Current Anaesthesia & Critical Care (2002) 13, 87^91 2002 Published by Elsevier Science Ltd.cdoi:10.1054/cacc.2002.0384, available online at http://www.idealibrary.com onFOCUS ON: BURNS AND PLASTICSAnaesthesia for plastic surgery in childrenS. M. FenlonAnaesthetic Department, QueenVictoria Hospital NHS Trust, East Grinstead, West Sussex RH19 3DZ, UK KEYWORDS Summary Children constitute a signi¢cant and interesting part of the workload in surgery, plastic, paediatrics, plastic surgery Many congenital and acquired problems are referred for sole or joint in- . anaesthesia volvement with plastic surgeons. In the same way that surgeons have narrowed their focus to areas of special interest, so have anaesthetists. Paediatric practice has become a sub-specialty within anaesthesia, and the ¢eld of plastic surgery in the paediatric po- pulation is a further branch to this specialization.The onus is on those currently practi- cing to maintain and improve standards, even in areas where the surgery or anaesthesia appears mundane. As in all areas of paediatric practice, the nature of the work requires adaptability to the often unusual, and occasionally unexpected; whilstconstantly striving to maintain as friendly and supportive an environment as possible for apprehensive chil- dren and their parents. Many of the children will attend for further surgery and their outlook is easily tarnished by one bad experience. 2002 Published by Elsevier Science Ltd. cINTRODUCTION the UK. Cleft lip and usually cleft palate are obvious at birth, though associated abnormalities may be moreThe earliest accounts of attempted constructive and re- subtle and continuous involvement of paediatriciansconstructive surgery without anaesthesia make for har- prior to and during cleft repair is essential.4 Many suchrowing reading.The early pioneers in plastic surgery not associations have now been described,5 and doubtlessonly alleviated their patient’s su¡ering, they made sur- more will come to light together with further de¢nitiongery both safer and more e¡ective.1 of the genetic component. Some conditions have major Plastic surgery caters for patients of all ages, and in its implications for the anaesthetist, particularly abnormalpaediatric branch presents patients from birth to teen- airway anatomy; others such as cardiac defects may in-agers. Anaesthetists undertaking this work should meet £uence the optimal timing and location of surgery.6 Ofthe requirements suggested by a number of bodies at- particular relevance is the Pierre Robin Sequence of mi-tempting to limit ‘occasional practice’ in paediatric anaes- crognathia, large tongue and airway obstruction. Thesethesia.2 Sta⁄ng of wards, recovery and other areas children are more likely to cause di⁄culty in airway man-within the hospital, as well as the hospital environment agement during induction of anaesthesia and in the post-itself, must meet certain standards.3 operative period.7 However, the condition improves This article is divided according to the procedures with age and a scoring system may help identify thosemost commonly performed at this institution. Many who should have surgery delayed to allow the airway toareas such as burns management are dealt with else- improve.8where in this issue, and detail is limited to avoid unneces- Occasionally, the child with CLAP also has di⁄culty insary repetition. feeding, and further to this may su¡er the e¡ects of re- peated pulmonary aspiration.9 Failure to thrive may have other aetiologies, which should be excluded. FeedingCLEFT LIP AND PALATE SURGERY aids, a period of nasogastric tube feeding, and airwayPrimary cleft lip and palate (CLAP) surgery presents support such as nasopharyngeal airway insertion maysome of the youngest patients. CLAP is one of the most be needed to help overcome some of the problems thesecommon congenital malformations, and may be diag- babies su¡er.10 Early communication between surgeon,nosed in the antenatal period by ultrasound scanning. anaesthetist, and other members of the cleft team isThe incidence is between 1:300 and 1:600 live births in vital in dealing with these complicated cases. The timing of surgery is governed by the desire for anCorrespondence to: SMF. aesthetic result and furthering development of normal0953-7112/02/$^ see front matter
