Emergence, Extubation & Recovery
- Remove the throat pack (count checked) and examine for swelling of the tongue & uvula / oedema before waking.
- Gentle suction under vision. Reverse neuromuscular block with neostigmine + glycopyrrolate.
- Extubate the child awake, with full airway reflexes and regular breathing. If swelling is present → postpone extubation and ventilate/observe.
Reduced airway calibre after palate repair · oedema of the tongue (prolonged gag/retractor pressure) · lingual/laryngeal oedema · residual effect of anaesthetic drugs · blood clot ("coroner's clot") in the nasopharynx · bleeding. A tongue stitch may be left by the surgeon to pull the tongue forward.
Post-operative Analgesia & Regional Blocks
Aim for multimodal, opioid-sparing analgesia — most children do not have severe pain, and opioids risk respiratory depression in an airway already at risk.
| Drug | Dose & route |
|---|---|
| Paracetamol | PO 10–15 mg/kg 6-hourly · IV 15 mg/kg (≤7.5–15 mg/kg in neonates) TDS · PR 30–40 mg/kg loading then 20 mg/kg 6-hourly |
| Ibuprofen | PO 10–20 mg/kg 6–8-hourly |
| Ketorolac | 0.5 mg/kg IV |
| Diclofenac | 1–1.2 mg/kg IV · 1 mg/kg PR |
| Morphine (severe pain only) | 0.02 mg/kg IV 3–4-hourly (safe starting dose in infants) — monitor for apnoea/bradycardia/desaturation |
Opioids are generally avoided but may be given in carefully titrated doses. Early feeding — a full stomach appears to comfort the child.
Cleft palate:
• Greater & lesser palatine + nasopalatine (sphenopalatine) blocks — the greater palatine foramen lies medial & anterior to the 2nd upper molar; ~1 mL of 0.25% bupivacaine + adrenaline (1:200,000).
• or bilateral maxillary nerve blocks (suprazygomatic, landmark or ultrasound-guided): needle to the pterygopalatine fossa, inject 0.15 mL/kg (max 5 mL) of 0.25% bupivacaine.
• or a sphenopalatine ganglion block.
Cleft lip/palate has a high birth prevalence in India and is frequently repaired in high-volume charitable camps (e.g. Smile Train). Practical implications: children often present malnourished, anaemic and with recurrent URTI — insist on the Rule-of-10 thresholds and defer for active infection. A shared airway with an oral RAE tube, Dingman gag and throat pack is the standard, and infraorbital / palatine nerve blocks with bupivacaine are a cheap, effective, opioid-sparing mainstay where PCA is unavailable. Ensure paediatric-sized difficult-airway equipment, forced-air warming and reliable recovery monitoring are in place at camp sites.