General anaesthesia for the child patient Flashcards
Definition
the induction of a state of
unconsciousness with the absence of pain
sensation over the entire body, through
the administration of anaesthetic drugs.
It is used during certain medical and
surgical procedures
What is the purpose of general anaesthesia
Analgesia (loss of response to pain)
Amnesia (loss of memory)
Immobility (loss of motor reflexes)
Hypnosis (unconsciousness)
Paralysis (skeletal muscle relaxation)
Indications for the use of GA in children
The child needs to be fully anaesthetized
before dental treatment procedures can be
attempted.
The surgeon needs the child fully
anaesthetized before dental treatment can be
performed.
Key points for GA in children-
- Children undergoing general anaesthesia for dental extractions should receive the same standard of assessment and preparation as children admitted for any other procedure under general anaesthesia Hospital Appointment
- Can only take place in a hospital setting
- Can only be administered by a consultant anaesthetist
- Critical care unit must be available
- Specialist Paediatric nursing
The responsibilities of the referring dentist in GA?
Since … GAs are carried out in a …
2001, hospital setting
- Decide that if a child requiring dental extractions is not manageable within general dental practice setting ,they make the appropriate referral
- Adhere to referral guidelines and make use of the recommended proforma
What are other options beside GA
*Routine conservative treatment
*If child is cooperative consider LA +/-RA
*Single Extraction ? LA
Consider when looking at other options beside GA
*Preference of child
*Preferable in certain medical conditions
When is GA NOT justified?
*Caries is asymptomatic with no infection
*Orthodontic extractions
*Patient /parent request
Indications for GA?
Dental extractions should only be performed under GA when …
this is considered to be the most clinically appropriate method of management
Young child
Special needs
Anticipated distress from local anaesthetic (bad
experience)
Multiple extractions
Surgical extractions
Duties of a referring dentist?
- Responsibility to explain the risk of GA
mortality is approx 3/1mill
. Morbidity symptoms associated with the
procedure/distress at induction/recovery/nausea post op
bleeding
- Discuss the alternative treatment choice
- Explain why the option of GA has been chosen
- Keep a copy of the referring letter
. Must be aware of the
appropriateness of the care provided by sedation or
GA service
The assessing dentist must be (professionally)
deally a specialist in paediatric dentistry Or
equivalent ie with experience in Paediatric Dentistry
and trained in…
The assessing dentist must be ideally a specialist in paediatric dentistry or equivalent ie with experience in paediatric dentistry and trained in
behavioral management of children, including
conscious sedation (particularly inhalational sedation).
planning and management of children requiring dental
extractions under general anaesthesia
The Assessment appointment for GA - when should it occur
Assessment should ideally be undertaken at a separate appointment. (called preliminary anaesthetic appointment and preformed by an assessing dentist).
The assessment appointment for GA- what do you need to decide?
Decide if general anaesthesia required
Whose opinion do you need in a GA assessment?
ananaesthetist
What information is provided?
Verbal and written
What is there a need for in GA assessment?
Sedative premedication
Information sharing
Discharge planning
Explanation of fasting instructions
An appropriate regimen for analgesia
What are the pre op instructions for GA in children?
- Accompanied by responsible adult who can give
consent - If unwell before appointment to contact surgery/hospital
for advice - Fasting instructions
- Take medication as normal
- No nail varnish
- No School
- Lift home
Who can give consent for childrens GA?
Always mother
Father if name is on the birth certificate (since April 2002)
* Gillick Competent
* Social workers/Foster parents
* Adoptive Parents
Who cannot give consent in GA for children?
Grandparents unless a court order has been sought
Explanation of risk in GA?
Will be administered BY an anaesthetic
consultant who has undergone specialist training in pediatric anaesthesia
In an operating theatre, with
a team trained in the care of children.
There is a small but real risk of a catastrophe
Documentation of risk for explanation GA?
Agreement should be reached between the
dental and anaesthetic teams concerning how and when anaesthetic risk is explained and documented.
What are the types of anaesthesia?
*Day Procedure short-case
*Day Procedure intubation anaesthesia
*In patient stay intubation anaesthesia
What cases would result in short-case day procedure GA?
Severe pulpitis
Sub mandibular abscess
Surgical drainage
Symptomatic teeth causing pain in
more than one quadrant
What cases would count for short-case day procedure anaesthesia?
Under 5 requiring multiple extractions
Ankylosis extractions
Allergy to LA
Extraction of 1st permanent molar
Biopsy
Debridement and suturing
Indications for intubation?
- Restricted access to airway or whole patient
- Protection against contamination of airway from above /below
- Requirement for muscle relaxation
Indications for day procedure intubation anaesthesia?