88 CURRENT ANAESTHESIA & CRITICAL CAREspeech and dentition, but tempered by the practical con- analgesics postoperatively, preferring instead to use co-siderations of operating on very young children. Primary deine. It has been shown that the pharmacokinetic andcleft lip repair is usually undertaken at 3 months of age, analgesic properties of morphine are similar in youngand palate repair between 6 and 9 months when mouth children to adults. If required, morphine can be usedbreathing is established.4 The present tendency towards safely in appropriate doses as long as there is adequateearlier palate repair aims to improve speech develop- postoperative observation.22 Codeine phosphate mayment. Neonatal lip repair, at one time more widely prac- be insu⁄cient, and it may be that other opioids could beticed, is now uncommon in this country.11 Intra-uterine more e¡ectively employed in the paediatric population.23repair, whilst established in animal models, has not yet Surgery may be prolonged, and adequate precautionsbeen extended to humans.12 All babies require an estima- against hypothermia should include temperature moni-tion of pre-operative haemoglobin as many have a phy- toring and forced air warming blankets. Accurate mea-siological anaemia at the time of surgery for cleft lip. surement of blood loss is di⁄cult, though an attempt There are studies supporting the use of oral atropine can be made to judge the amount collected on swabsas a premedicant, though the observed incidence of oxy- and in suction apparatus. In palate surgery, losses aregen desaturation was not reduced in the study by Shaw usually replaced with crystalloid infusion.24 Someet al.13 In this hospital, we do not usually premedicate authors quote signi¢cant rates of blood transfusion fol-these children. Our practice is to induce anaesthesia by lowing CLAP surgery, though in our own experienceinhalation with sevo£urane in 100% oxygen; intravenous the need for transfusion is rare.25 On completion of sur-access, if not previously established, is then secured. gery, the oropharynx is inspected to remove the throatOnce a suitable depth of anaesthesia is reached, con¢r- pack and any blood clot, and to assess any continuingmation of facemask ventilation is followed by paralysis bleeding.There is an association between slow recoveryachieved with either a depolarizing or a longer acting and postoperative airway obstruction and time shouldmuscle relaxant.We favour the latter. Di⁄cult face mask be allowed for adequate elimination of anaestheticventilation is extremely rare, though a di⁄cult view at agents.24laryngoscopy is a more frequent ¢nding and can to some The child is extubated when fully awake, and supple-extent be predicted pre-operatively.14 Use of a straight mentary oxygen given by mask. At this time, particularlaryngoscope blade, the lateral or molar approach, and attention is paid for signs of airway obstruction.This mayexternal laryngeal manipulation can help, as may a piece occur at any part of the upper respiratory tract. If seen,of gauze packed into the cleft lip.15,16 Techniques employ- thought should be given to possibilities such as upper air-ing the laryngeal mask and ¢breoptic bronchoscope have way narrowing, blood clot, retained throat pack, tonguebeen described.17 As mentioned above, if di⁄culty is swelling from retraction, or inadequate mouth breath-encountered, thought should be given to postponing ing. Active management will depend on the aetiology; itsurgery to a later date. The anatomy and neuromuscular may be su⁄cient to apply continuous positive airwayco-ordination of the upper airway may improve pressure for a time. Further to this, careful insertion ofwith age.7 an oro-pharyngeal airway, naso-pharyngeal airway, or Prior to surgery, the airway is secured with an endo- even re-intubation may be needed. Close observationtracheal tube. The preformed RAE type of tube passes continues into the recovery period, again watching forout