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Original Research: Perioperative adverse airway events in cleft lip and palate repair Perioperative adverse airway events
in cleft lip and palate repair
aAdenekan AT, MBBS, DA, FWACS
aFaponle AF, MBChB, FWACS, FMCA
bOginni FO, BChD, FMCDS, FWACS
Departments of aAnaesthesia and Intensive Care and bOral and Maxil ofacial Surgery, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria Correspondence to: Dr Anthony Adenekan, e-mail: [email protected]
Keywords: cleft lip and palate, perioperative period, adverse airway events, general anaesthesia, developing nations
Abstract
Background: Airway-related problems account for the majority of anaesthetic morbidity in paediatric anaesthesia, but more
so for cleft lip and palate repair. The aim of this study was to assess the frequency, pattern, management and outcome of
adverse airway events during the perioperative period in cleft lip and palate patients.
Method: This was a prospective cohort study conducted in a tertiary hospital in a suburban south-western Nigerian town.
One hundred and sixteen patients who had cleft lip and palate repair over a five-year period were included. The demographic
data, surgical diagnosis, congenital anomalies, procedures performed, medical problems, perioperative anaesthetic and
surgical complications were studied.
Results: Adverse airway events were observed in six patients (4.6%). These included postoperative chest infection (n=2),
failed intubation (n=1), difficult intubation (n=1), post-extubation bronchospasm (n=1), and laryngeal oedema (n=1). Al ,
except one, who developed complications were patients with combined cleft lip and palate. No mortality was recorded.
Conclusion: Adverse perioperative airway events in cleft lip and palate surgery are common and are more likely to be
associated with combined cleft lip and palate than with isolated lip or palate defects. These complications usual y occur
immediately fol owing extubation or in the early postoperative period. The severity may necessitate intensive care unit
admission and specialised care.
Peer reviewed. (Submitted: 2011-02-10. Accepted: 2011-06-01.) SASA
South Afr J Anaesth Analg 2011;17(6):370-373
Background
developing nations, where lack of trained medical personnel stil hinders a high-quality dedicated team approach Cleft lip and palate is one of the most common congenital to delivery of care to orofacial cleft patients. Many of anomalies requiring surgical treatment.1 Its aetiology is these patients from resource-poor nations are managed complex and largely unknown, but usual y attributed through surgical outreach programmes funded by donor to genetic and environmental factors in isolation or in organisations around the world. 4,10,11 This has resulted in an combination. Cleft lip and palate is also associated with increase in the number of cases managed in the hospital at an increased incidence of congenital abnormalities in other organ systems, including craniofacial disorders, which may pose chal enges in airway management. Airway- The authors sought to determine the incidence of related problems have been identified as the major cause perioperative adverse airway events in cleft lip and palate of anaesthetic morbidity in cleft lip and palate surgery for surgery managed by a local team at their centre, to identify many years.2 Fatality due to airway compromise has also the associated factors, and to analyse the management of the been reported fol owing cleft lip and palate surgery.3,4 There patients with a view to make appropriate recommendations are a few studies on perioperative complications in cleft lip for the anaesthetic management of cleft lip and palate and palate surgery, but these are largely from developed In most developed countries, cleft lip and palate care has evolved into organised cleft teams based in regional or Approval for this study was obtained from the Hospital supraregional centres.1 The situation is different in most Ethics Committee. One hundred and sixteen patients who Original Research: Perioperative adverse airway events in cleft lip and palate repair Original Research: Perioperative adverse airway events in cleft lip and palate repair had cleft lip and palate repair under general anaesthesia with endotracheal intubation at the centre during a five-year period (May 2005 to April 2010) were prospectively studied. The patients’ biographical data, diagnosis and weight and the procedure performed were documented. Records of their American Society of Anesthesiologists (ASA) physical status, preoperative medical and airway problems, associated congenital anomalies, intubation outcomes, intraoperative anaesthetic complications and duration of surgery were taken. The associated postoperative surgical Figure 1: Patients’ age distribution
complications, airway problems and treatment were also recorded. For the purpose of this study, perioperative adverse airway event was defined as an airway complication requiring intervention that occurred in the operating room (OR), post-anaesthesia care unit (PACU), or in the ward until discharge after surgery.
