Anaesthetic Challenges in Primary Cleft Lip and Palate Surgeries: A Retrospective Study
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JMSCR Vol||09||Issue||03||Page 206-214||March 2021
http://jmscr.igmpublication.org/home/
ISSN (e)-2347-176x ISSN (p) 2455-0450
DOI: https://dx.doi.org/10.18535/jmscr/v9i3.36
Anaesthetic Challenges in Primary Cleft Lip and Palate Surgeries: A
Retrospective Study
Authors
Chadha Meenu MD , Shrivastava Gaurita MD, DNB2, Goyal Praveen MD3,
1
Waskel Shailendra DA4, Chauhan Jaideep S MDS5, Sharma Sarwpriya MDS6
1
Consultant & Pain Physician, Head, Department of Anesthesiology, CHL Hospitals, AB Road, LIG Square,
Indore (M.P.) India
2,3,4
Consultant, Department of Anesthesiology, CHL Hospitals, AB Road, LIG Square, Indore (M.P.) India
5
Consultant & Head, Department of Maxillofacial Surgery & ‘Smile Train’ Cleft Centre, CHL Hospitals,
AB Road, LIG Square, Indore (M.P.) India
6
Consultant, Department of Maxillofacial Surgery & ‘Smile Train’ Cleft Centre, CHL Hospitals, AB Road,
LIG Square, Indore (M.P.) India
Corresponding Author
Chadha Meenu MD
Abstract
Background: Cleft lip and palate are one of the commonest congenital craniofacial anomalies. The aim of
this study was to do a retrospective analysis of patients who underwent primary cleft surgeries.
Method: After approval from the institutional ethical committee retrospective analysis of 975 patients who
underwent primary cleft lip, primary cleft palate and primary combined surgeries was done. The
anaesthesia technique and complications were noted from the anaesthesia records. The data recorded was
demographic profile, haemoglobin level, preexisting comorbidities, type of surgery and perioperative
complications.
Result: The overall pre-existing morbidities, perioperative and post-operative complications were reported
in 109 (11.2%), 117 (12%) and 52 (5.3%) participants respectively. In the pre-existing morbidities, Upper
respiratory tract infection (URTI) was reported as the most common pre -existing morbidity (6.7%),
various syndromes in 32 patients (3.3%). Congenital cardiac condition occurred in 1.2% In the
perioperative complications, bronchospasm occurred in 4.1% most of these patients had URI and difficult
intubation occurred in 3.3%. Post operatively 1.2% had bleeding and all of these patients had to be
intubated postoperatively. It was noted that difficult intubation was more in cleft palate surgery 19 patients
than cleft lip surgery 13 patients. Failed intubation occurred in equal number of patients in cleft lip and
palate. Post-operative bleeding was also more in cleft palate surgery and post-operative bronchospasm
occurred only in cleft palate surgeries
Conclusion: We observed URTI as the major preoperative challenge in addition to intra and post-
operative complications. A thorough preoperative evaluation is imperative.
Keywords: Anesthesia; Cleft lip and palate; Endotracheal Intubation; Pierre Robin; Respiratory tract
infection; Anaemia.
Chadha Meenu MD et al JMSCR Volume 09 Issue 03 March 2021 Page 206JMSCR Vol||09||Issue||03||Page 206-214||March 2021
Introduction A retrospective study of 975 patients who
Cleft lip and palate are one of the commonest underwent cleft lip repair, cleft palate repair and
congenital craniofacial anomalies, considered combined (cleft lip and palate repair) from May
together, they constitute the third most common 2017 to September 2020 was done. A total
congenital anomaly that requires surgical number of 1067 patients were operated during this
correction at an early age. Cleft lip with or period but, 975 patients were analysed and 92
without cleft palate occurs in 1 in 600 live births, patients were excluded from the study because of
cleft palate alone is less common and occurs in 1 incomplete documentation.
