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Literature Review

Correlation of Cleft Type With Incidence of Perioperative Respiratory Complications in Infants with Cleft Lip and Palate.

Takemura H, Yasumoto K, Toi T, Hosoyamada A. Paediatric Anaesthesia 2002;12:585-588

In this retrospective survey, the authors determined the association of the incidence of perioperative respiratory complications with the increasing severity of common cold symptoms (Common Cold Score) in 339 infants, age 2-5 months, undergoing surgery for repair of cleft lip and palate The Common Cold Score is comprised of 10 symptoms or findings as follows: 1) nasal obstruction, rhinorrhea, sneezing. 2) redness of pharynx, swelling of tonsils. 3) cough, sputum, hoarseness. 4) abnormal breath sounds. 5) high fever, over 38 C. 6) loss of appetite, vomiting, diarrhea. 7) abnormal findings on chest x-ray. 8) increase in white cell count of over 12 thousand. 9) common cold symptoms within the 2-week preoperative period. 10) ageing factor (immune factor): under 6 months of age. Each item was assigned 1 point. The degree of severity was was graded in 3 groups: healthy group 0-2 points, borderline group 3-4 points, high-risk group 5-10 points. The infants were also divided into 3 groups with regards to surgery: group 1 (n=125) cleft lip and jaw, group 2 (n=154) unilateral cleft lip and palate, group 3 (n=60) bilateral cleft lip and palate. The respiratory complications were categorized as desaturation, laryngospasm, increased airway secretions, bronchospasm, and bouts of coughing.

All patients received atropine 0.015 mg/kg, i.m. Anesthesia was induced with a face mask using 5% sevoflurane, 33% oxygen and balance nitrous oxide. Intubation was achieved without the use of muscle relaxants and patients were mechanically ventilated. Sevoflurane was adjusted to 1.5 to 3 %. Opioids were not administered.

Comments: 326 (96%) of the patients were classified in the healthy group, with the remaining 13 (4%) in the borderline group, there were none in the high-risk group. Respiratory complications were noted in 12 out of 326 patients (4%) in the healthy group and in 3 out of 13 patients (23%) in the borderline group (P<0.001). As per grouping of surgical severity, respiratory complications were noted in 2 out of 119 (1.7%) patients in group 1, in 5 out of 151 (3.3%) patients in group 2, and 5 out of 56 (8.9%) in group 3. Statistical significance was noted between groups 1 and 3. We note, that the healthy infants with bilateral cleft lip and palate had the highest incidence of respiratory complications. The authors feel that perhaps these patients had more frequent respiratory infections because of the surgical anomaly, rhinorrhea may have been underestimated and repeated infections may have induced in these infants a reactive airway. The authors feel that as there was a higher incidence of respiratory complications in patients with borderline common cold scores, therefore elective surgery for the repair of cleft lip and palate in this group be postponed. By the same token, they have shown that even in the healthy group there was a higher incidence of respiratory complications in infants with wide clefts. This finding leaves us in a quandary. The debate as to when to cancel an infant's surgery because of a common cold remains a moot point. Any process that helps delineate risk factors for any procedure is usually helpful. But in the final analysis it is a judgment call whether one should decline to administer anesthesia in the name of patient safety, and this requires clinical acumen, only gained through experience.

Reviewed by: Hoshang J. Khambatta, MD

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