General Anaesthesia for Dental Treatment for Children Flashcards

Question

discharge criteria

Answer 1

* Fully conscious, able to maintain clear airway, exhibits protective reflexes * Satisfactory oxygenation and respiration * 2-5yrs 24-30 breaths/min * 5-12yrs 20-24 breaths/min * CVS stable- no unexplained cardiac irregularities, no persistent bleeding, pulse and BP acceptable, adequate peripheral perfusion (press fingertip, should blanch) * Heart rate 2-10yrs mean 80 beat/min * BP for 1-10yrs= 90+ 2xage in yrs * Pain, nausea and vomiting controlled * Temperature in normal limits * Eaten, drunk, been to toilet

Answer 2

* Pain control * Travel home * Rest / quiet play * Monitoring * What to look out for – pain, bleeding etc * Next day off school/nursery – rest needed * Extraction advice * Soft diet * **Prevention** * **Follow up** * **Discharge letters**

Answer 3

active process * Primary care dentist makes initial decision that GA may be necessary (although this may change at assessment visit) * Explanation of **risks** and **benefits** of **GA and all other alternative options** * E.g. Prevention only, Biological caries management, LA +/- IS, IV, doing nothing * Explanation of how different treatment modalities might affect the treatment plan- GA treatment plans more radical with reliable and clear prognostic outcomes * i.e. you should be confident the plan will last at least 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

Answer 4

* 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) * 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

Answer 5

ideally be done 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 * Pre-op information- pre-op preparation including fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements (travel, time off), post-op care and pain control * Booklets for anaesthetic dental for adult and child available **For GA MUST have written consent**

Answer 6

needs to be written active process

Answer 7

pre-op preparation including fasting, proposed treatment, GA procedure, adult escort with no other children, post-op arrangements (travel, time off), post-op care and pain control Booklets for anaesthetic dental for adult and child available

Answer 8

* 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 Must include * Recent radiographs or if not available explanation of why (e.g. I have attempted to take bitewings/ periapicals but the patient is uncooperative)

Answer 9

* Neonates baby within 44 weeks of age from the date of conception * Infants child up to 12 months of age * Child 1-12 years * Adolescent 13-16 years

Answer 10

baby within 44 weeks of age from date of conception

Answer 11

child up to 12 months of age

Answer 12

1-12 years

Answer 13

13-16 years

Answer 14

reduce as pt increases in age

Answer 15

SLOW HEART RATE associated with reduced cardiac output. associated with hypoxia should be treated with oxygen and ventilation initially. * External cardiac compression will be required in the neonate with a heart rate of 60 beats per minute or less, or 60-80 beats per minute with adequate ventilation.

Answer 16

Sinus arrhythmia is common in children and all other irregular rhythms are abnormal

Answer 17

problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called tachycardia. When a heart beats too slowly, the condition is called bradycardia

Answer 18

Hypoglycaemia common in the stressed neonate and glucose levels should be monitored regularly. * Neurological damage may result from hypoglycaemia so an infusion of 10% glucose may be used to prevent this. Infants and older children maintain blood glucose better and rarely need glucose infusions. * Glycogen stores are located in the liver and myocardium. Hyperglycaemia is usually iatrogenic

Answer 19

* Use this time to develop rapport and trust with the child and parent. Address the child first and then include the parents in discussion. Address the queries and fears of the child as well as those of the parent. Explain the planned approach to induction so both parent and child know what to expect. * It is important to take a medical and anaesthetic history. * Any previous problems with anaesthetics including family history * Allergies * Previous medical problems including congenital anomalies * Recent respiratory illness * Current medications * Recent immunisations * Fasting times * Presence of loose teeth. * Conduct a physical examination as appropriate concentrating on the airway and cardiorespiratory systems. * Children must be weighed. All drug doses relate to body weight. Weight (kg) can be estimated by: (age + 4) x 2. This is less accurate over 10 years. * Investigations may occasionally be necessary: * Haemoglobin – large expected blood loss, premature infants, systemic disease, congenital heart disease * Electrolytes – renal or metabolic disease, intravenous fluids, dehydration * CXR – active respiratory disease, scoliosis, congenital heart disease * Discuss post-operative pain management. If suppository medications are to be used, consent should be obtained from the parent and the child if they are able to understand

