GA for dental treatment for children Flashcards
(41 cards)
1
Q
What is general anaesthetic?
A
- Any technique using equipment or drugs which produces a loss of consciousness in specific situations associated with medical or surgical interventions
- Loss of consciousness or abolition of protective reflexes
2
Q
What does PICU stand for?
A
- Paediatric intensive care unit
3
Q
How do anaesthetic agents produce anaesthesia?
A
- By depressing specific areas of the brain
4
Q
How do inhaled GA agents work?
A
- Inhaled agents enter through lungs, distributed to tissues by the circulation, reach specific sited in the CNS by crossing the blood brain barrier.
- Magnitude of CNS depression is proportional to partial pressure as they reach the CNS
5
Q
How do IV GA agents work?
A
- IV agents are given straight into the circulation, distributed through body and reach specific sites in CNS by crossing the blood brain barrier
6
Q
What are the differences in anatomy of children that may affect GA? (6)
A
- Large head, short neck, large tongue
- Narrow nasal passages
- Are obligate nasal breathers at birth
- High anterior larynx
- Larynx narrowest at cricoid cartilage
- Large floppy epiglottis
7
Q
What is the respiratory p h ysiology of a child like? (4)
A
- Low functional residual capacity
- Closing volume is greater than FRC up to 5 years of age, leading to increased ventilation/perfusion mismatch
- Horizontal ribs, weak intercostal muscles leading to relatively fixed tidal volume
- Oxygen consumption is high 6ml/kg/min compared to 3ml/kg/min in adults
8
Q
What is the temperature regulation of a child like? (5)
A
- High surface area to body weight ratio
- Large head surface area and heat loss
- Require a higher temperature for a thermoneutral environment
- Immature responses to hypothermia (poor shivering and vasoconstriction)
- Brown fat metabolism increases oxygen consumption (brown fat metabolism uses a lot more oxygen)
9
Q
What is the nervous system of children like? (3)
A
- Increased incidence of periodic breathing and apnoeas
- Ventilatory response to CO2 is more readily depressed by opiates
- Immature neuromuscular junction leads to increased sensitivity to muscle relaxants
10
Q
What are common inhaled agents for GA? (5)
A
- Nitrous oxide, sevoflurane (agent of choice for induction), halothane, isoflurane, desflurane
11
Q
What is the inhaled agent of choice for inhaled induction?
A
- Seloflurane
12
Q
What is an IV, GA agent?
A
- Propofol (used for induction and in some situations for maintenance)
13
Q
The anaesthetist will decide on what drug they will use to give a GA. What does this depend on? (8)
A
- Length and type of procedure
- Patient preferences for induction
- Medical history
- Previous GA experience
- Anaesthetists recommendations
- Equipment
- Staff
- Other resources
14
Q
Children can’t maintain their own airway when they are anaesthetised. What are different types of airway that can be used? (3)
A
- LMA (laryngeal mask airway) - most common
- Nasal endotracheal intubation
- Oral endotracheal intubation
REGARDLESS THROAT PACK IS REQUIRED
15
Q
Why is nasal endotracheal intubation good?
A
- As the tube isn’t in the mouth so you have more access
16
Q
What is a throat pack?
A
- A throat pack is some gauze that when you are working you would pack into the tube
- Towards the back of the mouth and away from where you are working so it catches the saliva, the water you are using, and any blood or bits of material
- Anything that could fall down and go into the airway
17
Q
What are the conscious levels/stages of anaesthesia? (4)
A
- Stage 1: Induction
- Stage 2: Excitement
- Stage 3: Surgical anaesthesia
- Stage 4: Respiratory paralysis/overdose
- Historically observed with ether, modern anaesthetics are FAR more potent so induction and passage through stages is rapid
18
Q
What happens in the excitement stage of anaesthesia?
A
- The patient’s bodyis moving around
- Parents need to be warned about this as if we don’t warn them it can be quite upsetting
19
Q
What is in the GDC standards document for the GDC’s expectations of the GDP when referring for GA? (3)
A
- As a registered dental professional you could be held responsible for the actions of any member of your team who does not have to register with the GDC
- Be competent in when, how and wh ere to refer a patient for GA
- Evaluate the risks and benefits of treatment under GA
20
Q
What are the possible indications that a GA is required to treat a child patient? (2)
A
- Child needs to be asleep for treatment because there is a belief that they are too young, too anxious, or too uncooperative to accept treatment any other way i.e. the child needs to be fully anaesthetised
OR
- Dentist needs patient to be guaranteed to be completely still, operation is complex i.e. the surgeon needs the child to be fully anaesthetised
21
Q
What is the main contraindication for GA?
A
- If the risks of the procedure do outweigh the benefits
22
Q
What are the major risks of GA?
