Optimizing Perioperative Anesthesia Protocols for Global Delivery of Safe Cleft Surgery.

Abstract

Background: The purpose of this article is to highlight the nuances in the perioperative anesthetic management of a patient with a cleft lip and/or palate (CL/P) through underscoring the importance of nutrition and fasting guidelines in the preoperative period, airway and pain management intraoperatively, and feeding and pain management in the immediate postoperative period.

Methods: The authors outline key concepts in the perioperative anesthetic management of patients with CL/P through a literature review and the senior author's (Z.G.) experience providing anesthetic care in a low- or middle-income country.

Results: A comprehensive preoperative examination is required to identify concurrent morbidities or anomalies and implement appropriate treatment before surgical repair. Patient optimization is critical for favorable outcomes after CL/P repair and begins in the preoperative period and ends after patient stabilization postoperatively. Anesthesia providers contribute to perioperative management through the assessment, monitoring, and treatment of malnutrition; safe feeding and fasting times preoperatively and postoperatively; using reliable pain scales and regimens intraoperatively and postoperatively; and being in clear and constant communication with all members of the cleft care team to maintain patient safety.

Conclusions: A patient with a CL/P undergoing surgical repair requires a thorough preoperative history and physical examination, nutritional assessment, and a nil per os protocol that mitigates prolonged fasting. Intraoperatively, intubation and extubation with the assistance of a video laryngoscope and adherence to a throat pack protocol are essential. Postoperatively, a standardized pain management protocol with nonopioid medications and early reinitiation of feeding are integral for optimizing outcomes.