Contrastación de resultados de la primera hipótesis

It is important to remain vigilant and ensure the throat pack is removed at the end of surgery and this should be included as part of the swab count according to the WHO Surgical Safety Checklist.7,10

Southern African Journal of Anaesthesia and Analgesia 2017; 23(2)(Supplement 1) 132

Ensure the oropharynx is inspected for any blood clots and that haemostasis has been achieved. Suctioning should be kept to a minimum especially with CP repairs to avoid disrupting the

surgical repair and may cause bleeding.7,10 _{Non-depolarising}

muscle relaxants should be adequately antagonised if they were used during the procedure. Extubate the child fully awake once the protective reflexes have returned.7

Postoperative management

It is estimated that 15–20% of CLP repairs are associated with postoperative morbidity and a reoperation risk of around 2%

related to bleeding and airway obstruction complications.9

Airway complications range from episodes of mild stridor to complete airway loss requiring re-intubation.10

All children should be monitored in the recovery room until they are fully awake, their pain has been well controlled and there are no signs of bleeding.10

Factors to consider in the postoperative period:

1. Airway obstruction

a. Most commonly seen in recovery in the immediate postoperative period but careful monitoring allows for early detection as it may occur within the first 12–24 hours but even up to 48 hours post-surgery.7,9 _Massive

tongue swelling cases usually present within 90 minutes of the end of surgery.10

b. Most likely to occur in children with a preoperative airway concern.7 _{Especially in children with congenital}

abnormalities, namely Pierre Robin sequence.9 _{Insert a}

nasopharyngeal airway (NPA) at the end of the procedure in micrognathic patients.9

c. Occurs due to7,9_:

i. Congenital abnormalities associated with micrognathia.

ii. Anaesthetic or surgical complications10_:

1. Swelling of the tongue from gag pressure, usually because of prolonged surgical time related to a wider cleft. The mouth is held open by the gag which exerts pressure on the alveolar ridge and tongue. Mucosal oedema results if too much pressure is applied for a prolonged period or the incorrect size retractor blade is used. This is due to impaired venous and lymphatic drainage, and is worsened by neck overextension and if steep Trendelenburg is used.9,11 _{The Boyles-}

Davis gag should be released for 5–10 minutes every hour especially during prolonged surgery. Upon removal of the gag inspect the whole oropharynx and base of the tongue.9 _{Should the}

tongue appear swollen or dusky in colour, decide whether extubation is appropriate and consider placing a NPA. The child should be closely observed in a high care environment or placed in ICU ventilated until the swelling has resolved.9

2. A retained throat pack. 3. Bleeding or blood clots.

4. Laryngospasm.

5. Reduction in pharyngeal tone due to residual volatile agent effects.

6. Inadequate mouth opening.

7. Respiratory depression from opioid analgesia. 8. Laryngeal oedema as result of a difficult

intubation.

9. Or a combination of factors.

d. Management depends on the degree of the obstruction: i. Simple manoeuvres:

1. Place the child in the left lateral or prone, pull the tongue forward to relieve the obstruction. Consider placing a tongue suture to relieve the obstruction.10

2. Consider providing temporary continuous positive airway pressure until the child has fully recovered.10

3. As far as possible avoid placing an oropharyngeal airway as insertion may damage the surgical repair but if in extremis it may be lifesaving.10

ii. Other airway devices: 1. Place a NPA or LMA.

iii. Re-intubation: required if simple manoeuvres cannot establish a safe airway.10

1. Should reintubation be necessary, consider using a fibre optic scope and as a last resort in severe airway obstruction, a surgical airway.9 _It

is imperative to be familiar with the paediatric difficult airway algorithms.4

2. If there are any concerns on emergence of airway compromise, keep the child intubated and ventilated until the swelling subsides.9

3. Anticipate a difficult intubation even if with the initial procedure it may have been straight forward, as postoperative swelling and bleeding may distort the view at laryngoscopy.10

iv. Postoperative monitoring:

1. Ideally all patients should be monitored in a high- dependency unit but patients at particular risk as a result of an associated syndrome or any who complicate should be monitored in ICU.7 2. Postoperative analgesia

a. Multimodal analgesic strategies should be continued into the postoperative period. This should include regular dosing of paracetamol and NSAIDs (infants over six months) and oral (tilidine 1 mg/kg) or intravenous opioids in selected cases and older children (morphine 0,05–0,1 mg/kg) provided airway obstruction is not a problem.3,7 _{Alternatively, consider rectal analgesics.}3

b. If a nerve block is performed intraoperatively, this analgesia will continue into the postoperative period.

c. Infants may be reluctant to swallow for 24 hours post- repair and intravenous fluids may be required until oral intake has been re-established.3

Conclusion

Every three minutes, a child somewhere in the world is born with a CLP, who, as a result is often unable to eat, speak, socialise or smile.1 _{In Africa, approximately one in every 1 000 babies is born}

with a cleft lip or cleft palate.1 _{If they do not receive reconstructive}

surgery, they may have many healthcare issues.1 _{Despite the}

anaesthetic challenges we may face, the benefits of surgical repair are life-changing to these children and very rewarding.4

This is not simple cosmetic surgery nor a simple anaesthetic.3

References

1. Smile O. Operation Smile South Africa: Operation Smile South Africa; 2017 [updated 2017; cited 2017 2017]. Available from: www.southafrica. operationsmile.org.

2. Reena, Bandyopadhyay K, Paul A. Postoperative analgesia for cleft lip and palate repair in children. Journal of Anaesthesiology Clinical Pharmacology. 2016;32(1):5-11.

3. Bösenberg A. Anaesthesia for cleft lip and palate surgery. Southern African Journal of Anaesthesia and Analgesia. 2007;13(5):9-14.

4. Govender P. Anaesthesia for cleft lip and palate surgery. Anaesthesia. 2014;6(15). 5. Somerville N, Fenlon S. Anaesthesia for cleft lip and palate surgery. Continuing

Education in Anaesthesia Critical Care and Pain. 2005;5(3):76-9.

6. What is cleft palate and  cleft lip? [cited © 2012-2015 Transforming Faces. Available from: http://www.transformingfaces.org/.

7. Rawlinson E. Anaesthesia for cleft lip and palate surgery. Update in Anaesthesia. 2015;30(30):154-8.

8. Steward DJ. Anesthesia for patients with cleft lip and palate. Seminars in Anesthesia, Perioperative Medicine and Pain. 2007;26(3):126-32.

9. Lee C-A. Anaesthesia for Cleft Lip and Palate Surgery. PACSA supplement 3 November 2012. 2012.

10. Rawlinson E. Postoperative airway complications after cleft palate repair. Anaesthesia Tutorial of the Week 2011(236):1-11.

11. Aziz S. Severe glossal edema after primary palatoplasty. Journal of Oral Maxillofacial Surgery. 2009;67:1326-8.

South Afr J Anaesth Analg

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FCA 2 REFRESHER COURSE

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