over the lower lip, where it is ¢xed centrally, allowing signs of airway obstruction or bleeding. Once the childfor optimal surgical access. The shared airway presents is awake, and no bleeding seen, feeding with clear £uidsopportunities for inadvertent extubation at almost any can begin and is usually comforting. Parents are encour-stage.18 A throat pack is used for lip surgery though pa- aged to come and join their child at this time.late surgery is usually conducted without. Anaesthesia is Later in life these children may require further sur-maintained by controlled ventilation with volatile anaes- gery to improve speech quality, dental development andthetic agents. There may be some advantages to using facial appearance. Awake ¢breoptic nasendoscopy allowsdes£urane in this age group for its extremely rapid wash- accurate evaluation of velo-pharyngeal incompetence,out characteristics.19 Intraoperative analgesia is provided and planning of future surgery to improve speech,12 Sur-with fentanyl 1^2 mcg/kg intravenously, in combination gery to improve naso-pharyngeal sphincter function canwith local anaesthetic in¢ltration. For lip repair, infra- compromise the airway postoperatively so close obser-orbital nerve blocks have been shown to be e¡ective20. vation is needed in the recovery period. Paracetamol is commonly prescribed for postopera-tive analgesia, and may be given as a loading doseperi-operatively per rectum. Non-steroidal anti-in£am-matory drugs are used by many paediatric anaesthetists COSMETIC SURGERYfor children from 3 months of age.21 Due to fears of re- The anxiety felt by parents of children having cosmeticspiratory depression and excessive sedation, some procedures may exceed that usually encountered. Theauthors recommend avoiding the use of potent opioid surgery is often performed at their request, and may
ANAESTHESIA FOR PLASTIC SURGERY IN CHILDREN 89not be considered essential by the child at the time. Cos- has not been shown on postoperative pain, this techni-metic surgery in children is usually limited to correction que does allow for reduced anaesthetic use, and providesof prominent ears, removal of small areas of accessory excellent postoperative analgesia.34 Digital transplantstissue, and excision of skin lesions of varying sizes. The require continuous observation of arterial and venouslarger lesions may require serial excision in multiple sur- integrity. This may be augmented by using a pulse oxi-gical episodes. Tissue expanders can be used to provide meter probe attached to the operated digit, and com-a source of local autologous skin by a process of paring measurements with those from a normal digit.35skin expansion.12 Some large skin naevii may have malig-nant potential.26 Pinnaplasty aims to restore the antihelical fold of the TRAUMAexternal ear, thus allowing the pinna to lay parallel to the The case-load of traumatic injury to the face and handshead. In older children, or for single ear surgery, local of children presenting to plastic surgery units is increas-anaesthesia may su⁄ce; but general anaesthesia is usually ing. Though the degree of injury is usually less than thatrequired. Field in¢ltration or regional block with local seen in adults, general anaesthesia is more likely to be re-anaesthesia will both provide excellent postoperative an- quired for the child, particularly in the younger agealgesia.27 Packing the external auditory meatus following groups. These cases should be dealt with by appropri-pinnaplasty causes postoperative nausea and vomiting ately senior sta¡ at arranged times; night-time operatingand is now generally avoided. Nausea and vomiting is is rarely justi¢ed.36 More serious pathology, particularlyfurther reduced by avoiding opioids with a prolonged head injury, may occur in association with otherwise ap-duration of action, maintaining anaesthesia by the intra- parently trivial injury.venous infusion of propofol,28 and the prophylactic ad- Clear guidelines exist for fasting of elective patientsministration of ondansetron.29 and, anaesthetists often apply similar rules to emergency Pre-auricular skin tags are usually removed