Anaesthesia was administered by the two anaesthetists (co-authors). Inhalational induction with halothane in oxygen or intravenous induction with ketamine or thiopentone sodium was used. Laryngoscopy and endotracheal intubation was performed using a straight or curved blade, as appropriate, Figure 2: Patients’ American Society of Anesthesiologists
under deep inhalational anaesthesia or muscle relaxant (suxamethonium). Intubation outcomes were recorded Table I: Cleft type cross-tabulated against adverse peri-
as: easy if successful with one or two attempts, difficult if requiring three to four attempts, and failed when intubation Adverse perioperative
was not possible with four attempts by an experienced Cleft type
airway event
anaesthetist. Duration of surgery was defined as the time from skin/mucosal incision to the last stitch. Statistical Package for the Social SciencesTM 16.0 software was used for data management and analysis. Al the quantitative parameters were expressed as proportions and mean ± standard deviation (SD). To test for the difference in the proportions between different groups, a chi-square test of significance or Fisher’s exact test was employed with a 110 (94.8%)
116 (100%)
One hundred and sixteen patients were included in the Fisher’s exact test
study, consisting of 53 (45.7%) males and 63 (54.3%) females, who had 131 surgeries. The age at the time of Table II: Associated congenital anomalies
surgery ranged from two months to 50 years, with a mean of 6.1 years (± 9.4 years). The patients’ distribution by age Congenital anomalies
Frequency
The mean weight was 17.4 kg (± 17.4 kg) with a range aASD with hypertelorism and glandular hypospadias of 3-75 kg, while the mean duration of surgery was Low-set ears with orbital hypertelorism and mid- 96.1 minutes (± 52.6 minutes). Al the patients except one had an ASA physical status of 1 or 2 (Figure 2). Microcephaly, micrognathia with low-set ears and The distribution of the cleft types are shown in Table I, while Table II shows the associated congenital anomalies seen in five (4.3%) of the patients. Seventy-five per cent had Mil ard 116 (100)
cheiloplasty, with or without rhinoplasty, and 25.2% had Original Research: Perioperative adverse airway events in cleft lip and palate repair Original Research: Perioperative adverse airway events in cleft lip and palate repair Seven (6%) patients had mild cough and catarrh or chronic fol owing 247 consecutive palatoplasties.12 About 5% of the nasal discharge preoperatively. One of these (14.3%) had patients in this series experienced perioperative adverse a perioperative adverse airway event (difficult intubation airway events. However, the current review included patients associated with desaturation), compared to five (4.5%) of for both lip and palate surgery in isolation or as combined the remaining 109 patients who had no preoperative airway procedures, and three (10%) of the 33 palatoplasty cases symptoms. The relationship between the presence of mild cough and catarrh or chronic nasal discharge at the time Late presentation of patients with cleft deformities is very of surgery and the risk of perioperative adverse airway common in developing countries.13 Only forty per cent of event was not statistical y significant (p= 0.26). Al the cases the patients in this study had their repair done before the with adverse perioperative airway events had a combined age of one. Similar findings were reported by Adeyemo et al cleft lip and palate, except for one who had an isolated in Lagos, Nigeria: only 71.3% of the patients in their study cleft palate repair. Three (10%) of the 33 palatoplasty had their repair by the age of six years.3 Younger age has cases had perioperative adverse airway events. These been associated with increased incidence of perioperative perioperative adverse airway events are described in Table adverse airway events in orofacial cleft and paediatric III, along with the clinical features of the six patients (4.6%). anaesthesia in general.7,12,14 Xue et al7 and Gunawardana14 Postoperative surgical complications (palatal fistula in three showed that the frequency of difficult laryngoscopy and patients and wound dehiscence in two patients) were not intubation is higher in orofacial cleft patients younger significantly associated with perioperative adverse airway than six months of age. The relatively lower incidence of events (p= 0.28). There was significant association between perioperative adverse airway events in the current study perioperative adverse airway events and the type of cleft is attributable to the age at the time of surgery (mean lip and palate (p = 0.02) (see Table I), but not between 6.1 years), compared to 1.5 years noted by Antony and perioperative adverse airway events and the age of the Sloan.12 This factor has to be considered when drawing up patient at the time of surgery (p= 0.38).