Answer 20

* 6 hours for solids and milk if greater than 12 months of age * 4 hours for breast milk and formula feeds if less than 12 months of age * 2 hours for unlimited clear fluids (as this decreases gastric acidity and volume) There is an increased incidence of nausea and vomiting with long fasting periods.

Answer 21

In our institution, sedative pre-medication is infrequently used. Psychological preparation and enlisting the help of the parents may decrease the need for sedative pre-medication. Sedation has a significant failure rate, tastes bad, increases time spent in recovery and delays discharge for day stay procedures. However, an appropriately chosen drug, timed correctly can produce a calm or cooperative child. We most commonly use analgesic pre-medication drugs such as paracetamol, ibuprofen or codeine phosphate given more than a half hour pre-operatively. EMLA or amethocaine cream is applied to identifiable veins on those children for whom an intravenous induction is planned. Allergy is possible to both these topical anaesthetic agents. Following may be useful: * Midazolam 0.5 mg/kg with a maximum of 15 mg given orally 15-30 minutes preoperatively. It has a variable result and can produce a very unpleasant excitatory phase. Timing is important for best effect. A sweetener may be necessary. * Chloral hydrate 50 mg/kg orally to a maximum of 1g. This also can produce an unpleasant excitatory phase and has a bitter taste. It is also used for sedation. * Ketamine 3-8 mg/kg orally 30-60 minutes pre-operatively. * Temazepam 0.5-1 mg/kg orally for older children 1 hour pre-operatively. * Clonidine 2-4mcg/kg orally. It may cause hypotension. Beware narcotics in infancy because of apnoea. Sedation should be used cautiously in those children with airway problems and should be avoided altogether in neurosurgical patients especially if they have raised intracranial pressure.

Answer 22

A parent may join their child at the time of induction. It is not compulsory but can be useful in many instances. There must be a member of staff available to accompany the parent from the anaesthetic room after induction. It must be remembered that being present at induction can be very stressful for the parent. Warm the theatre and prepare any warming devices. Keeping children warm can be a simple thing to do to improve post-operative wellbeing and outcomes. Use bandages or cotton undercast padding to wrap the limbs and head. Plastic can also be useful to prevent radiant heat loss. Prepare emergency drugs such as atropine and suxamethonium in a diluted concentration that you are familiar with to make dosing easy if an emergency should arise. If you do not give anaesthetics to children regularly, calculate and write down the doses of the drugs you may use appropriate for the patient’s weight. Have your equipment ready and checked. * Oropharyngeal airway. * Face masks * Laryngeal mask * Endotracheal tube * Laryngoscope and blades * Breathing circuit (T piece) * Monitoring

Answer 23

An inhalational induction can be an excellent technique for the child that fears needles or has difficult venous access. However, it is a two person technique. A skilled assistant will need to maintain the airway in the asleep child while intravenous access is obtained. If this help is unavailable, intravenous inductions should be carried out. A correctly sized oropharyngeal airway may be used. Choose one that is the same length as that from the corner of the mouth to the angle of the jaw. * Halothane and sevoflurane are the agents of choice for gaseous induction. * Halothane has a slightly sweet smell and is well tolerated. Induction is moderately slow but the rate is increased with the addition of 50-65% nitrous oxide. Halothane has a slower offset and longer duration of action as it is more soluble. Arrhythmias are more likely to occur. Halothane production is gradually being discontinued in many places. * Sevoflurane is non-irritant and has a more rapid onset and offset of action as it is less soluble. A concentration of 8% can be used initially or it can be wound up gradually. Nitrous oxide use increases the rate and depth of anaesthesia obtained. It has improved haemodynamic stability. MAC values are 3.3 in infants, 2.5 in children and 1.7 in adults. Use is associated with emergence delirium. Best sites for IV access: * Back of hand * Inner wrist * Long saphenous vein \ * Other veins on the dorsum of foot * Cubital fossa veins are difficult to find in infants and tissue easily at this site * Elastoplast (non sterile) provides a secure means of fixation Intravenous induction can be undertaken with propofol, thiopentone or ketamine. Preoxygenation for a rapid sequence induction can be difficult in small children and should be undertaken if able.