in 2000 live births[1]. The anaesthesia technique and complications were
Congenital cleft can involve the lip, alveolus, hard noted from the anaesthesia records. The data
and soft palate, can be complete or incomplete, recorded was demographic profile, haemoglobin
unilateral or bilateral or may be associated with level, preexisting co-morbidities, type of surgery
syndromes and other anomalies. These defects of and perioperative complications. For the purpose
the upper airway predispose the child to difficulty of statistical analysis, the patients were divided
in swallowing, regurgitation of milk, aspiration into four groups 0-6 months, 6 months- 2 years, 2-
and subsequent pulmonary infections. Associated 4 years, above 5 years. The data collected was
syndromes include Pierre Robin, Treacher Collins entered in Microsoft Excel and subjected to
and Goldenhar syndromes. statistical analysis using Statistical Package for
Age is a crucial factor in cleft repair surgeries. Social Sciences (SPSS, IBM version 20.0). The
Most of the protocols favors early surgical level of significance was fixed at 5% and p ≤ 0.05
intervention for repair of cleft lip at about 12 was considered statistically significant.
weeks of age while palatal repair is ideally carried Kolmogorov- Smirnov test and Shapiro-Wilks test
out later between 6 to 12 months of age. We too were employed to test the normality of data. Chi
follow the same protocol. Surgical repair of cleft square test was performed for quantitative
lip and palate carried out at the appropriate time variables.
helps to correct facial deformity, prevents All the patients were seen preoperatively by the
malnutrition and anaemia. surgeon, paediatrician and the anaesthesiologist.
Anesthetic management of the surgical repair of Patients who had raised counts but were clinically
orofacial clefts is quite challenging because of the asymptomatic were started on prophylactic
age of the patient (mostly infants), hematological antibiotics a day before surgery and taken after a
parameters, recurrent upper respiratory tract decline in count the next day. Those patients with
infection, malformation of the orofacial tissues, frank respiratory tract infection, wheezing and
under development, sub-optimal weight, and crepts were deferred for surgery, while those who
associated congenital anomalies. Review of had running nose and a clear chest were included.
literature mentions higher incidence of Anaemic patients were also not taken for surgery.
perioperative respiratory complications when Out cut off for the haemoglobin level was 8.5
associated with the common cold symptoms in gm%.
children for cleft repairs[2,3] In order to determine Routine preoperative fasting guidelines were
the type of challenges and perioperative followed according to the Smile Train Protocol.
complications during the surgical cleft repair, we Preoperative fasting was observed 4 hours for
conducted a retrospective observational study of milk, 6 hours for solid food and 2 hours for clear
975 patients over a period of 3 years 4 months. fluid. No patient received any sedative
premedication to avoid risk of airway obstruction
After preoxygenation for 3 minutes anaesthesia
Material and Methods was induced with I/V fentanyl 2µgm/kg, propofol
Chadha Meenu MD et al JMSCR Volume 09 Issue 03 March 2021 Page 207JMSCR Vol||09||Issue||03||Page 206-214||March 2021 1.5- 2 mgm/kg and succinylcholine 1.0-1.5 expertise in dealing with paediatric airway was mgm/kg. The trachea was intubated with cuffed considered as difficult intubation and failure to Ring- Adair Elwyn (RAE) endotracheal tube of intubate after three attempts as failed intubation. appropriate size. After confirming proper position Bradycardia was defined as heart rate ( HR)< 20% of the endotracheal tube, it was taped below the of baseline, tachycardia if HR >30% of baseline, lower lip in the mid line to minimise distortion of hypotension when mean arterial blood pressure facial anatomy. Pharyngeal packing was done (MBP) 30% of with moistened ribbon gauze. Bilateral air entry the baseline value. Hypothermia was considered was again confirmed after final positioning. when body temperature was less than 95° F and Anaesthesia was maintained with oxygen, nitrous fever if