General Anaesthesia Flashcards
Definition of ga
- A state of controlled unconsciousness during which you feel nothing
- pharmological means of achieving pain control and behaviour management that enables dental treatment for children
Number of XGAs for U18s in 2016
43000
Why is there a need for GA
- Combination of prevalence of disease and ability of children to cope with treatment
- 31% of 5yos and 45% of 8yos have experience of decay
Socio-economic inequalities and decay link
- Children from lower income fams twice as likely to have decay
- More likely to experience toothache and report problems in their daily life caused by their oral health
Care pathway for GA
- Referred child from a primary care setting
- Assessment appointment
- Hospital appointment/ special care hospital setting if mh complex/ other treatment form indicated eg ihs
What should a GDP do when referring pt for GA
- discuss need for referral
- make fam aware of risks associated with treatment
- refer to a local ga service provider
- clearly justify the need for ga
When should u consider la+/- ihs for children
- Cooperate children
- Routin conservation
- Single extractions
- Preference of child/patient
- Preferable in certain medical conditions
what should assessment of ga patient entail and who should do it
- Ideally a paeds specialist
- Assessment, diagnosis, tx plan, management of children
- trained and experienced in behavioural management of children including conscious sedation
What general considerations should be taken into account
- Co-operative ability of child
- Perceived anxiety and how child has responded to similar procedures
- degree of surgical trauma anticipated
- complexity of the operative procedure
- medical status of child
2 main indications for ga
- The child is too young, too anxious or uncooperative to accept treatment by any other means
- Surgeon needs the guarantee of a completely still patient usually because the planned procedure is complex
all the indications for ga
- no cooperation
- very young children
- anticipated distress from la (based on past experience)
- multiple extractions
- surgical extractions
- preference of child/parent
- preferable in certain medical conditions
- extensive treatment
- difficult or complex dental treatment
Contraindications of ga and extenuating circumstances of these contras
The following circumstances rarely justify GA
- Carious, asymptomatic teeth with no clinical or radiographic signs of sepsis
- Orthodontic extraction of sound permanent premolar tooth in a healthy child
- Patient/carer preference, except where other techniques have already been tried
However, extenuating circumstances that override the above limitations include:
- physical, emotional, learning impairments or combinations of two or more of these
- children who have attempted treatment using la alone or la with ihs and still unable to cooperate
- medical problems which are better controlled with the use of ga
Examples of treatment that may require ga
- Severe pulpitis
- Sub mandibular abscess
- Dento-alveolar surgery
- Multiple XGAs in under 5s
- symptomatic teeth causing pain in. more than 2 quadrants
- symptomatic teeth where bilateral idb maybe needed
- Ankylosis extractions
- Extraction of FPMs
- Biopsy
- Debridement and suturing
- Full mouth rehabilitation
- EUA (special needs children)
Minor risks of GA
- Pain
- Headache
- Sore throat
- Sore nose
- Nausea
- Vomiting
- Upset stomach
What risks do you have to inform the patient
- Minor risks
- Risks of procedure (eg extraction consent
- Major risks
How likely is death from GA
- Less than 1 in 100,000
- 1 child in 10,000 develop serious allergic reaction
What should be included in consent form and what type of consent
- Verbal and written consent
- Informed consent
- Tx plan, benefits and risks
- Alternative tx options
- Process of GA, side effects and complications
- Pre op fasting, appropriate escorts, suitable transport home, post op care and analgesia
who can consent for tx
- Childs mother
- childs father if married to the mother at birth
- Unmarried fathers with parental responsibility
Where should child ga taken place
- Always in a hospital setting
- Ideally paediatric environment
What is a day case
- Child not kept overnight
- Goes home after normal bodily functions are restored
types of ga
Open airway
Laryngeal mask
Intubation
What are the types of ga and pros/cons
Open airway (NAMI)
Laryngeal mask
- Not good for long procedures
- Prone to dislodgement
Intubation
- Oral or nasal
- Nasal better for dentistry
What form of ga would u use in a short procedure eg. xls of a single tooth in young child
McKesson nasal mask
- Leaves mouth free for access
- Airway left open and gauze used to protect
- Short procedures only
What form of ga would u use for multiple xlas or small and simple surgical procedure
Laryngeal mask
- Sits over vocal chords
- Not in trachea
- Limited access
- Easily dislodgement
- Not good if super long tx
What would u use for long complex tx
- Oral or nasal tube
- Robust airway is required
- Complex surgical procedure
- Greater access if nasal tube but perhaps link with post op nasal bleeds
What should u check on the day
- Check fasting
- Go for a piss
- Rx available
- Special test results available
- Patient and guardian present for consent and recovery
What needs to be checked during discharge/recovery
- Monitor pulse, oxygen levels, BP, ECG
- Can walk without feeling faint
- Orientated in time and space
- Not dehydratted
- Can drink
- Haemostasis
- Written instruction to parents
- Review arranged
what should post op instructions cover
- analgesia
- post op nausea and vomiting
- residual effects of ga
- bleeding
- mouth care
- details of sutures in situ
- eating
- return to school or normal activities
- lines of communication in the event of post operative problems
- prevention of caries