Answer 24

* Back of hand * Inner wrist * Long saphenous vein \ * Other veins on the dorsum of foot * Cubital fossa veins are difficult to find in infants and tissue easily at this site * Elastoplast (non sterile) provides a secure means of fixation Intravenous induction can be undertaken with propofol, thiopentone or ketamine. Preoxygenation for a rapid sequence induction can be difficult in small children and should be undertaken if able.

Answer 25

* Straight Magill blades are useful in neonates and infants. A size 0 blade is best in babies less than 4 kg. A curved blade is usually easier once the child is 6-10 kg. * Uncuffed tubes are used until 8-10 years of age. * A small leak should be present. The leak is too large if it compromises ventilation. * Tube size = age/4 + 4.5 is generally a better fit than age/4 + 4 up to 10 years Tube length in cm = age/2 +12 (or ID x 3 for an oral ETT and add 2cm for a nasal tube is easier to remember). **This is only a guide and the tube length will always need to be checked clinically**. * 1 LMA up to 5 kg; 1.5 LMA 5-10 kg; 2 LMA 10-20 kg; LMA 2.5 20 – 30 kg; LMA 3 for over 30 kg * Preformed RAE tubes may be too long. * Secure the endotracheal tube with 1cm wide elastoplast, ensuring that the tape wraps about the tube and at least one tape is fixed to the less mobile maxilla. Re-check tube length at the time of taping

Answer 26

* Add regional analgesia where necessary * Beware intravenous narcotics in infancy especially ex-premature infants and neonates. * Use intravenous fluids for cases with expected blood loss, intra-abdominal, or those taking longer than 30 minutes. * Extubation laryngospasm tends to occur less frequently if the child is fully awake at the time of extubation. * You may need to be with a child in recovery until fully awake if the recovery staff are inexperienced with children.

Answer 27

A range of techniques are available, comprising four overlapping categories: behavioural techniques, local anaesthesia (LA), conscious sedation, and general anaesthesia (GA)

Answer 28

* The child needs to be fully anaesthetised before dental treatment procedures can be attempted. * The surgeon needs the child fully anaesthetised before dental treatment can be performed. neither of these indications are absolute. Both require a degree of judgement on the part of the dental surgeon. The decision to use GA is complicated by the knowledge that there is a small but real risk of death associated with GA. The knowledge that the majority of operative care can be carried out using either LA or LA with conscious sedation, sets dentistry aside from other paediatric surgical specialties where GA is the norm

Answer 29

* The co-operative ability of the child. * The perceived anxiety and how the child has responded to similar procedures. * The degree of surgical trauma anticipated. * The complexity of the operative procedure * The medical status of the child

Answer 30

* Severe pulpitis requiring immediate relief. * Acute soft tissue swelling requiring removal of the infected tooth/teeth. * Surgical drainage of an acute infected swelling. * Single or multiple extractions in a young child unsuitable for conscious sedation. * Symptomatic teeth in more than one quadrant. * Moderately traumatic or complex extractions e.g. ankylosed or infra-occluded primary molars, extraction of broken-down permanent molars. * Teeth requiring surgical removal or exposure. * biopsy of a hard or soft tissue lesion. * Debridement and suturing of orofacial wounds. * Established allergy to local anaesthesia. * Post operative haemorrhage requiring packing and suturing. * Examination under GA, including radiographs, for a special needs child where clinical evidence exists that there is a dental problem which warrants treatment under GA