an anaesthetic plan for orofacial cleft patients, particularly during surgical outreach programmes. Discussion
Difficult intubation is known to be a main factor in deaths Anaesthesia for cleft lip and palate surgery is known to associated with anaesthesia in surgical patients.7 A case of carry a high risk of adverse airway events.3 In a review of difficult intubation with desaturation, which proved easier perioperative airway complications fol owing pharyngeal when the patient returned without an upper respiratory flap palatoplasty, Peña et al reported an incidence of 10% in tract infection (URTI), was noted in this study. The ongoing the 88 patients studied,3 while Antony and Sloan recorded infection and inflammation could have contributed to the an incidence of 5.7% in their study of airway obstruction difficulty in intubation and desaturation experienced during Table III: Perioperative adverse airway events and patient characteristics
Patient Biodata and characteristics
Airway complications
Treatment
4.5 months, 6.5 kg, right cleft lip and palate, Difficult intubation and desaturation 11 months, 6 kg, left cleft lip and palate, Best laryngoscopic view was Cormack and Postponed until child is 10 kg associated microcephaly, micrognathia and Lehane III: failed intubationhypertelorism 2.5 years, 13 kg, cleft soft palate with bifid 1 year, 8.6 kg, left cleft lip and palate, had Reintubation in the OR, nursed in the ICU with ETT for 72 hours, hydrocortisone, nebulised adrenaline, oxygen, antibiotics and analgesic, discharged POD 7 15 months, 9 kg, left cleft lip and palate, Postoperative chest infection 24 hours after Oxygen, hydrocortisone, antibiotics, had palatoplasty, IV diazepam 1 mg stat in PACU, then 5 mg every 8 hours for 24 hours 8 months old, 5.5 kg, bilateral cleft lip and Postoperative chest infection 24 hours after Oxygen, nebulised salbutamol, IV furosemide, digoxin, antibiotic, hydrocortisone and supplemental oxygen, improved after 72 hours, discharged POD 7 Original Research: Perioperative adverse airway events in cleft lip and palate repair Original Research: Perioperative adverse airway events in cleft lip and palate repair the initial presentation of this patient for anaesthesia and obstruction.12,15,16 Although the presence of a syndromic surgery. A case of failed intubation in which anaesthesia disease in the patients in the current series could not be was safely reversed was also recorded. The current study established because of the unavailability of a geneticist’s suggests an association between perioperative adverse services, the only child with failed intubation had associated airway events and combined cleft lip and palate compared microcephaly, micrognathia and orbital hypertelorism to isolated cleft lip. Takemura et al5 and Xue et al7 noted a suggestive of a syndromic disorder. A thorough physical similar finding in their reports on infants with more severe examination and the ability to detect anomalies that could cleft lip and palate: those who had bilateral cleft lip and impact on the management outcome of cleft lip and palate palate had a significantly higher incidence of perioperative is routine in the authors’ practice and should be emphasised respiratory complications than those with simple cleft lip.
particularly in resource-poor nations.
Early feeding difficulties associated with cleft lip and Conclusion
palate are known to result in inadequate weight gain, and nasal cavity irritation from food and saliva, coupled Adverse respiratory airway events are not uncommon with impairment of the nasal filtration function, can cause in orofacial cleft surgery. These complications usual y infections, such as rhinitis, sinusitis and tympanitis. Thus, occur immediately fol owing extubation or in the early infants with orofacial cleft may present with recurring postoperative period. More severe forms may necessitate respiratory infections. Surgical repair promotes an admission to an intensive care unit and specialised care. improvement in these conditions and therefore al efforts This study suggests that combined cleft lip and palate, should be made to avoid undue cancel ation of surgery. palatoplasty, and younger age are associated with an However, the risks of anaesthesia and perioperative adverse increased incidence of perioperative adverse airway events.
airway event, should be individual y balanced against the benefits of surgery within the limit of safety. One of the Conflict of interest
eight patients with mild URTI at the time of surgery had a The authors declare no financial support or conflict of perioperative adverse airway event (difficult intubation with associated desaturation postintubation). This resulted in longer hospital stay, but the association between URTI and References
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Extensive pharyngeal packing could also have contributed 12. Fillies T, Homann C, Meyer U, et al. Perioperative complications in infant cleft repair. Head & Face Medicine 2007;3:9. Available from http://www.head-face- 13. Adeyemo WL, Ogunlewe MO, Desalu I, et al. Cleft deformities in adults and children Orofacial cleft is associated with over 200 syndromes aged over six years in Nigeria: Reasons for late presentation and management or sequences, and several have significant anaesthetic challenges. Clinical, Cosmetic and Investigational Dentistry 2009;1:63-69.
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