P. M. Velankar, MD, Preety Sahu, PG Resident (MD Anesthesiology)
A six months old female infant weighing 6.5 kg was brought to International Medical Mission organized by a Non-Governmental Organization (NGO) for repair of cleft lip. The baby was evaluated and prepared for surgery in all respects. On the operating table, she was premedicated with glycopyrrolate 25 µg IV. General anesthesia was induced with inj. ketamine 6 mg, supplemented with nitrous oxide, oxygen (50:50) and halothane in Goldman vaporizer using Jackson Rees circuit. Inj. atracurium 3 mg was given. After confirming bag-mask ventilation Ambu® Laryngeal Mask (ALM) size 1.5 was inserted without any difficulty, the cuff inflated and the ALM was secured in the centre of the lower lip. The child was then positioned for surgery. The surgeon packed the oral cavity all around above the level of the ALM cuff. Anesthesia was maintained with N2O, O2 (60:40) and halothane with controlled ventilation. During surgery the child was monitored with pulse oximeter and heart rate and arterial O2 saturation were noted to be within normal limits. Surgery lasted for about 50 minutes. Intra operatively 20 ml of pediatric electrolyte solution was infused. At the end of surgery residual effect of atracurium was reversed with neostigmine+atropine, pack was removed, oral suction done and ALM removed without deflating the cuff after ensuring adequate ventilation and good muscle tone. Post operative course was uneventful.
We used ketamine in this case to facilitate IV induction and to provide inta-operative analgesia as we did not have fentanyl which is an ideal intra-operative analgesic.1 Ketamine has also been used previously for induction and maintenance of anesthesia for cleft lip surgery in rural areas.2 We had to use halothane in Goldman vaporizer for induction of GA as the only available option.
Ideal tracheal tube for cleft lip surgery is preformed RAE tube(south polar), as it can be fixed centrally over the lower lip allowing for optimal surgical access.1 However, infants with Pierre-Robin,Treacher-Collins and Goldenhar syndromes and other cases of difficult airway have been successfully managed with LMA.1,3 It has also been used as a conduit through which fibreoptic bronchoscope can be passed to facilitate tracheal intubation.1 LMA has also been used in intra oral surgery like adenotonsillectomy and for airway maintenance and protection for syringing and probing in children as a better alternative to endotracheal tube.4,5 We used ALM as an alternative to tracheal tube in this case though it was not a case of difficult intubation and found it safe to secure the airway. Moreover, because of it’s shape it can be easily fixed to the centre of lower lip.
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