cleftlip
TRANSCRIPT
CLEFT LIP / PALATEANAESTHESIA MANAGEMENT
Dr.P.NARASIMHA REDDY MD;DA
Prof.&HOD. of AnaesthesiologyNarayana Medical College Nellore.
ANDHRAPRADESH.
DEFINITIION
1. Defect in the Lip
2. Defect in the Palate
3. Defect in Lip & Palate
Our problems
1. Anaesthesia for infant / Paediatric patients
2. Due to Clefts &
3. Other associated anomalies
Incidence
1. More in Asians
2. Lip common in males
3. Palate common in females
4. Genetic influence more common in CLP
EMBRYOLOGY
1. Face is formed by 5 process which surround stomodium.
2. Frontonasal one
3. Maxillary one + one
4. Mandibular one + one
5. Olfactory pits appear at fifth week of IUL
6. One on either side of midline, inferior aspects of FNP
EMBRYOLOGY contd..
7. FNP is divided into a) Central M.N. process &
b) Lateral nasal processes (two)
8. Olfactory Pits become nares
9. MNP form septum, philtrum & premaxilla
10. LNP forms side of the nose
EMBRYOLOGY contd..
11. Maxillary process forms cheek, whole upper lip, upper jaw & part of palate.
12. Mandibular process forms lower jaw.
13. So, UPL is formed by MNP + LNP on each side.
14. Failure to fuse MNP+LNP = Cleft Lip
EMBRYOLOGY contd..
15. Palate is formed by 3 components.a) Premaxilla is developed from MNP
b) 2 + 3 is from palatine process of Maxilla
16. Prepalatal (primary) Clefts are caused by lack of mesodermal development, one central + 2 lateral process (failure to fuse).
17. Post palatal (secondary) Cleft is due to failure of palatal ridges to rotate and fuse at 10-12 WKs of IUL.
CLASSIFICATION
1. Cleft Lip complete, incomplete, unilateral & bilateral.
2. Cleft palate primary, secondary, complete, incomplete, unilateral & bilateral.
3. Submucosal.
GENETICS
1. More clefts are described syndromic.
2. FOGH – ANDERSON – genetic study 1942.
3. Syndromes are a) P.R.Syndrome.
b) T.C.Syndrome.
c) Goldenhar Syndrome etc..
AETIOLOGY
1. Interaction between genetic & environmental factors.
2. Environmental factors triggers Clefting.
3. Gene TGFA.
PATHOPHYSIOLOGY
1. Pharynx is communicating with nasal fossae & oral cavity.
2. Complex process like swallowing, breathing, hearing & speech are impaired.
3. Feeding problems.4. Eustrachian tube is blocked, middle ear
infections.5. Due to regurgitation of feeds – Chronic
rhinorrhoea.
PATHOPHYSIOLOGY cont…
6. Tooth & alanasai development delayed.
7. Velopharyngeal function defective.
8. Psychological problems at the time of school age.
9. Speech problems.a) Plosives P/K/D/T
b) Fricatives S/SH/F
MEDICAL THERAPY
1. Risk of aspiration.
2. Airway obstruction.
3. Feeding difficulties.
MEDICAL THERAPY Cont..
4. Multidisciplinary approach a) Paediatrician b) Nurse practioner c) Plastic surgeon d) Dentist e) ENT specialistf) Genetist g) Speech therapist h) Psychologisti) Pead.Surgeon & finally Anaesthetist
TIMING OF SURGERIES
1. 3/12 - CL repair
2. 6/12 - Presurgical Ortho dantist.
3. 9/12 - Speech therapy
4. 9/12-1 – CP repair (development ? )
5. 1-7 yr - Ortho dantic
ANAESTHETIC MANAGEMENT It includes
1. Preparation of the patients.
2. Preparation of the parents/Grand parents.
3. Fasting guidelines &
4. Lab investigations
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.
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
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
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.
ANAESTHETIC MANAGEMENT Con. Rule of ten
Wt 10lbs, Hb 10 gr% and 10 Wk age. Monitors
Spo2
Etco2
ECG Temp. Blood loss estimation Precardial steth.
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
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.
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!
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
ANAESTHETIC MANAGEMENT Con. Extubation
Coup Obstruction No airways inserted Minimum suction Tongue stitch Lateral / prone position
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
ANAESTHETIC MANAGEMENT Con. In difficult situations
Awake intubation Fibre optic intubation Retrograde intubation also tried