General anaesthesia for dental treatment for children

Question 1

What is general anaesthetic

Answer 1

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

Question 2

is ga done in general practice

Answer 2

no, facilities must include access to paediatric intensive care unit (PICY) or rapid transfer

Question 3

how do anaesthetics work

Answer 3

anaesthetic agents produce anaesthesia by depressing specific areas of the brain

Question 4

how do inhaled agents work

Answer 4

enter through lungs, distributed to tissues by the circulation, reach specific sites in the CNS by crossing the BBB. Magnitude of CNS depression is proportional to partial pressure as they reach the CNS.

Question 5

how do IV agents work

Answer 5

given straight into circulation, distributed through the body and reach specific sites in the CNS by crossing the BBB

Question 6

how does a child’s anatomy differ to an adults

Answer 6

1. large head, short neck, large tongue
2. narrow nasal passages
3. obligate nasal breathers at birth
4. high anterior larynx
5. larynx narrowest at cricoid cartilage
6. large floppy epiglottis (why children suffer from croup)

Question 7

how does a child’s respiratory physiology differ to an adults

Answer 7

1. low functional residual capacity (FRC)
2. closing volume is greater than FRC up to 5 years, leading to increased ventilation/perfusion mismatch
3. horizontal ribs, weak intercostal muscles leading to relatively fixed tidal volume
4. O2 consumption is high (6ml/kg/min compared to 3ml/kg/min in adults)

Question 8

how does a child’s temperature regulation differ to an adults

Answer 8

1. high surface area to body weight ratio
2. large head surface area and heat loss
3. require a higher temperature for a thermoneutral environment
4. immature responses to hypothermia (poor shivering and vasoconstriction)
5. brown fat metabolism which increases O2 consumption

Question 9

how does a child’s nervous system differ to an adults

Answer 9

1. increased incidence of periodic breathing and apnoeas
2. ventilatory response to CO2 is more readily depressed by opiates
3. immature neuromuscular junction leads to increased sensitivity to muscle relaxants

Question 10

common inhaled drugs?

Answer 10

• nitrous oxide
• sevoflurane
• halothane
• isoflurane
• desflurane

Question 11

common IV drugs?

Answer 11

• propofol

Question 12

who decides on what drugs to use

Answer 12

the anaesthetist

Question 13

what factors influence what drugs the anaestheist decides to use?

Answer 13

• type of procedure
• patient preferences for induction
• medical history
• previous GA experience
• anaesthetists recommendations
• equipment
• staff

Question 14

what are the different types of airway used during anesthetic

Answer 14

• LMA (laryngeal mask airway - most common for dental)
• nasal endotracheal intubation
• oral endotracheal intubation

Question 15

what is essential to use alongside an airway no matter the type

Answer 15

a throat pack

Question 16

what is a throat pack

Answer 16

Some gauze placed towards the back of the mouth away from where you are working so that it catches saliva, water, any blood, material that could fall into the airway

Question 17

what are the different stages of anesthesia

Answer 17

1. induction
2. excitement
3. surgical anaesthesia
4. respiratory paralysis/overdose

Question 18

what are the GDC expectations with regard to dentists and anaesthesia

Answer 18

• 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 GOD
• be competent in when, how and where to refer a patient for GA
• evaluate the risks and benefits of treatment under GA

Question 19

If you have difficulty maintaining an airway in a baby what factors may be causing the problem and what can you do about it?

Answer 19

large head and high larynx means airway may become obstructed if child is not positioned optimally, eg with head on a pillow, or with head and neck extended. The head needs to be in a neutral position. A large tongue may cause obstruction, a guedel airway may help. An incorrect mask size may result in leaks, have a range available.

Question 20

Why should babies and small children be ventilated rather than breathing spontaneously through an endotracheal tube?

Answer 20

Endotracheal tubes have a higher resistance than the normal airway as they are long and narrow in diameter. This increases work of breathing.

Question 21

How can you tell that a spontaneously breathing child is getting fatigued?

Answer 21

Respiratory rate will rise initially then fall. Tidal volume will decrease, end tidal CO2 will rise. Eventually they will desaturate, but this is a late sign.

Question 22

Why is it important to maintain a normal heart rate in a child?

Answer 22

The stroke volume is relatively fixed and cardiac output is rate dependent. Bradycardia will reduce cardiac output. Excessive tachycardia will prevent adequate ventricular filling in diastole.

