Cleft Lip / Palate Repair
Patient phenotype
Cleft lip: typically 3-6 months, healthy infant. Cleft palate: 9-18 months. Some with syndromes (Pierre Robin, 22q11, Stickler, Treacher Collins) — difficult airway. Often otitis media + URI.
Procedure
Lip: 1-2 hours, simpler. Palate: 2-4 hours, palatal mucosa elevated, layers closed. Position: supine, head extended (Rose position). Surgeon shares airway.
Anesthetic plan
GETA with oral RAE tube (south-pointing, secured midline-down) or nasal RAE for some surgeons. Inhalational induction + IV after asleep. Caudal block or palatal infiltration for postop pain.
Setup
- ·Pediatric circuit + warmed
- ·Oral RAE (or nasal) ETT
- ·Tape + reinforced fixation midline (surgeon shares airway)
- ·Tonsillectomy table or shoulder roll
- ·Bilateral preoxygenation (small lungs)
- ·Drugs: dex (PONV + edema), ondansetron, acetaminophen IV, dilute opioid
Biggest concerns by phase
Difficult airway in syndromic patient
Pierre Robin = micrognathia + glossoptosis + cleft palate → very difficult mask + intubation. Have video laryngoscope, supraglottic airway, fiberoptic. Awake fiberoptic in some neonates. Consult senior anesthesiologist.
URI + recent illness
Cleft kids have frequent OM + URI. Bronchospasm + laryngospasm risk elevated for 2-4 weeks post-URI. Postpone if active illness, fever, or wheeze. Mucus discussion with parents.
Inhalational mask induction with sevoflurane
Sevo 8% mask + 100% O₂. Once asleep: IV (often hand or scalp), then secure airway. Mask seal can be challenging with cleft lip — wet gauze in cleft helps seal.
Shared airway — secure tube
Surgeon places mouth gag (Dingman) — can dislodge or kink ETT. RAE tube taped to lower lip midline. Confirm bilateral breath sounds + ETCO2 after gag placement. Recheck if surgeon repositions.
Blood loss + hypotension
Vascular palate. EBL up to 10% of blood volume in palate cases. Type & screen mandatory; transfusion uncommon but available. Maintain MAP for cerebral perfusion (small infants).
Airway edema + extubation strategy
Edema after palate manipulation. Awake extubation, suction blood/clots, position lateral. Post-extubation airway obstruction common — humidified O₂, racemic epinephrine ready. Some prefer overnight monitoring.
Pain + feeding + airway
Multimodal pain: scheduled acetaminophen + dilute morphine PRN. Avoid heavy opioid (apnea). Soft diet. Arm restraints to prevent pulling on suture line.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
10-month-old with cleft palate, 6.5 kg, mild URI 1 week ago (resolved). Soft palate repair scheduled. Plan for airway + intraop?
What an examiner probes for
- ▹URI risk window
- ▹Inhalational induction + careful airway secure
- ▹Oral RAE midline-down
- ▹Caudal or palatal infiltration analgesia
- ▹Awake extubation + post-extubation monitoring
Sources
- Coté Pediatric Anesthesia 6e Ch 25
- Smith's Anesthesia for Infants and Children
Anatomy reference
Sourced reference images. 4 matches for "facial mouth oral".
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