Download - Cleftlip
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CLEFT LIP / PALATEANAESTHESIA MANAGEMENT
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Dr.P.NARASIMHA REDDY MD;DA
Prof.&HOD. of AnaesthesiologyNarayana Medical College Nellore.
ANDHRAPRADESH.
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DEFINITIION
1. Defect in the Lip
2. Defect in the Palate
3. Defect in Lip & Palate
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Our problems
1. Anaesthesia for infant / Paediatric patients
2. Due to Clefts &
3. Other associated anomalies
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Incidence
1. More in Asians
2. Lip common in males
3. Palate common in females
4. Genetic influence more common in CLP
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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
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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
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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
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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.
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CLASSIFICATION
1. Cleft Lip complete, incomplete, unilateral & bilateral.
2. Cleft palate primary, secondary, complete, incomplete, unilateral & bilateral.
3. Submucosal.
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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..
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AETIOLOGY
1. Interaction between genetic & environmental factors.
2. Environmental factors triggers Clefting.
3. Gene TGFA.
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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.
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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
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MEDICAL THERAPY
1. Risk of aspiration.
2. Airway obstruction.
3. Feeding difficulties.
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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
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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
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ANAESTHETIC MANAGEMENT It includes
1. Preparation of the patients.
2. Preparation of the parents/Grand parents.
3. Fasting guidelines &
4. Lab investigations
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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.
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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
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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
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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.
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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.
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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
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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.
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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!
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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
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ANAESTHETIC MANAGEMENT Con. Extubation
Coup Obstruction No airways inserted Minimum suction Tongue stitch Lateral / prone position
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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
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ANAESTHETIC MANAGEMENT Con. In difficult situations
Awake intubation Fibre optic intubation Retrograde intubation also tried
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