- Greater than 15 minutes long
- Full mouth rehabilitation
- Dento alveolar surgery
Indications for In-patient hospital stay intubation anaesthesia?
*Medically compromised
*These should be managed in collaboration with
the child’s paediatrician.
*underlying medical condition in categories ASA
III or ASA IV should be admitted to a paediatric
ward and clinical care shared with a paediatric
team
What is the care pathway for GA?
Multiprofessional
Mandatory Criteria
Risk factors
Pre-op assessment
Pain relief
Admission Assessment
Pre-op checklist
Anaesthetic chart
Theatre Nursing
Operation Note
Transfer from theatre to recovery
Who is in the anaesthetic team?
- Anaesthetist
- Surgeon
- Dental Nurse
- Pre –op nurse
- Anaesthetic Nurse
- Auxiliary nurse
- Recovery Staff
What is the mode of administration of GA?
Induction of anaesthesia is either via … or …
inhalation anaesthetics (gases)
or injectable intravenous anaesthetics
What are the most widely used volatile anaesthetics today? and what are they often combined with?
Desflurane isoflurane and sevoflurane
Nitrous oxide
What are some of the injectable IV anaesthetics?
- Propofol
- Etomidate
- Barbiturates such as methohexital and thiopentone
- Benzodiazepines such as midazolam
Most commonly … for IV GA
the two forms are combined
IV… the two forms are combined with the injection given to and the gas given to…
induce anaesthesia
maintain a state of unconsciousness
Anaesthesthetists prefer to use
IV injections
Why do anaesthestetists prefer to use IV injections for GA in children?
They are faster,
generally less painful
more reliable than intramuscular or subcutaneous injections
Anaesthetic machine allows
composing a mixture of oxygen,
anaesthetics and ambient air
anaesthetic machine deliveres the mixture of oxygen anaesthetics and ambient air
to the patient and monitoring patient and machine
parameters
Liquid anaesthetics are
vaporised
in the machine.
All of these agents- oxgyen anaesthetics and ambient air share the property of being quite
hydrophobic
and as gases the dissolve in oils better than in water
Dental equipment needed in GA
- +/- Local anaesthetic
- Mouth props
- Mouth packs
- Appropriate forceps
- Surgical drill
- Sutures
Analgesia … pain after surgery usually starts
after the antiesthetic drugs have worn off
Analgesia… pain can be the result of
unavoidable surgery trauma or pre existing
infection
Unless contraindicated,
…
should be used for analgesia
(NSAIDs) and / or
paracetamol
nsaids and/or paracetamol may be
combined or given separately
before,during or after surgery
What are complications of GA
*Wound infection (is uncommon and treatment
should be guided by the pathogen)
*Bleeding (/Patients /parents should be given
written and verbal instruction on how to care for
their wounds)
*Downiness ,nausea, vomiting headaches
Complications of GA- analgesia is usually enough but sometimes what is indicated
antibiotics
Recovery - what is there a risk of
Inhaling a foreign object, airway obstruction can occur as the surgeon is operating around the airway
What is important about recovery
The most dangerous time and it is VERY
important to keep the airway clear
What can result from the effects of the anaesthetic and ancilliary drugs?
Respiratory depression
What must be on hand during GA recovery
Equipment and drugs for dealing with medical emergencies
During recovery the patient should
Be laid on their side and their airway protected
What is given during recovery
supplementary oxgyen
What must be available during recovery
Suction
Post op care for GA
- No rinsing
- No eating hard foods
- No active sports for 24hours
- Emergency contact number
- Ideally follow up appointment with hygienist
- Discharge letter to GDP
Pre op?
Important instructions must be given
Recorded in the case notes and reemphasized after discharge
During extraction consider
- Position of patient – head ring
- Position of operator
- Use of prop
- Throat pack/airway protection
- Airway control/mandible positioning
- Hands under forceps!
- Placement of forceps
- Tooth movement – apical pressure, palatal movement before buccal
- Counter-resistance
- Soft tissue management
additional points to consider during extraction?
- Direction of movement for primary teeth differs to permanent
teeth - Surgicel?
- Local anaesthetic?
- Pain relief – pre and post-op
Equipment
- Props?
- Open and closed lower molar forceps
- Couplands elevators
What equipment to avoid in extraction under GA
- Avoid Cryers elevators with primary teeth
- Avoid luxators
What is important during extraction?
Soft tissue/ airway control
Never events
WHO checklist
* Whiteboard
* Standardised procedure with team
* Count teeth from front.
* Systematic approach (quadrant order, upper before lower, posterior before anterior)