more than 100° F. oxide and sevoflurane and atracurium 0.5 mgm/kg on controlled ventilation. Standard intraoperative Results monitoring included ECG, SpO2, EtCO2, NIBP The data collected was entered in Microsoft Excel and temperature monitoring. Paracetamol and subjected to statistical analysis using suppository 20mg/kg was put in after induction. Statistical Package for Social Sciences (SPSS, At the end of the surgery oral suction was done IBM version 20.0). The level of significance was and pharyngeal pack removed. Residual fixed at 5% and p ≤ 0.05 was considered neuromuscular blockade was reversed with statistically significant. Kolmogorov- Smirnov test neostigmine and glycopyrollate in titrated doses. and Shapiro-Wilks test were employed to test the Tracheal extubation was done after return of normality of data. Chi square test was performed consciousness, good spontaneous respiration, for quantitative variables. adequate tidal volume and when protective This retrospective analysis was carried out to reflexes were obtained. If the child was below 1 determine the anaesthetic challenges in primary year old or was fasting more than 4 hours 1% cleft lip and palate surgeries. The results are based dextrose along with the balanced salt solution on analysis of 975 participants determining the Ringer lactate was given. To make up this 1% we anaesthetic challenges. The study participants added 4 ml 25% dextrose to 96ml Ringer lactate were characterized into different groups and to make up 100ml. Children more than 1 year or majority of them were in the age group of 6 10 kg were given Ringer lactate. months-2years (69%). Major proportion of the Post-operatively, all the patients were nursed in participants were males (61%) as compared to lateral position to optimise airway and to females (39%) and majority of the surgeries were minimise chances of aspiration. Monitoring for cleft lip surgery (53.1%), with cleft palate (44.4%) bleeding, vomiting or airway obstruction was and combined surgeries in (2.5%) (Fig.1). done. All perioperative and post-operative Our cut off level for hemoglobin was 8.5g/dl Only complications and challenges were documented. 25.7% patients had a hemoglobin level between For the study purposes, fall in SpO 2
JMSCR Vol||09||Issue||03||Page 206-214||March 2021
difficult intubation occurred in 32 (3.3%) and patients than cleft lip surgery 13 patients (Fig.5).
most of these children were syndromic. Post Failed intubation occurred in equal number of
operatively 12 (1.2%) had bleeding and all of patients in cleft lip and palate, most of these
these patients had to be reintubated children were syndromic and had retrognathia.
postoperatively (Fig.4). Similarly, post-operative bleeding was also more
In the association between type of surgery and in cleft palate surgery and post-operative
perioperative complications we noted that difficult bronchospasm occurred only in cleft palate
intubation was more in cleft palate surgery 19 surgeries (Graph 6)
800
700 673
595
600
518
500
433
380
400
300
226
200
100 52
24 24
0
Male
Cleft Lip
Cleft Palate
Combined
6 months – 2 years
Female
2years – 4 years
0-6 months
Above 5 years
Age Gender Type of surgery
Graph 1: Descriptive characteristics of the study participants
32 URTI
65 Congenital cardiac
12 condition
Others
Graph 2: Pre-existing comorbidities among study participants
Chadha Meenu MD et al JMSCR Volume 09 Issue 03 March 2021 Page 209JMSCR Vol||09||Issue||03||Page 206-214||March 2021
8 15 Bradycardia
32 10
Decreased SpO2
12
Bleeding
Bronchospasm
40
Difficult Intubation
Failed Intubation
Graph 3: Peri operative complications among study participants
Bleeding
12 12 Forgotten Pack
Laryngeal oedema
Bronchospasm
3 1 Reintubation
8
Graph 4: Postoperative complication among study participants
30
26
25
19
20
15 14
13 Cleft Lip
10 Cleft Palate
10 9
8
5
5 4 4 4
1
0
Bradycardia Decreased Bleeding Bronchospasm Difficult Failed
SpO2 Intubation Intubation
Graph 5: Association between type of surgery with perioperative complications in the present study
Chadha Meenu MD et al JMSCR Volume 09 Issue 03 March 2021 Page 210JMSCR Vol||09||Issue||03||Page 206-214||March 2021
9
8 8 8
8
7
6
5
4 4 Cleft Lip
4
Cleft Palate
3
2
2
1 1
1
0 0
0
Bleeding Forgotten Pack Laryngeal Bronchospasm Reintubation
