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BDS3 Caries Symposium > GA for dental treatment for children > Flashcards

GA for dental treatment for children Flashcards

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
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2
Q

What does PICU stand for?

A
  • Paediatric intensive care unit
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3
Q

How do anaesthetic agents produce anaesthesia?

A
  • By depressing specific areas of the brain
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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
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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
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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
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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
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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)
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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
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10
Q

What are common inhaled agents for GA? (5)

A
  • Nitrous oxide, sevoflurane (agent of choice for induction), halothane, isoflurane, desflurane
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11
Q

What is the inhaled agent of choice for inhaled induction?

A
  • Seloflurane
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12
Q

What is an IV, GA agent?

A
  • Propofol (used for induction and in some situations for maintenance)
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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
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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

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15
Q

Why is nasal endotracheal intubation good?

A
  • As the tube isn’t in the mouth so you have more access
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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
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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
Q

What are GA risks and complications that the parent needs to be made aware of? (9)

A
  • 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
Q

Why is it necessary to have space, facilities, equipment and appropriately trained staff when performing a GA?

A
  • 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
Q

What is included in the WHO surgical safety checklist?

A
  • Breif before list, debrief after

- For every patient every time: sign in, time out, sign out

28
Q

During dental treatment, especially extractions on the lower arch, what must the dentist be aware of if the patient is under GA?

A
  • 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
Q

GA has risks so we want to minimise the number of GA’s a patient has. What is one way we can do this?

A
  • 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
Q

Some medical conditions require careful work up for GA. Give a few examples of these? (10)

A
  • Sickle cell disease
  • Down’s syndrome
  • Bleeding disorders
  • Cardiac conditions
  • Renal disease
  • Diabetes
  • Liver disease
  • Cystic fibrosis
  • Severe asthma
  • Epilepsy
31
Q

What are the post-op discharge criteria for a patient? (6)

A
  • 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
Q

What are post-op instructions you would give to the parent? (11)

A
  • 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
Q

Is consent an active or passive process?

A
  • Active
34
Q

The primary care dentist makes the initial decision that GA may be necessary. What must they explain in the appointment with the patient? (3)

A
  • 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
Q

Who can consent for children? (13)

A
  • 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
Q

Consent to medical treatment can be given by a child under the age of 16 if they are ‘Gillick Competent’. What does this mean?

A
  • 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
Q

When should the first stage of consent be done for GA treatment?

A
  • 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
Q

Pre-op information should be given at the first appointment about the GA treatment. What should be included in this? (7)

A
  • 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
Q

What type of consent must you get for GA treatment?

A
  • MUST have written consent for a GA
40
Q

What should be included in a referral letter for a GA? (9)

A
  • 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
Q

What MUST be included in a referral letter, and if these are not available it MUST be stated why they are not available?

A
  • Recent radiographs

BDS3 Caries Symposium (7 decks)

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