Clefts are caused by lack of mesodermal development, one central + 2 lateral process (failure to fuse). Post palatal (secondary) Cleft is due to failure of palatal ridges to rotate and fuse at 10-12 WKs of IUL.
- 14. CLASSIFICATION Cleft Lip complete, incomplete, unilateral & bilateral. Cleft palate primary, secondary, complete, incomplete, unilateral & bilateral. Submucosal.
- 15. GENETICS More clefts are described syndromic. FOGH – ANDERSON – genetic study 1942. Syndromes are P.R.Syndrome. T.C.Syndrome. Goldenhar Syndrome etc..
- 16. AETIOLOGY Interaction between genetic & environmental factors. Environmental factors triggers Clefting. Gene TGFA.
- 17. PATHOPHYSIOLOGY Pharynx is communicating with nasal fossae & oral cavity. Complex process like swallowing, breathing, hearing & speech are impaired. Feeding problems. Eustrachian tube is blocked, middle ear infections. Due to regurgitation of feeds – Chronic rhinorrhoea.
- 18. PATHOPHYSIOLOGY cont… Tooth & alanasai development delayed. Velopharyngeal function defective. Psychological problems at the time of school age. Speech problems. Plosives P/K/D/T Fricatives S/SH/F
- 19. MEDICAL THERAPY Risk of aspiration. Airway obstruction. Feeding difficulties.
- 20. MEDICAL THERAPY Cont.. Multidisciplinary approach Paediatrician Nurse practioner Plastic surgeon Dentist ENT specialist Genetist Speech therapist Psychologist Pead.Surgeon & finally Anaesthetist
- 21. TIMING OF SURGERIES 3/12 - CL repair 6/12 - Presurgical Ortho dantist. 9/12 - Speech therapy 9/12-1 – CP repair (development ? ) 1-7 yr - Ortho dantic
- 22. ANAESTHETIC MANAGEMENT It includes Preparation of the patients. Preparation of the parents/Grand parents. Fasting guidelines & Lab investigations
- 23. ANAESTHETIC MANAGEMENT Con. It is team approach Mortality & morbidity due to airway difficulty. Proper history & examination of the child. Searching for any other congenital abnormalities. 10-15 % cardiac problems. Ch. Rhinorrhoea, Ch.airway obstruction, right ventricular hypertrophy & corpulmonale.
- 24. ANAESTHETIC MANAGEMENT Con. Nutrition & hydration Premedication Sedative premedication – midazolam, not indicated in CP Fentanyl 1-2 mikes/kg followed by rectal paracetamol 20-40 mg/kg
- 25. ANAESTHETIC MANAGEMENT Con. Fasting guidelines Clear fluides Breast milk Cow milk Solids 3 months 2 4 4 6 3-12 2 4 6 6 Child 2 - 6 6
- 26. ANAESTHETIC MANAGEMENT Con. Lab investigations Hb % and cross matching if blood loss is expected Any other relevant investigation depending on the complaint and system involved.
- 27. ANAESTHETIC MANAGEMENT Con. Rule of ten Wt 10lbs, Hb 10 gr% and 10 Wk age. Monitors Spo 2 Etco 2 ECG Temp. Blood loss estimation Precardial steth.
- 28. ANAESTHETIC MANAGEMENT Con. Induction Inhalational Halothane / sevoflurane IV induction Thio / propofol Intubation Blade slipping into Cleft Airway abnormalities ET tubes Oral RAE reinforced tubes Mouth gauges Dingman, Dot , pressure on the tube
- 29. ANAESTHETIC MANAGEMENT Con. Anaesthesia circuit Jackson rees modification of Ayre’s Tpiece Position of the patient For lip a roll under the shoulder For palate pillow under the body of the patient and head hyper extended. Throat pack inserted Accidental extubation Tube fixation should not alter facial symmetry.
- 30. ANAESTHETIC MANAGEMENT Con. Ventilation Spontaneous for lip only? Controlled – ideal Less Co2 Less bleeding Rapid recovery Local analgesia Lidocaine with Adri. (5-10 mikes) Bil.infra.orbi.block No NSAIDS!
- 31. ANAESTHETIC MANAGEMENT Con. Muscle relaxants Scoline for intubation Vecuron for maintenance Fluids Isolyte P+0.45 saline calculating starvation time per op losses. Blood loss more than 10% transfuse blood. Early post op oral fluids Temperature Avoid hypothermia
- 32. ANAESTHETIC MANAGEMENT Con. Extubation Coup Obstruction No airways inserted Minimum suction Tongue stitch Lateral / prone position
- 33. ANAESTHETIC MANAGEMENT Con. Post op management See for blood loss Airway obstruction Hypoxia Post op analgesia Morphine / pethidine / pentazocine in correct calculated doses avoiding sedation Local blocks Rectal medication
- 34. ANAESTHETIC MANAGEMENT Con. In difficult situations Awake intubation Fibre optic intubation Retrograde intubation also tried
- 44. THANK YOU