Intra-operative Management
Monitoring
ECG, SpO₂, NIBP, EtCO₂, temperature, urine output, and a precordial/oesophageal stethoscope. Watch airway pressures — a rise indicates kinking or compression of the ETT by the gag (the shared-airway early warning).
1
Induction — tailored to the airway
- Anticipated difficult airway → inhalational (sevoflurane) induction maintaining spontaneous ventilation; keep depth adequate before instrumenting.
- No anticipated airway difficulty → IV induction is acceptable. Secure IV access; have the difficult-airway trolley & a range of tube sizes ready.
2
Laryngoscopy & intubation — the shared-airway tricks
- A large cleft can trap the laryngoscope blade or tube — pack the defect with a rolled gauze / dental roll to prevent the blade slipping in and to avoid trauma; alternatively insert the blade from the side (right paraglossal) approach. Video laryngoscopy improves the view.
- Avoid injuring a protruding pre-maxilla in bilateral clefts; the tongue can lodge in the palatal cleft during mask ventilation (dislodge it).
- Use a preformed oral RAE ("south-pole") tube (Ring–Adair–Elwyn) — its bend rests in the midline on the chin, keeping the circuit away from the surgical field and fitting the slot of the Dingman–Dott mouth gag. ETT size ≈ (age/3) + 3.5 mm ID (uncuffed), one size smaller if cuffed (~4.0 mm for a 1-year-old). In very small infants a correctly-sized RAE may protrude too far — use a smaller cuffed or flexometallic/reinforced tube.
- Insert a throat pack (absorbs blood, protects the airway); ETT checked for misplacement & obstruction after positioning.
3
Positioning
- Cleft palate: Rose position — body elevated on a pillow, head/neck extended over the edge, head steadied on a ring. Cleft lip: shoulder roll, head & neck extended.
- Risk: inadvertent extubation during head extension — connect the circuit with a straight connector, stabilise it on the chest in the midline, and tape the eyes closed.
4
Maintenance
- Air/O₂ ± N₂O with a volatile agent (sevoflurane/isoflurane) + fentanyl; muscle relaxation as required (short cases often spontaneous/assisted).
- Fluids by weight (maintenance + deficit + losses); prevent hypothermia (fluid warmer + forced-air blanket); assess blood loss and transfuse as needed.
- Monitor glucose in infants; empty the stomach of swallowed blood before extubation.
5
Adrenaline infiltration by the surgeon
- Adrenaline 1:200,000 is infiltrated for a bloodless field — but it sensitises the myocardium to catecholamines with volatile agents → arrhythmia risk. Maximum: ~5 µg/kg with halothane, ~10 µg/kg with iso/sevoflurane; if given with lignocaine 0.5%, the dose is limited by lignocaine (~7 mg/kg). Communicate with the surgeon before injection.