in the ¢rst cases.37 Whilst each case should be managed on its mer-year of life.They may contain cartilage, but are easily ex- its, a number of individual factors may help make the de-cised under general anaesthesia supplemented with in¢l- cision as to how the airway should be managed.38tration of local anaesthetic.More severe abnormalities of As mentioned above, most trauma surgery is simple,the external ear may occur as part of a syndrome with but occasionally severe tissue loss will need more com-other defects that result from abnormal development of plex surgery with tissue transfer. Environmental tem-the ¢rst and second branchial arches.30 In these cases, perature control, attention to £uid balance calculations,aesthetic correction is undertaken as part of the overall and the use of supplementay regional anaesthetic techni-management of the associated problems. ques where possible are major considerations. Experi- enced postoperative monitoring of both patient and tissue £ap are necessary. Flap donor sites, for example la-HAND SURGERY tissimus dorsi muscle, are not always amenable to regio- nal anaesthesia and postoperative analgesia can be wellCongenital hand deformities range from simple acces- managed by opioid infusion tailored to accepted localsory digits to complete absence of digits and associated guidelines.To this may be added a patient controlled facil-hand structures. Thus, surgery varies from short proce- ity according to the level of understanding of the child.22dures to surgically complex prolonged operations such astoe-to-hand transfer. The anaesthetic management ofsuch cases is usually straightforward, requiring attentionto detail in respect of positioning, temperature control SURGERY FOR THERMAL INJURYand e¡ective analgesia. The surgical tourniquet, occa- Management of acute burns in children is a highly specia-sionally employed in two sites, has the potential to cause lized subject, and initial treatment has as its primary aimpermanent injury and so care should be taken with ap- restoration of skin integrity. Scarring left from thepropriate tourniquet size, padding and duration of use. healed burn and skin grafting may need further surgeryTourniquets are a source of signi¢cant surgical stimulus, to improve the functional and aesthetic result. Theseand may require potent intraoperative analgesia.31 An in- children often make several trips to the operating thea-teresting e¡ect of tourniquet use is its potential to raise tre, and continuity of care is helpful. This permits indivi-core temperature intraoperatively.32 dual likes and dislikes to be catered for, at times when the Regional blocks, particularly the axillary approach to maintenance of even small degrees of control can be verybrachial plexus block, are useful for analgesia. Multiple important to the child.site injections appear to confer no bene¢t over the single Again, the surgery ranges from minor scar revision toinjection in children.33 Insertion of a catheter into the prolonged and extensive reconstruction and anaesthesiaplexus sheath via the axillary approach allows continuous is adapted accordingly following discussion with theblockade to be established. Whilst a pre-emptive e¡ect surgeon. Airway di⁄culties and problems in securing
90 CURRENT ANAESTHESIA & CRITICAL CAREvenous access can prolong anaesthetic induction and 6. Daly H, Moscuzza F. Anaesthesia for the child with congenitaltheatre timings should be adjusted appropriately. Scar- heart disease undergoing non-cardiac surgery. In: Kaufman L, Gins-ring deformity to the upper airway may result in di⁄cult burg (eds). Anaesthesia Review 14. London: Churchill Livingstone, 1998; 57^71.laryngoscopy and, more rarely, di⁄cult face mask venti- 7 HenrikssonT G, Skoog V T Identi¢cation of children at high anaes- . .lation. The former can be managed by laryngeal mask in- thetic risk at the time of primary palatoplasty. Scand J Plast Re-sertion or ¢breoptic-assisted intubation following constr Surg Hand Surg 2001; 35: 177^182.induction of general anaesthesia. The latter represent a 8. Caouette-Laberge L, Bayet B, Larocque Y The Pierre Robin se- .more