Cleftlip

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Cleftlip

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

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