Oedema
Graph 6: Association between type of surgery with postoperative complications in the present study
Discussion such as difficult intubation, endotracheal tube
This study made us realise that more than three compression, disconnection or accidental
[1]
attempts for intubation is detrimental. extubation . It is not always possible to assess a
Postponement of the case for 6 months led to a difficult airway preoperatively. In our study we
better chance of successful intubation in noted 19 (1.94%) difficult intubations in cleft
syndromic babies. palate and 13 (1.33%) in cleft lip and failed
975 cleft surgeries were evaluated on the basis of intubation in 8 patients (0.82%) in cleft lip and
medical records regarding perioperative palate surgeries. The increase incidence of
complications. In our study, the incidence of difficult intubation in cleft palate is because of a
URTI was 1.43% and 4.10 % in cleft lip and wider cleft which was associated with higher
palate cases respectively. It increases the risk of intubation grade. Main reason for difficult
laryngospasm from 1.7% to 9.6% and a threefold laryngoscopy is cleft alveolus, protruding maxilla
increase in bronchospasm in children [4]. Tiret et and a high arched palate. Our incidence of airway
al. reported incidence of anaesthesia related complications was more in patients having cleft
complications within 24 h in 4.3/1000 infants and palate repair compared to cleft lip repair. This was
0.5/1000 in children with 0.01% death [5]. also observed by Frilles[6]
Cohen et al. reported higher peri-anaesthesia The main limitation of the study was it since, it
morbidity in paediatric patients (35%) compared was a retrospective study, few patients had to be
to adults (17%) [5]. excluded from the study because of incomplete
Congenital heart disease is common in cleft data.
patients, we had 12 patients with cardiac disease. The strength of our study was that we reported a
VSD was most common, 9 patients had VSD, 1 low incidence of failed intubation in spite of
had ASD and 2 were operated Fallots tetralogy. associated difficult airway and syndromic babies.
None of these patients had any intra or post- The difficult intubation scenario was very well
operative complication. managed by our senior consultants, strict
A significant proportion of the anaesthetic monitoring, optimal positioning, proper external
morbidity in cleft repair is related to the airway laryngeal maneuver and use of stylet. The routine
Chadha Meenu MD et al JMSCR Volume 09 Issue 03 March 2021 Page 211JMSCR Vol||09||Issue||03||Page 206-214||March 2021 practice of reassessing the ventilation after tube airway reactivity and may result in laryngeal and fixation, oral packing and application of mouth bronchospasm[9]. Takemura et al.[3] defined gag helped in prevention of tube kinking and perioperative respiratory symptoms (PRC) as displacement. Any child with hypoplastic occurrence of laryngospasm or bronchospasm mandible or wide cleft palate increases the risk of during induction; increased airway secretions and tongue prolapse into the nasopharynx and may desaturation (
JMSCR Vol||09||Issue||03||Page 206-214||March 2021
and bronchospasm occurred in 11 patients and it complications in infants with cleft lip and
was corrected by jaw thrust, chin lift, steroids, palate. Paediatr Anaesth. 2002;12:585–8.
oxygen by face mask and bronchodilators. 4. Kotur PF. Surgical repair of cleft lip and
Bleeding occurred in 12 patients and all of these palate in children with upper respiratory
patients required re intubation to see and stop the tract infection. Indian J Anaesth. 2006;
bleeding. 50:58–9.
Quereshi et al[14] have found hypothermia as a 5. Kalpana R Kulkarni, Mohan R Patil,
very common complication after long surgeries Abasaheb M Shirke, Shivaji B Jadhav.
but in our study, hypothermia was not seen Perioperative respiratory complications in
because proper measures were taken like warm cleft lip and palate repairs: An audit of
fluid and warm blanket intraoperatively. 1000 cases under ‘Smile Train
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thorough history, proper physical examination and over a 30-month period. Pediatr
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