Answer 31

Severe pulpitis and acute infection

Answer 32

* Carious, asymptomatic teeth with no clinical or radiographic signs of sepsis. * Orthodontic extraction of sound permanent premolar teeth in a healthy child. * Patient/carer preference, except where other techniques have already been tried Except when * Physical, emotional, learning impairment or a combination of two or more of these. * Children who have attempted treatment using LA alone or LA combined with conscious sedation and been unable to co-operate. * Medical problems which are better controlled with the use of GA. * Discuss with paediatrician – need written advice, severe conditions admit to ward

Answer 33

* Once decided to use GA explain to the parents that the anaesthetic is not administered by a dentist, but by an anaesthetic consultant who has undergone specialist training in paediatric anaesthesia (or by an anaesthetic specialist registrar under their direct supervision). * explained that the procedure will take place in an operating theatre, with a team trained in the care of children. * The potentially serious nature of the procedure should be clearly explained to the parent(s) and, where appropriate, the patient. * Small but real risk of a catastrophe during GA. * Agreement should be reached between the dental and anaesthetic teams concerning how and when anaesthetic risk is explained and documented. * A key principle of the consent process is that a clinician cannot take informed consent for a procedure which they are not trained to perform themselves. However, the decision to use GA ultimately rests with the dentist, so some explanation of risk is required. Details of this process should be subject to local arrangements, but it is likely that clarification of a recommended procedure will come from a future guideline.

Answer 34

Comprehensive planning aims to ensure all Tx is carried out under one GA * The practice of extracting the most grossly carious and/or symptomatic teeth and leaving restorable teeth for future visits as an outpatient using LA with or without sedation is to be criticised REMOVE ANY Q TEETH AS DON'T WANT ANOTHER GA AS RISK MORTALITY

Answer 35

* Radiographs

Answer 36

Most predictably successful restoration should be given * Temporary/provisional restoration should be considered for certain circumstances e.g imminent exfoliation

Answer 37

* Specific written consent should be obtained at the time of treatment planning and updated on the day of operation. * This provides a suitable period of reflection for the parents and/or child (18). * Care should be taken to ensure that the parent understands whether primary teeth, permanent teeth or both are included in the treatment plan. * Even if the extraction of permanent teeth is following the prescription of an orthodontist, it is the operator’s duty to ensure that the parents fully understand that the teeth are not replaced naturally. * It is good practice to obtain written consent from the child where it is thought that they have sufficient understanding and emotional maturity (18). * Interpreting services must be used if it is thought that the parents may not understand the nature of the proposed treatment. * further reinforced by asking that the parent read the consent form carefully with an interpreter who is able to explain medical/dental terms in the parents’ own language. * It is not uncommon for a young child to have better English language skills than their parents. In these circumstances it is not acceptable to use the child as an interpreter. * A blanket consent such as “restorations and extractions as necessary” is inadequate, * except where it is agreed that an examination under anaesthesia (EUA) is required before treatment planning can be completed. * It should be explained that the decision about the number of fillings and extractions can sometimes only be made when the child is anaesthetised and that this decision is left to the judgement of the operating clinician. * If agreement cannot be achieved, further referral to a colleague should be offered.

Answer 38

* Ideally the diagnosis and treatment planning should be carried out on a separate day from that of the GA * several advantages, including: * Allowing the dentist sufficient time to fully explain the treatment required and assess the parents’ understanding. * Allowing the parent and child time to consider the proposed treatment, and ask further questions if necessary. * The pre-operative anaesthetic assessment may be carried out immediately prior to surgery unless the dentist is uncertain as to a patient’s suitability for day surgery - in which case they may ask for an anaesthetic review well in advance of surgery.

