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Caries symposium 2 > General anaesthesia for dental treatment for children > Flashcards

General anaesthesia 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

is ga done in general practice

A

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

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3
Q

how do anaesthetics work

A

anaesthetic agents produce anaesthesia by depressing specific areas of the brain

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4
Q

how do inhaled agents work

A

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.

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5
Q

how do IV agents work

A

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

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6
Q

how does a child’s anatomy differ to an adults

A
  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)
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7
Q

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

A
  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)
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8
Q

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

A
  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
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9
Q

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

A
  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
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10
Q

common inhaled drugs?

A
  • nitrous oxide
  • sevoflurane
  • halothane
  • isoflurane
  • desflurane
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11
Q

common IV drugs?

A
  • propofol
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12
Q

who decides on what drugs to use

A

the anaesthetist

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13
Q

what factors influence what drugs the anaestheist decides to use?

A
  • type of procedure
  • patient preferences for induction
  • medical history
  • previous GA experience
  • anaesthetists recommendations
  • equipment
  • staff
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14
Q

what are the different types of airway used during anesthetic

A
  • LMA (laryngeal mask airway - most common for dental)
  • nasal endotracheal intubation
  • oral endotracheal intubation
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15
Q

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

A

a throat pack

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16
Q

what is a throat pack

A

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

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17
Q

what are the different stages of anesthesia

A
  1. induction
  2. excitement
  3. surgical anaesthesia
  4. respiratory paralysis/overdose
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18
Q

what are the GDC expectations with regard to dentists and anaesthesia

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 GOD
  • be competent in when, how and where to refer a patient for GA
  • evaluate the risks and benefits of treatment under GA
19
Q

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

A

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.

20
Q

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

A

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

21
Q

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

A

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.

22
Q

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

A

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.

23
Q

what are the 2 main indications for GA for children

A
  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
24
Q

what is the main GA conraindication

A

when risks do not outweigh the benefits

25
Q

what are the major risks of GA

A

chance of serious outcome/ major adverse event = 3 in a million

serious outcomes are death, will not wake up again, brain damage

26
Q

what are minor risks and complications of GA

A
  • 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
27
Q

what are some GA safety precautions

A
  • GA has small risk of mortality so it must be justified
  • ## airway is shared - dentist and anaesthetist
28
Q

what are some GA safety precautions

A
  • 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)
29
Q

what is really important to remember when working on the mandible

A

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

30
Q

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

A

sometimes possible to do a joint GA with other medical specialities

31
Q

what is the post op discharge criteria

A
  • 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
32
Q

what are the post-op instructions

A
  • 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
33
Q

describe the process of GA consent

A
  • 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
34
Q

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

A
  • 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
35
Q

when can a child consent to medical treatment

A

can consent under 16 years old if ‘gillick competent’

36
Q

when should the first stage of GA consent happen and why

A

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

37
Q

what pre-op info should be given

A

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

38
Q

is verbal consent enough for GA

A

no, GA MUST have written consent

39
Q

what should a referral letter for GA include

A
  • 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)
40
Q

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

A

true

41
Q

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

A

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

42
Q

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

A

false (can apply to the courts for it)

43
Q

adoptive parents have parental responsibility following completion of the adoption process

A

true

44
Q

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

A

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

Caries symposium 2 (7 decks)

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