Optimizing Perioperative Anesthesia Protocols for Global Delivery of Safe Cleft Surgery

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.

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.

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.

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.