complex scenario and may require an airway quence: review of 125 cases and evolution of treatment modalities. Plast Reconstr Surg 1994; 93: 934 ^942.to be secured prior to anaesthesia. Achieving this in 9. Tobin M, Stevenson G W, Hall S C. Anesthetic considerations foran awake child is rarely possible and some form of the pediatric plastic surgical patient. Plast Surg Nurs 1994; 14:light anaesthesia will usually be needed to achieve 71^78, 85.co-operation.39 10. Marques I L, de Sousa T V, Carneiro A F, Barbieri M A, Bettiol H, Gutierrez M R. Clinical experience with infants with Robin se- quence: a prospective study. Cleft Palate Craniofac J 2001 Mar; 38: 171^178.HYPOSPADIAS REPAIR 11. Asher-McDade C, Shaw W C.Current cleft lip and palate manage-Hypospadias is a relatively common congenital condition ment in the United Kingdom. Br J Plast Surg.1990; 43: 318 ^321. 12. Sadove A M, Eppley B L. Pediatric plastic surgery. Clin Plast Surgwith an incidence quoted as high as 1:300 live male 1996 23: 139^155.births.40 Other conditions often associated with hypos- 13. Shaw C A, Kelleher A A,Gill C P, Murdoch L J, Stables R H, Black Apadias are undescended testes and inguinal hernia. Iso- E. Comparison of the incidence of complications at induction andlated hypospadiasis is rarely associated with upper emergence in infants receiving oral atropine vs no premedication.urinary tract disorders, and further investigation is not Br J Anaesth 2000; 84: 174 ^178. 14. Gunawardana R H. Di⁄cult laryngoscopy in cleft lip and palate sur-recommended in this group.41 A single- or two-stage re- gery. Br J Anaesth 1996; 76: 757^759.pair is usually carried out at about 3 years of age when 15. Hatch D J. Airway management in cleft lip and palate surgery. Br Jcontinence is established, and co-operation with cathe- Anaesth 1996; 76: 755^756.terization is better.General anaesthesia is supplemented 16. Brown J M. Anaesthesia for cleft surgery. In: Patel H (ed.). Anaes-with a caudal block to minimize opioid use and lead to a thesia for Burns, Maxillofacial and Plastic Surgery. London: Edward Arnold,1993; 43^52.smooth pain-free recovery.Various methods of prolong- 17 Andrews P J, Marchant R B. A new technique for di⁄cult intuba- .ing the block have been described.41,42 Children will have tion in babies.Technic 1995; 143.an indwelling urinary catheter, usually per urethrum, for 18. Clark M X, Knights D T, Henley M. A risk associated with the2^ 6 days postoperatively. Early mobilization reduces sur- shared airway in reconstructive palate surgery. Anaesthesia 2001;gical complications though care must be taken to prevent 56: 1028.pulling on or blockage of the catheter.40 19. Wolf A R, Lawson R A, Dryden C M, Davies F W. Recovery after des£urane anaesthesia in the infant: comparison with iso£urane. Br J Anaesth1996; 76: 362^364. 20. Bosenberg A T, Kimble F W. Infraorbital nerve block in neonatesFURTHER READING for cleft lip repair: anatomical study and clinical application. Br J Anaesth 1995; 74: 506 ^508.Many excellent general texts and articles exist detailing paediatric 21. de Lima J, Lloyd-Thomas A R, Howard R F, Sumner E, QuinnT M. anaesthetic techniques for surgery, which apply as much to children Infant and neonatal pain: anaesthetists’ perceptions and prescrib- having plastic surgery. For guidance on management of general ing patterns. BMJ1996; 313: 787 . issues surrounding anaesthesia in children, readers may refer to es- 22. Kart T, Christrup L L, Rasmussen M. Recommended use of mor- tablished texts.44 More speci¢c detail can be found for pre-medica- phine in neonates, infants and children based on a literature re- tion,45 pre-operative fasting,46, peri-operative £uid balance47 and view: Part 2Fclinical use. Paediatr Anaesth 1997; 7: 93^101. analgesia.48 23. Williams D G, Hatch D J, Howard R F. Codeine phosphate in pae- diatric medicine. Br J Anaesth 2001; 86: 413^ 421. 24. Xue F S, An G, Tong S Y, Liao X, Liu J H, Luo LK. In£uence ofREFERENCES surgical technique on early postoperative hypoxaemia in children undergoing elective palatoplasty. Br J Anaesth 1998; 80: 1. Bodley P. Development of anaesthesia for plastic surgery. J R Soc 447^ 451. Med1978; 71: 839^ 843. 