A
- Rare
- Serious outcome/major adverse event 1:400,000, 3 in a million
- Death, will not wake up again, brain damage
- Parents must be warned even though there is a very small risk. Dentists must be sensitive in how they broach this
23
Q
What are common minor risks and complications of GA that you must warn the parent of? (8)
A
Common:
- Pain
- Headache
- Nausea, vomiting
- Sore throat
- Sore nose/nose bleed
- Drowsiness
- Upset (when come round from anaesthesia)
- Increased anxiety about future dental treatment
24
Q
What are common risks from the treatment when the child has had treatment under GA? (8)
A
- Pain
- Bleeding
- Swelling
- Bruising
- Loss of space
- Visible restorations
- Restorations may be lost/fail/wear through
- Stitches
25
What are GA risks and complications that the parent needs to be made aware of? (9)
- Damage of mouth/oropharynx from intubation
- Minor idiosyncratic/allergic reactions - nausea and vomiting
- Malignant hyperpyrexia (RARE but VERY important to ask re FH of this! need specific care - It is a reaction to inhaled anaesthetic agents)
- Slow recovery from anaesthetic
- Prolonged apnoea after muscle relaxant (suxamethonium)
- 'awareness' - paralysed but not effective anaesthesia
- Laryngospasm
- Coughing/moving during procedure - anaesthetic too light during stimulation e.g. extractions
- Prolonged bleeding intra-operatively or bleeding post-op
26
Why is it necessary to have space, facilities, equipment and appropriately trained staff when performing a GA?
- As there is a small risk of mortality so if an emergency arises and resuscitation is required we need the resources close by
- Agreed protocols to summon help and ensure timely transfer to specialist anaesthetic and medical care e.g. PICU or high dependency
27
What is included in the WHO surgical safety checklist?
- Breif before list, debrief after
| - For every patient every time: sign in, time out, sign out
28
During dental treatment, especially extractions on the lower arch, what must the dentist be aware of if the patient is under GA?
- The mandible can easily fall or be pushed backwards and the chin to the chest - OBSTRUCTUNG AIRWAY
- Dentist must be aware of this and lift the mandible or anaesthetist/assistant may help to hold mandible forward
29
GA has risks so we want to minimise the number of GA's a patient has. What is one way we can do this?
- May be possible to do a joint GA with other medical specialities e.g. ENT- tonsils, Haem/Onco-lumbar punctures, cardiac- TOE. Plastics - dressing/stitching, Maxfac - cleft surgery
30
Some medical conditions require careful work up for GA. Give a few examples of these? (10)
- Sickle cell disease
- Down's syndrome
- Bleeding disorders
- Cardiac conditions
- Renal disease
- Diabetes
- Liver disease
- Cystic fibrosis
- Severe asthma
- Epilepsy
31
What are the post-op discharge criteria for a patient? (6)
- Fully concious, able to maintain clear airway, exhibits protective reflexes
- Satisfactory oxygenation and respiration (2-5yrs = 24-30 breaths/min and 5-12yrs = 20-24 breaths/min)
- CVS stable - no unexplaines cardiac irregularities, no persistent bleeding, pulse and BP acceptible, adequate peripheral perfusion (HR 2-10yrs mean 80BPM, BP for 1-10yrs = 90 + 2 x age in yrs)
- PAin anusea and vomiting controlled
- Temperature in normal limits
- Eaten, drunk and been to toilet
32
What are post-op instructions you would give to the parent? (11)
- Pain control
- Travel home
- Rest/quiet play
- Monitoring
- What to look out for - pain, bleeding etc
- Next day off school/nursery
- Extraction advice
- Soft diet
- Prevention
- Follow up
- Discharge letters (sent back to the referring dentist and doctor)
33
Is consent an active or passive process?
- Active
34
The primary care dentist makes the initial decision that GA may be necessary. What must they explain in the appointment with the patient? (3)
- Explain the risks and benefits of GA and all other alternative options
- Explain how different treatment modalities might affect the treatment plan - GA treatment plans are more radical with reliable and clear prognostic outcomes (i.e. you should be confident the plan will last 5 years without child having pain)
- Advise that 1st appointment will be for treatment planning ONLY and that plan may change with a specialist opinion
35
Who can consent for children? (13)
- Birth mother automatically
- Father if married to mother at time of childs birth (Eng/W/NI), conception (Scot) or subsequently
- Unmarried father if named on birth certificate after 04/05/2006 Scot
- Unmarried father whos child registered before the date or if not mentioned on the birth certificate DOES NOT automatically have parental responsibility
- Adoptive parents (if legally adopted)
- Child's mother and father if both on birth certificate after 04/05/2006
- Married step parents and registered civil partners can acquire parental responsibility
- Legally appointed guardian
- PErson with a residence order concenring the child
- Local authority that is designated to care of child
- Local authority or person with an emergency protection order for the child
- If no legal guardian the social services will need to be involved
- N.B. foster parents and kinship carers DO NOT have automatic parental responsibility
36
Consent to medical treatment can be given by a child under the age of 16 if they are 'Gillick Competent'. What does this mean?
- Children under the age of 16 can consent to medical treatment if they have sufficient maturity and judgement to enable them fully to understand what is proposed.
37
When should the first stage of consent be done for GA treatment?
- First stage of consent should ideally be done on a separate day before the operation to give parents and children time to fully understand the risks, benefits and alternatives and to give them time to ask questions etc
38
Pre-op information should be given at the first appointment about the GA treatment. What should be included in this? (7)
- Pre-op preparation including fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements, post-op care and pain control
39
What type of consent must you get for GA treatment?
- MUST have written consent for a GA
40
What should be included in a referral letter for a GA? (9)
- Patient name
- Patient address
- Patient/parent contact numbers - landline and mobile
- Patient MH
- Patient GP details
- Parental responsibility
- Justification for GA
- Proposed TP
- Previous treatment details
41
What MUST be included in a referral letter, and if these are not available it MUST be stated why they are not available?
- Recent radiographs
