general anaesthesia for the child patient Flashcards
what is the definition of a general anaesthetic?
> the induction of a state of unconsciousness with the absence of pain sensation over the entire body, through the administration of anaesthetic drugs
what is the purpose pf general anaesthesia? (5)
- Analgesia (loss of response to pain)
- Amnesia (loss of memory)
- Immobility (loss of motor reflexes)
- Hypnosis (unconsciousness)
- Paralysis (skeletal muscle relaxation)
what are the two indications for 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
what are the rules for giving GA to a child in the UK?
> 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
> support by Specialist Paediatric nursing
based on the 2001 causewellow report, where are all GA carried out ?
> in a hospital setting
what must the dentist referring a child for GA decide on/ do?
> 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 certain things you should condisider before offering a GA?
> Routine conservative treatment
> If child is cooperative consider LA +/-RA
> Single Extraction ? LA
> Preference of child
> Preferable in certain medical conditions
when is GA not justified?
> Caries is asymptomatic with no infection
> Orthodontic extractions
> Patient /parent request
when is a GA appropiatre to use?
> Dental extractions should only be performed under general anaesthesia 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
what are the duties of the 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
> The referring dentist must be aware of the appropriateness of the care provided by sedation or GA service
after being referred by the GDP, the patient is assed by another dentist in the hospital setting, who are they and what should they be trained in?
> 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
when should the assessment appointment take place?
> Assessment should ideally be undertaken at a separate appointment
> this gives enough time for consent
what happens at the assessment appointment?
> Decide if general anaesthesia required
> Preliminary anaesthetic assessment performed by assessing dentist
> Access to the opinion of ananaesthetist,
> The need for sedative premedication is decided
> Information sharing, discharge planning and an
> Explanation of fasting instructions together with an appropriate regimen for analgesia
> Verbal & written information provided
> Sufficient time should be provided to allow the parent / carer and child to arrive at considered opinion and to give informed consent
what are the Pre Op instructions for GA?
> 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 GA?
> Mother can always give consent
> Father if name is on the birth certificate after April 2002
> Grandparents cannot give consent unless a court order has been sought
> Gillick Competent
> Social workers/Foster parents (if its been approved)
> Adoptive Parents
who administers the GA?
> GA will be administered BY an anaesthetic consultant who has undergone specialist training in pediatric anaesthesia
where does the GA procedure take place?
> Procedure will take place in an operating theatre, with a team trained in the care of children.
is there a risk of catastrophe during a GA?
> There is a 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.
what are the 3 types of anaesthesia?
> Day Procedure short-case
> Day Procedure intubation anaesthesia
> In patient stay intubation anaesthesia
what cases take place in day procedure?
> Severe pulpitis
> Sub mandibular abscess
> Surgical drainage
> Under 5 requiring multiple extractions
> Symptomatic teeth causing pain in
more than one quadrant
> Ankylosis extractions
> Extraction of 1st permanent molar
> Biopsy
> Debridement and suturing
> Allergy to LA
what are the indication for intubation ?
> Restricted access to airway or whole patient (large swelling, or genetic malformations)
> Protection against contamination of airway from above /below
> Requirement for muscle relaxation
what are the indication for treatment in day procedure intubation anaesthesia ?
> Greater than 15 minutes long
> Full mouth rehabilitation
> Dento alveolar surgery (buried canine)
what are in indication for patients that need an in patient hospital stay?
> Medically compromised (eg patient with diabetes)
> 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 (big team)
> Mandatory Criteria (carry out check list below) =
- Risk factors
- Pre-op assessment
- Pain relief
- Admission Assessment
- Pre-op checklist
- Anaesthetic chart
- Theatre Nursing
- Operation Note (what you do)
- Transfer from theatre to recovery
who is part of the GA team?
> Anaesthetist
> Surgeon
> Dental Nurse
> Pre –op nurse
> Anaesthetic Nurse
> Auxiliary nurse
> Recovery Staff
how is the GA administered?
> induction of anaesthesia is either via =
- inhalation anaesthetics
or
- injectable intravenous anaesthetics
> Most commonly the two forms are combined, with the injection given to induce anaesthesia and a gas used to maintain a state of unconsciousness.
what is an example of commonly used inhalation anaesthetics?
> Desflurane isoflurane and sevoflurane are the most widely used volatile anaesthetics today.
> They are often combined with nitrous oxide.
what is an example of commonly used injectable intravenous anaesthetics ?
> Propofol
> Etomidate
> Barbiturates such as methohexital and thiopentone
> Benzodiazepines such as midazolam
what do anaesthetists prefer to use, IV or inhalation?
> Anaesthetists prefer to use intravenous injections as they are faster, generally less painful and more reliable than intramuscular or subcutaneous injections
what is an anaesthetic machine?
> Allows composing a mixture of oxygen, anaesthetics and ambient air, delivering it to the patient and monitoring patient and machine parameters.
> Liquid anaesthetics are vaporised in the machine.
> All of these agents share the property of being quite hydrophobic (i.e., as liquids, they are not freely miscible /mixable—in water, and as gases they dissolve in oils better than in water).
what dental equipment is present in theatre?
> +/- Local anaesthetic
> Mouth props
> Mouth packs
> Appropriate forceps
> Surgical drill
> Sutures
after extractions pain is common, what is used to manage this?
> Unless contraindicated, non‐steroidal anti‐inflammatory drugs (NSAIDs) and / or paracetamol should be used for analgesia
> These drugs may be combined or given separately before,during or after surgery
when does post op pain start and what causes this ?
> Pain after surgery usually starts after the antiesthetic drugs have worn off
> Result of unavoidable surgery trauma or pre existing infection
what are the complications of General anaesthesia?
> Analgesia is usually suffice, however sometimes antibiotics are indicated
> 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
> bleeding, Downiness ,nausea, vomiting, headaches
when are patients allowed to leave?
> approx 2 hours after
> patient should have stopped bleeding and nurses happy with post op
why is recovery very important post GA extractions ?
> Airway obstruction can occur as the surgeon is operating around the airway and there is a risk of inhaling a foreign object
> Recovery period is the most dangerous time and it is VERY important to keep the airway clear
> Respiratory depression can result from the effects of the anaesthetic and ancillary drugs
what should be kept on hand during the recovery period?
> Equipment and drugs for dealing with medical emergencies must be on hand
> suction should be available
how should a patient be positioned during recovery?
> During recovery the patient should be laid on their side and their airway protected
what is supplemented during recovery?
> Supplementary oxygen is given during recovery
what post op instructions/ care should be given after GA extractions?
> Important instructions must be given preoperatively recorded in the case notes and reemphasized after discharge
> No rinsing
> No eating hard foods
> No active sports for 24hours
> Emergency contact number
> Ideally follow up appointment with hygienist
> Discharge letter to GDP