Answer 39

hospital setting with adequate 'critical care facilities'

Answer 40

Airway management, pain control, underlying medical conditions, management/extent of blood loss and duration of the procedure are a shared responsibility. * Effective communication with the anaesthetist is the key to providing optimal care for the child under GA. Complete clinical records itemising each procedure carried out under GA are required, these should be easily distinguishable from out-patient records. Details of the anaesthetic procedures are the responsibility of the anaesthetist

Answer 41

most predictable and durable restorations for anything but the smallest of carious lesions in primary molars

Answer 42

* should be provided with caution under GA, given the clinical failure rates of the medicaments available. * Exceptional circumstances (e.g. haemangioma/lymphangioma in supporting tissues) may be a contra-indication to extraction. primary tooth restored under GA should be expected to exfoliate naturally without failure.

Answer 43

shared between the dentist, the anaesthetist and the recovery nursing staff.

Answer 44

* Patients and parents should receive verbal and written post-operative instructions * Advice should be given of any symptoms that might be experienced in the first 24 hours following discharge. * Analgesics including paracetamol BNF should be recommended for use in the 24 to 48 hours following discharge. * Specific instructions regarding mouth care after surgery should be given. * The nature of any sutures placed should be described and an appointment made for post-operative assessment. It is wise to arrange such a follow up to ensure that healing is progressing normally and that any absorbable (dissolving) sutures have been lost spontaneously in addition to following any local policies for discharge,

Answer 45

* morbity * behavioural/emotional effects * cost

Answer 46

*We hope the following information will be of help to you:* You will be able to take your child home when you and the nurses feel confident that s/he * can walk steadily around the ward * is reasonably comfortable * is not feeling sick * is drinking water/juice and able to hold it down Eating and Drinking: Your child needs to have a soft, smooth diet and nothing which is too warm or too cold, to avoid discomfort and further bleeding. Oral Hygiene: It is important to maintain good oral hygiene as this will promote healing. * ON THE DAY OF EXTRACTIONS: avoid rinsing their mouth as this may start bleeding. * THE FOLLOWING TWO DAYS AFTER THE OPERATION: * You may try salt water mouthwashes and gently introduce tooth brushing as and when comfortable. Young children may not be able to rinse. * Boil water and pour it into a tumbler. Dissolve a level teaspoon of common salt. Allow to cool until it can be used without burning Problems to look for: * Pain: Some discomfort is inevitable. Aim is for your child to be as comfortable as possible after their operation. They may be discharged with pain relieving medication - follow the advice from the nursing staff on how to take this medication. If you do not have medication at home please buy paracetamol or ibuprofen syrup from a pharmacy. * Swelling: Facial swelling is common and will disappear within a few days. You may find it helpful to wrap something cool (e.g. frozen peas) in a towel and rest it on the swollen area for a few minutes, but not for extended time periods * Bleeding: Do not be alarmed if there is a small amount of blood from the extraction sockets. Roll up a clean handkerchief or gauze, moisten with warm water, place over the socket and have your child bite firmly for at least 10 minutes. If this fails to control the bleeding after about 30 minutes, seek professional help. * Stitches: Any dissolving stitches should be gone in a week. Non-dissolving stitches need to be removed and you should receive an appointment for this. Now that your child is going home, we wish to remind you that after a general anaesthetic there is a period in which his/her judgement, performance and reaction time are affected by the anaesthetic, even though the child may feel quite normal again. It is therefore very important in the 24 hours after the operation that your child: * is not allowed to do anything potentially dangerous to her/himself or others, such as playing in an adventure playground, riding a bicycle, climbing trees, swimming, or going out by themselves. * remains in the immediate care of a responsible adult. * is given painkillers if necessary or as directed by the dentist. For urgent enquiries please contact………………

Answer 47

*FALSE - she can only consent in emergency situations as mother retains parental responsibility*

Answer 48

*FALSE - they do not obtain parental responsibility but they can apply to the courts for it*

Answer 49

FALSE - it stays with both parents unless given up or removed by a court

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General Anaesthesia for Dental Treatment for Children Flashcards

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