25. Doyle E, Hudson I. Anaesthesia for primary repair of cleft lip and 2. Lunn J N. Implications of the national con¢dential enquiry into peri- cleft palate: a review of 244 procedures. Paediatr Anaesth 1992; 2: operative deaths for paediatric anaesthesia. Paediatr Anaesth 139^145. 1992; 2: 69^72. 26. Hutcinson J M S. In: Muir I F K (ed.), Plastic Surgery in Paediatrics. 3. Department of Health. Welfare of Children and Y oung People in London: Lloyd-Luke,1987 ,1^10. Hospital. London: HMSO,1991. 27 Cregg N, Conway F, Casey W. Analgesia after otoplasty: regional . 4. Sommerlad B C. Management of cleft clip and palate.Curr Paediatr nerve blockade vs local anaesthetic in¢ltration of the ear. Can J 1994; 4: 189^195. Anaesth 1996; 43: 141^147 . 5. Shprintzen R J, Siegel-Sadewitz V L, Amato J, Goldberg R B. 28. Woodward W M, Barker I, John R E, Peacock J E. Propofol infusion Anomalies associated with cleft lip, cleft palate, or both. Am J vs thiopentone/iso£urane anaesthesia for prominent ear correc- Med Genet 1985; 20: 585^595. tion in children. Paediatr Anaesth 1997; 7: 379^383.
ANAESTHESIA FOR PLASTIC SURGERY IN CHILDREN 9129. Paxton D, Taylor R H, Gallagher T M, Crean P M. Postoperative 39. Barham C J. Anaesthesia for maxiofacial surgery. In: Patel H (ed.). emesis following otoplasty in children. Anaesthesia 1995; 50: Anaesthesia for Burns, Maxillofacial and Plastic Surgery. London: 1083^1085. Edward Arnold,1993.30. Muir I F K, McLay K A. In: Muir I F K (ed.). Plastic Surgery in Paedia- 40. Grobbelaar A O, Laing J H, Harrison D H, Sanders R. Hypospadias trics. London: Lloyd-Luke,1987; 82^92. repair: the in£uence of postoperative care and a patient factor on31. Kam P C A, Kavanagh R, Y oong F F Y The arterial tourniquet: . surgical morbidity. Ann Plast Surg 1996; 37: 612^ 617. pathophysiological consequences and anaesthetic implications. 41. Khuri F J, Hardy B E, Churchill B M. Urologic anomalies associated Anaesthesia 2001; 56: 534 ^545. with hypospadias. Urol Clin North Am1981; 8: 565^571.32. Bloch E C,Ginsberg B, Binner Jr R A, Sessler D I. Limb tourniquets 42. Gunduz M, Ozcengiz D, Ozbek H, Isik G. A comparison of single and central temperature in anesthetized children. Anesth Analg dose caudal tramadol, tramadol plus bupivacaine and bupivacaine 1992; 74: 486^ 489. administration for postoperative analgesia in children. Paediatr33. Carre P, Joly A,Cluzel Field B,Wodey E, Lucas M M, Eco¡ey C. Ax- Anaesth 2001; 1 323^326. 1: illary block in children: single or multiple injection? Paediatr 43. Sharpe P, Klein J R,Thompson J P et al. Analgesia for circumcision in Anaesth 2000; 10: 35^39. a paediatric population: comparison of caudal bupivacaine alone34. Altintas F, Bozkurt P, Ipek N,Y ucel A, Kaya G.The e⁄cacy of pre- with bupivacaine plus two doses of clonidine. Paediatr Anaesth versus postsurgical axillary block on postoperative pain in paedia- 2001; 1 695^700. 1: tric patients. Paediatr Anaesth 2000; 10: 23^28. 44. Sumner E, Hatch D J (eds). Paediatric Anaesthesia.London: Arnold,35. Jones N F, Gupta R. Postoperative monitoring of pediatric toe-to- 1999. hand transfers with di¡erential pulse oximetry. J Hand Surg [Am]. 45. Sury M R J. Premedication in paediatric anaesthesia. In: Kaufman L, 2001; 26: 525^529. Ginsbury R (eds). Anaesthesia Review 11. London: Churchill Living-36. Campling E A, Devlin H B, Lunn J N. The Report of the National stone,1994; 193^206. Con¢dential Enquiry into Perioperative Deaths1989. London,1990. 46. Phillips S, Daborn A K, Hatch D J. Preoperative fasting for paedia-37 Emerson B M, Wrigley S R, Newton M. Pre-operative fasting for . tric anaesthesia Br J Anaesth.1994; 73: 529^536. paediatric anaesthesia. A survey of current practice. Anaesthesia 47 Rice H E, Caty M G,Glick P L. Fluid therapy for the pediatric surgi- . 1998; 53: 326^330. cal patient. Pediatr Clin North Am 1998; 45: 719^727 .38. Goodwin M W, Robinson K N. A pragmatic approach to fasting in 48. Morton N S. Prevention and control of pain in children. Br J paediatric trauma? Paediatr Anaesth 2000; 10: 452^ 453. Anaesth 1999; 83: 1 ^129. 18