Pre-operative Assessment & Optimisation
History — screen for
① Associated anomalies / syndromes (see §3) — and a perceived pause/obstruction during sleep (OSA).
② Acute ENT problems — active URTI, running nose, ear infection, hearing loss.
③ Cardiac symptoms — cyanosis on crying, failure to thrive, murmur → cardiology + echo.
④ Feeding difficulty — nasal regurgitation, poor weight gain, nutritional deficiency.
② Acute ENT problems — active URTI, running nose, ear infection, hearing loss.
③ Cardiac symptoms — cyanosis on crying, failure to thrive, murmur → cardiology + echo.
④ Feeding difficulty — nasal regurgitation, poor weight gain, nutritional deficiency.
Airway examination
Assess for retrognathia / micrognathia, mouth opening, the extent of the cleft (hard vs soft palate, uni/bilateral, protruding pre-maxilla), neck movement (associations), and any active nasal discharge. A normal-looking mouth opening & neck (no retrognathia) predicts an easier airway.
📊 COPUR — Colorado Paediatric Airway Score
A paediatric difficult-airway score for cleft/craniofacial children — grade each 1 (easy) → 4 (difficult): Chin (mandibular hypoplasia), Opening (interdental space: >40 / 20–40 / 10–20 / <10 mm), Previous intubation or OSA, Uvula/palate anatomy, Range of neck movement. A high score flags an anticipated difficult airway → plan accordingly.
| Investigation | Why |
|---|---|
| CBC (Hb, TLC/DLC) | Anaemia (malnutrition), active infection (URTI/LRTI) |
| Blood group & cross-match | Small blood volume; vascular field |
| Chest X-ray | LRTI, cardiac size, spine anomalies |
| ECG & 2D echocardiography | If a murmur is heard / CHD suspected; also screens for pulmonary hypertension (OSA) |
Optimisation & premedication Key
Defer for active URTI — postpone elective surgery for ~2–4 weeks after a respiratory infection (airway hyper-reactivity → laryngospasm/desaturation).
① Blood grouping & cross-match. ② Antibiotic prophylaxis (coexisting congenital anomalies / IE risk). ③ Avoid sedative premedication (airway obstruction risk). ④ Antisialagogue — inj. glycopyrrolate or atropine 0.02 mg/kg to reduce secretions & the chance of laryngospasm. Continue routine fasting guidelines.
① Blood grouping & cross-match. ② Antibiotic prophylaxis (coexisting congenital anomalies / IE risk). ③ Avoid sedative premedication (airway obstruction risk). ④ Antisialagogue — inj. glycopyrrolate or atropine 0.02 mg/kg to reduce secretions & the chance of laryngospasm. Continue routine fasting guidelines.
Anaesthesia-Related Concerns at a Glance
Anaesthesia concerns → what they translate to
Shared airwayTube kinking / obstruction / disconnection / accidental extubation · airway obstruction · laryngospasm · PONV
AirwayDMV & difficult intubationDifficult mask ventilation, difficult DL, special (RAE) ETT
PhysiologyPaediatricAnalgesia, fluid management, avoid hypothermia
SurgicalBleedingRetractor/gag → kinking, bleeding, extubation risk; adrenaline infiltration