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Paeds > General anaesthesia for the child patient > Flashcards

General anaesthesia for the child patient Flashcards

1
Q

Definition

A

 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

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2
Q

What is the purpose of general anaesthesia

A

 Analgesia (loss of response to pain)
 Amnesia (loss of memory)
 Immobility (loss of motor reflexes)
 Hypnosis (unconsciousness)
 Paralysis (skeletal muscle relaxation)

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3
Q

Indications for the use of GA in children

A

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.

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4
Q

Key points for GA in children-

A
  • 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
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5
Q

The responsibilities of the referring dentist in GA?
Since … GAs are carried out in a …

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
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6
Q

What are other options beside GA

A

*Routine conservative treatment
*If child is cooperative consider LA +/-RA
*Single Extraction ? LA

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7
Q

Consider when looking at other options beside GA

A

*Preference of child
*Preferable in certain medical conditions

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8
Q

When is GA NOT justified?

A

*Caries is asymptomatic with no infection
*Orthodontic extractions
*Patient /parent request

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9
Q

Indications for GA?
Dental extractions should only be performed under GA when …

A

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

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10
Q

Duties of a referring dentist?

A
  • 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

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11
Q

The assessing dentist must be (professionally)

A

deally a specialist in paediatric dentistry Or
equivalent ie with experience in Paediatric Dentistry
and trained in…

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12
Q

The assessing dentist must be ideally a specialist in paediatric dentistry or equivalent ie with experience in paediatric dentistry and trained in

A

behavioral management of children, including

conscious sedation (particularly inhalational sedation).

planning and management of children requiring dental
extractions under general anaesthesia

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13
Q

The Assessment appointment for GA - when should it occur

A

 Assessment should ideally be undertaken at a separate appointment. (called preliminary anaesthetic appointment and preformed by an assessing dentist).

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14
Q

The assessment appointment for GA- what do you need to decide?

A

 Decide if general anaesthesia required

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15
Q

Whose opinion do you need in a GA assessment?

A

ananaesthetist

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16
Q

What information is provided?

A

Verbal and written

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17
Q

What is there a need for in GA assessment?

A

Sedative premedication
Information sharing
Discharge planning
Explanation of fasting instructions
An appropriate regimen for analgesia

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18
Q

What are the pre op instructions for GA in children?

A
  • 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
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19
Q

Who can give consent for childrens GA?

A

Always mother
Father if name is on the birth certificate (since April 2002)
* Gillick Competent
* Social workers/Foster parents
* Adoptive Parents

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20
Q

Who cannot give consent in GA for children?

A

Grandparents unless a court order has been sought

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21
Q

Explanation of risk in GA?

A

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

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22
Q

Documentation of risk for explanation GA?

A

Agreement should be reached between the
dental and anaesthetic teams concerning how and when anaesthetic risk is explained and documented.

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23
Q

What are the types of anaesthesia?

A

*Day Procedure short-case
*Day Procedure intubation anaesthesia
*In patient stay intubation anaesthesia

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24
Q

What cases would result in short-case day procedure GA?

A

 Severe pulpitis
 Sub mandibular abscess
 Surgical drainage
 Symptomatic teeth causing pain in
more than one quadrant

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25
Q

What cases would count for short-case day procedure anaesthesia?

A

 Under 5 requiring multiple extractions
 Ankylosis extractions
 Allergy to LA
 Extraction of 1st permanent molar
 Biopsy
 Debridement and suturing

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26
Q

Indications for intubation?

A
  • Restricted access to airway or whole patient
  • Protection against contamination of airway from above /below
  • Requirement for muscle relaxation
27
Q

Indications for day procedure intubation anaesthesia?

A
  • Greater than 15 minutes long
  • Full mouth rehabilitation
  • Dento alveolar surgery
28
Q

Indications for In-patient hospital stay intubation anaesthesia?

A

*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

29
Q

What is the care pathway for GA?

A

 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

30
Q

Who is in the anaesthetic team?

