Paediatric anaesthesia04 / 17
Cleft palate repair in an infant11-month-old girl, 8.5 kg, for elective cleft palate repair
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- About a third of clefts come with a syndrome; look for a small jaw and heart lesions.
- Preformed oral RAE tube; watch for kinking or displacement when the gag opens.
- Tongue and palate swell under the gag; she wakes fully before extubation.
- No oral airway or vigorous suction after repair; a nasopharyngeal airway can help.
- Infant blood volume is about 75–80 mL/kg.
The patient
11-month-old girl, 8.5 kg, for elective cleft palate repair; cleft lip repaired at 4 months.
Cold 3 weeks ago, now resolved. Feeds slowly; weight on the 10th centile. Hb 10.2 g/dL. No echo; no murmur.
No regular drugs.
Vitals: HR 128, BP 86/50, SpO2 98% on air, RR 32.
The examiner asks
Answer aloud, then press Show.
Consider
What are your considerations?
Show the answerHide the answer
- An 11-month-old with cleft lip and palate, for elective palate repair. Patient
- At 11 months her blood volume is about 75–80 mL/kg, so a modest loss matters.
- A third of clefts are syndromic: I look for a small jaw, a heart lesion and other anomalies. Disease
- Slow feeding and low weight come with the cleft; her Hb of 10.2 adds little reserve.
- Shared airway under a mouth gag, blood in the pharynx, and swelling afterwards. Surgery
Prepare
How do you get her ready?
Show the answerHide the answer
- Her cold settled 3 weeks ago, past the 2-week mark, so I go ahead. Stem trigger
- Examine her jaw and mouth; a wide cleft can trap the laryngoscope blade. Airway
- No murmur or syndrome features, so no echo needed before surgery. Disease
- Group and screen, with blood available for a bleeding-prone repair.
Plan
How do you conduct the anaesthetic?
Show the answerHide the answer
- Gas or IV induction both suit her, with the difficult airway trolley in the room. Airway
- Preformed oral RAE tube, taped firmly in the midline.
- Once the gag is in, I recheck ventilation; it can kink or displace her tube.
- Throat pack recorded on the board, its tail left outside her mouth.
- Careful opioid doses with paracetamol 15 mg/kg IV. After surgery
Crisis
At the end, after the pack is out, blood pools in her pharynx and SpO2 falls to 90%. What do you do?
Show the answerHide the answer
- Blood in her airway: keep her deep, 100% oxygen, tube stays in. Crisis
- Gentle suction under direct vision, keeping off the fresh repair.
- Throat pack checked as removed and counted.
- Surgeon finds and controls the bleeding point before she wakes.
- Orogastric tube to empty her stomach of swallowed blood.
- Extubated only when fully awake, lying on her side. After surgery
Crisis
Thirty minutes later in recovery she snores with recession; SpO2 88%; her tongue looks swollen. What do you do?
Show the answerHide the answer
- Upper airway obstruction from tongue swelling under the gag. Crisis
- 100% oxygen, jaw thrust, sitting or lateral; no oral airway against her repair.
- Nasopharyngeal airway, ideally placed by the surgeon, to open her airway.
- Not improving: reintubate with the difficult airway kit and ventilate her in PICU.
- High-dependency care overnight with continuous oximetry. After surgery
Fatal mistakes
- Removing her tube while the throat pack remains.
- Deep extubation after palate repair.
- Missing tube kinking under the mouth gag.
- An oral airway forced against the fresh repair.
Checked against: Miller 10e · Stoelting 8e
Report a problem with this case
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.