Question 23

what are the 2 main indications for GA for children

Answer 23

1. child needs to be asleep for treatment because there is a beilef 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
2. dentist needs patient to be guaranteed to be completely still, operation is complex i.e. the surgeon needs the child to be fully anaesthetised

Question 24

what is the main GA conraindication

Answer 24

when risks do not outweigh the benefits

Question 25

what are the major risks of GA

Answer 25

chance of serious outcome/ major adverse event = 3 in a million serious outcomes are death, will not wake up again, brain damage

Question 26

what are minor risks and complications of GA

Answer 26

- pain - headache - nausea/ vomiting - sore throat - sore nose/ nose bleed - drowsiness - upset - increased anxiety about future dental treatment - risks from treatment (pain, bleeding, swelling, bruising, loss of space, visible restoations, restorations may be lost/fail/wear through, stitches) - damage to mouth/ oropharynx - minor allergic reactions - malignant hyper pyrexia (rare! but v important to ask FH of this!) - slow recovery - prolonged apnoea - prolonged bleeding - plus risks of your actual treatment

Question 27

what are some GA safety precautions

Answer 27

- GA has small risk of mortality so it must be justified - airway is shared - dentist and anaesthetist -

Question 28

what are some GA safety precautions

Answer 28

- GA has small risk of mortality so it must be justified - airway is shared - dentist and anaesthetist - need to have space, facilities, equipment, appropriately trained personnel - agreed protocols to summon help and ensure timely transfer to specialist anaesthetic and medical care - WHO surgical safety checklist (brief before, debrief after)

Question 29

what is really important to remember when working on the mandible

Answer 29

the mandible can easily fall/ be pushed backwards and the chin fall onto the chest which obstructs the airway! dentist must be aware of this

Question 30

what are ways to reduce the number of GAs a child needs to have

Answer 30

sometimes possible to do a joint GA with other medical specialities

Question 31

what is the post op discharge criteria

Answer 31

- fully conscious, able to maintain clear airway, exhibits protective reflexes - satisfactory oxygenation and respiration - CVS stable - pain, nausea and vomiting controlled - temperature in normal limits - eaten, drunk, been to toilet

Question 32

what are the post-op instructions

Answer 32

- pain control - travel home (private car or taxi) - 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

Question 33

describe the process of GA consent

Answer 33

- consent is an active process - primary care dentist makes initial decision that GA may be necessary - explaination of risks and benefits of GA and all alternative options - explaination of how different treatment modalities might affect the treatment plan - advise that 1st appointment will be for treatment planning only and that the plan may change with specialist opinion

Question 34

who can consent for children? (see lecture slide for full)

Answer 34

- Mother automatically - Father if married to mother at time of child’s birth (Eng/ W/NI), conception (Scot) or subsequently - Unmarried father if named on birth certificate (at reg or re-reg) after 15/04/2002 for NI, 1/12/2003 Eng+Wales, 04/05/2006 Scot Unmarried father whose child registered before these dates OR if not mentioned on birth certificate DOES NOT automatically have parental responsibility May acquire by a court registered parental responsibility agreement with the mother or by obtaining a parental responsibility order or a residence order from the courts - Adoptive parents (if legally adopted) - Child’s mother and father if both on birth certificate after 15/04/2002 for NI, 1/12/2003 Eng+Wales, 4/05/2006 Scot - Married step-parents and registered civil partners can acquire parental responsibility by a court registered parental responsibility agreement with the mother or by obtaining a parental responsibility order or a residence order from the courts - Legally appointed guardian - Person with a residence order concerning the child - Local authority that is designated to care for the child - Local authority or person with an emergency protection order for the child - If no legal guardian then social services will need to be involved N.B: Foster parents and kinship carers DO NOT have automatic parental responsibility

Question 35

when can a child consent to medical treatment

Answer 35

can consent under 16 years old if 'gillick competent'

Question 36

when should the first stage of GA consent happen and why

Answer 36

on a separate day before the operation to give parents and child time to fully understand all the risks, benefits and alternatives and to give time to ask questions etc

Question 37

what pre-op info should be given

Answer 37

fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements, post-op care and pain control

Question 38

is verbal consent enough for GA

Answer 38

no, GA MUST have written consent

Question 39

what should a referral letter for GA include

Answer 39

- Patient name - Patient address - Patient/ Parent contact numbers- landline and mobile - Patient medical history - Patient GP details - Parental responsibility - Justification for GA - Proposed treatment plan - Previous treatment details - Recent radiographs or if not available explanation of why (e.g. I have attempted to take bitewings/ periapicals but the patient is uncooperative)

Question 40

True or false: a biological mother always has parental responsibility unless it has been removed from her by a court

Answer 40

true

Question 41

True or false: a child is living with their maternal grandmother, there is no fathers name on their birth certificate and grandmother tells you that the child lives with her because mum has a chaotic life. In this case the grandmother can consent to all dental treatment

Answer 41

false (can only consent in emergency situations as mother retains parental responsibility)

Question 42

step parents automatically gain parental responsibiliity when they marry a child's biological parent

Answer 42

false (can apply to the courts for it)

Question 43

adoptive parents have parental responsibility following completion of the adoption process

Answer 43

true

Question 44

when parents divorce parental responsibility is given to the parent that the child lives with the majority of the time

Answer 44

false (it stays with both parents unless given up or removed by a court)