Anesthetic consideration in Clefts & Craniofacial surgery

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1 Anesthetic consideration in Clefts & Craniofacial surgery พญ.เด อนเพ ญ ห อร ตนาเร อง ภาคว ชาว ส ญญ ว ทยา คณะแพทย แพทยศาสตร มหาว ทยาล ยขอนแก น

2

3 Preoperative evaluation

4 Cleft lip & Cleft palate reconstruction History taking & Physical examination Poor feeding, poor speech and hearing Aspiration Presence of other anomalies Otitis media, rhinorrhea, URI Previous anesthetic history Risk for periop. resp. complication: common cold, wide cleft (8.9%) (Takemura H, 2002)

5 Cleft lip & Cleft palate reconstruction Laboratory investigation Depends on other anomalies & medical condition Hematocrit (large palate repair)

6 Craniofacial reconstruction History taking & Physical examination Anomalies of other systems, syndromes esp. CNS, pulmonary, cardiac Bleeding tendency Communicative disorder, speech&hearing Behavioral problems

7 Craniofacial reconstruction History taking & Physical examination *** evaluation of the airway *** Obstructive sleep apnea Previous anesthetic history

8 Craniofacial reconstruction Laboratory investigation Depends on other anomalies & medical conditions CXR, ECG, coagulation test, blood chemistry etc. Hematocrit & hemoglobin

9 Airway anomalies 20-37% have airway problems 65% with mandibular dysostosis (Treacher- Collins, Goldenhar s or hemifacial microsomia) 53% with craniofacial synostosis

10 Anatomical anomalies Oral cavity Ratio of volume of oral cavity to the tongue Maxillary or mandibular abnormalities Tongue enlargement Airway obstruction eg. Beckwith-Wiedemann syndrome

11 Beckwith-Wiedemann syndrome

12 Anatomical anomalies Anterior mandibular space Space that soft tis. of the tongue can be displaced into Mandibular hypoplasia or anterior larynx difficult larygoscopy and intubation eg. Pierre Robin sequence

13 Pierre Robin Sequence

14 Treacher Collins Syndrome

15 Anatomical anomalies Maxillary consideration Maxillary hypoplasia decrease oral cavity volume airway obstruction (esp. nasal obstruction) eg. Apert s syndrome

16 Apert s syndrome

17 Anatomical anomalies Temperomandibular joint Jaw opening and gliding Vertebral column Cervical and atlanto-occipital Difficult laryngoscopy and intubation eg. Apert s, Crouzon s, Goldenhar s

18 Congenital Ankylosis of TMJ

19 Hemifacial Microsomia

20 Preoperative preparation

21 Optimize medical condition Psychological preparation Informed consent NPO Cross match for blood and blood component (extensive craniofacial reconstruction) ICU preparation Preop. sedation should be used with caution (airway obstruction, increased ICP)

22 American Society of Anesthesiologist practice guideline;2002

23 Intraoperative anesthetic management

24 Cleft lip & Cleft palate reconstruction Induction&Intubation Intubation small incidence of difficult airway and intubation Maintenance Shared airway with surgeon Prevent inadvertent dislodgement of ET tube Local anesthetic with epinephrine injection Fluid management Temperature control

25 Cleft lip & Cleft palate reconstruction Postoperative period Most common problems Bleeding Airway obstruction Flaps, nasopharyngeal, lingual edema Pharyngeal pack -> extubate when fully awake, lateral position, nasopharyngeal airway

26 Cleft lip & Cleft palate reconstruction Postoperative period Postoperative pain management Infraorbital nerve block (for cleft lip repair) Acetaminophen Parenteral opioids

27 Craniofacial reconstruction Induction&Intubation Intubation Difficult airway No single technique is foolproof Difficult mask fitting, difficult ventilation, difficult intubation Maintain spontaneous respiration Several intubation techniques May require surgical airway

28 !!! Difficult AIRWAY!!!

29 laryngoscope Flexible fiberoptic laryngoscope Laryngeal mask airway Trachlight

30

31

32

33 American Society of Anesthesiologist practice guideline;2002

34

35

36 Craniofacial reconstruction Maintenance Associated condition Shared airway with surgeon Raised Intracranial pressure (intracranial procedure) Excessive blood loss Air embolism Fluid management Temperature control

37

38

39 Craniofacial reconstruction Postoperative period Postoperative swelling ET tube in place for hrs Blood loss CNS complications (intracranial procedure) Postoperative pain management Parenteral opioids

40 THANK YOU

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