A
  • Anaesthetist
  • Surgeon
  • Dental Nurse
  • Pre –op nurse
  • Anaesthetic Nurse
  • Auxiliary nurse
  • Recovery Staff
31
Q

What is the mode of administration of GA?
Induction of anaesthesia is either via … or …

A

inhalation anaesthetics (gases)
or injectable intravenous anaesthetics

32
Q

What are the most widely used volatile anaesthetics today? and what are they often combined with?

A

Desflurane isoflurane and sevoflurane

Nitrous oxide

33
Q

What are some of the injectable IV anaesthetics?

A
  • Propofol
  • Etomidate
  • Barbiturates such as methohexital and thiopentone
  • Benzodiazepines such as midazolam
34
Q

Most commonly … for IV GA

A

the two forms are combined

35
Q

IV… the two forms are combined with the injection given to and the gas given to…

A

induce anaesthesia
maintain a state of unconsciousness

36
Q

Anaesthesthetists prefer to use

A

IV injections

37
Q

Why do anaesthestetists prefer to use IV injections for GA in children?

A

They are faster,
generally less painful
more reliable than intramuscular or subcutaneous injections

38
Q

Anaesthetic machine allows

A

composing a mixture of oxygen,
anaesthetics and ambient air

39
Q

anaesthetic machine deliveres the mixture of oxygen anaesthetics and ambient air

A

to the patient and monitoring patient and machine
parameters

40
Q

Liquid anaesthetics are

A

vaporised
in the machine.

41
Q

All of these agents- oxgyen anaesthetics and ambient air share the property of being quite

A

hydrophobic
and as gases the dissolve in oils better than in water

42
Q

Dental equipment needed in GA

A
  • +/- Local anaesthetic
  • Mouth props
  • Mouth packs
  • Appropriate forceps
  • Surgical drill
  • Sutures
43
Q

Analgesia … pain after surgery usually starts

A

after the antiesthetic drugs have worn off

44
Q

Analgesia… pain can be the result of

A

unavoidable surgery trauma or pre existing
infection

45
Q

Unless contraindicated,
…
should be used for analgesia

A

(NSAIDs) and / or
paracetamol

46
Q

nsaids and/or paracetamol may be

A

combined or given separately
before,during or after surgery

47
Q

What are complications of GA

A

*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

48
Q

Complications of GA- analgesia is usually enough but sometimes what is indicated

A

antibiotics

49
Q

Recovery - what is there a risk of

A

Inhaling a foreign object, airway obstruction can occur as the surgeon is operating around the airway

50
Q

What is important about recovery

A

The most dangerous time and it is VERY
important to keep the airway clear

51
Q

What can result from the effects of the anaesthetic and ancilliary drugs?

A

Respiratory depression

52
Q

What must be on hand during GA recovery

A

Equipment and drugs for dealing with medical emergencies

53
Q

During recovery the patient should

A

Be laid on their side and their airway protected

54
Q

What is given during recovery

A

supplementary oxgyen

55
Q

What must be available during recovery

A

Suction

56
Q

Post op care for GA

A
  • No rinsing
  • No eating hard foods
  • No active sports for 24hours
  • Emergency contact number
  • Ideally follow up appointment with hygienist
  • Discharge letter to GDP
57
Q

Pre op?

A

Important instructions must be given
Recorded in the case notes and reemphasized after discharge

58
Q

During extraction consider

A
  • 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
59
Q

additional points to consider during extraction?

A
  • Direction of movement for primary teeth differs to permanent
    teeth
  • Surgicel?
  • Local anaesthetic?
  • Pain relief – pre and post-op
60
Q

Equipment

A
  • Props?
  • Open and closed lower molar forceps
  • Couplands elevators
61
Q

What equipment to avoid in extraction under GA

A
  • Avoid Cryers elevators with primary teeth
  • Avoid luxators
62
Q

What is important during extraction?

A

Soft tissue/ airway control

63
Q

Never events

A

WHO checklist
* Whiteboard
* Standardised procedure with team
* Count teeth from front.
* Systematic approach (quadrant order, upper before lower, posterior before anterior)

Paeds (11 decks)

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