Common Mistakes
Airway hyper-reactivity → laryngospasm, bronchospasm & desaturation. Postpone elective surgery ~2–4 weeks after a respiratory infection.
Can precipitate complete obstruction (especially Pierre Robin/OSA). Avoid sedatives; use an antisialagogue instead.
Pack the alveolar/palatal defect with rolled gauze and consider a right paraglossal or video-laryngoscopic approach.
The Dingman gag can kink or compress the RAE tube — a rising airway pressure or falling tidal volume is the warning; check the tube whenever the gag is opened or repositioned.
A retained pack causes fatal obstruction. Document placement, count, and remove before extubation.
Arrhythmias — respect 5 µg/kg (halothane) / 10 µg/kg (iso/sevo) and communicate with the surgeon.
Extubate awake with full reflexes; a stomach full of swallowed blood and a narrowed post-repair airway make regurgitation and obstruction likely.
Hypothermia and a proportionally large blood loss are easy to underestimate — warm actively, weigh swabs, cross-match.
Exam Pearls
Q: What are the anaesthetic concerns in cleft surgery?
Paediatric patient, difficult airway, shared airway, associated anomalies (syndromes + CHD), and bleeding.
Q: State the Rule of 10.
10 weeks age, 10 pounds (~4.5 kg), Hb ≥10 g/dL, TLC <10,000/mm³ — the readiness criteria for lip repair (age now relaxed to ~3 months).
Q: Which syndromes worsen vs improve the airway with age?
Pierre Robin improves (mandibular growth); Goldenhar worsens; Treacher Collins stays difficult.
Q: What tube and why?
Oral RAE ("south-pole") tube — preformed midline bend keeps the circuit off the surgical field and fits the Dingman gag; size (age/3)+3.5 uncuffed. Use a flexometallic tube if the RAE kinks under the gag.
Q: How do you induce the anticipated difficult airway?
Inhalational (sevoflurane) induction maintaining spontaneous ventilation; IV induction only if no airway difficulty is anticipated.
Q: Veau classification?
I soft palate; II hard+soft to incisive foramen; III complete unilateral (with lip); IV complete bilateral (pre-maxilla on nasal septum).
Q: Which nerve blocks for analgesia?
Cleft lip — bilateral infraorbital nerve block; cleft palate — greater/lesser palatine + nasopalatine, or bilateral maxillary (suprazygomatic) blocks, with 0.25% bupivacaine + adrenaline.
Q: Maximum adrenaline dose with volatile agents?
~5 µg/kg with halothane, ~10 µg/kg with isoflurane/sevoflurane (1:200,000).
Q: Why recurrent ear infections?
A misplaced tensor veli palatini → Eustachian-tube dysfunction → serous otitis media & conductive hearing loss.
Q: How is the child recovered?
Awake extubation with full reflexes after checking for tongue/uvula oedema and removing the throat pack; elbow restraints; nurse lateral, head down & extended.
References
- Dr. Tanya Chawla. Cleft Lip & Palate — anaesthesia viva notes (primary source for this page).
- Gropper MA, et al. (eds). Miller's Anesthesia, 9th Edition. Anesthesia for the Paediatric Patient; Cleft Lip & Palate. Elsevier; 2020.
- Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology, 7th Edition. Paediatric Anaesthesia. McGraw-Hill; 2022.
- Hines RL, Marschall KE (eds). Stoelting's Anesthesia and Co-Existing Disease, 8th Edition. Elsevier; 2022.
- Fillingham A, et al. Anaesthesia for cleft lip and palate surgery. BJA Education / CEACCP.