When GA is required for young patients

Question 1

What is GA?

Answer 1

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

Question 2

How does GA work?

Answer 2

Anaesthetic agents produces anaesthesia by depressing specific areas of the brain

Question 3

How does inhaled GA work?

Answer 3

Inhaled agents enter through lungs, distributed to tissues by the circulation, reach specific sites in the central nervous system by crossing the blood brain barrier. Magnitude of CNS depression is proportional to partial pressure as they reach the CNS.

Question 4

How does intravenous GA work?

Answer 4

Intravenous agents given straight into circulation, distributed through body and reach specific sites in CNS by crossing the blood brain barrier.

Question 5

Anatomically what are distinctions in child anatomy?

Answer 5

 Large head, short neck, large tongue
 Narrow nasal passages
 Are obligate nasal breathers at
birth
 High anterior larynx
 Larynx narrowest at cricoid cartilage
 Large floppy epiglottis

Question 6

Physiologically what are the distinctions in child anatomy?

Answer 6

 Low functional residual capacity (FRC)
 Closing volume is greater than FRC up to 5years of age, leading to increased ventilation/perfusion (V/Q) mismatch
 Horizontal ribs, weak intercostals muscles leading to relatively fixed tidal volume
 Oxygen consumption is high 6ml/kg/min compared to 3ml/kg/min in adults

Question 7

What are the distinctions in the child nervous system?

Answer 7

 Increased incidence of periodic breathing and apnoea
 Ventilatory response to CO2 is more readily depressed by opiates
 Immature neuromuscular junction leads to increased sensitivity to muscle relaxants

Question 8

What are the distinctions in the child temperature regulation?

Answer 8

 High surface area to body weight ratio
 Large head surface area and heat loss
 Require a higher temperature for a thermoneutral environment
 Immature responses to hypothermia (poor shivering and vasoconstriction)
 Brown fat metabolism which increases oxygen consumption
Nervous System
 Increased incidence of periodic breathing and apnoea
 Ventilatory response to CO2 is more readily depressed by opiates
 Immature neuromuscular junction leads to increased sensitivity to muscle relaxants

Question 9

What are common inhaled agents?

Answer 9

nitrous oxide
sevoflurane (agent of choice for induction)
halothane
isoflurane
desflurane

Question 10

What are common intravenous agents?

Answer 10

propofol (used for induction and in some situations for maintenance)

Question 11

What is used to keep the airway open?

Answer 11

 LMA (laryngeal mask airway)
 Nasal endotracheal intubation
 Oral endotracheal intubation

Question 12

What is used in any type of airway?

Answer 12

throat pack

A throat pack is a piece of absorbent cotton or gauze placed in the back of the throat during oral or dental surgery. Its primary purpose is to:

Prevent aspiration: This means stopping foreign objects like blood, saliva, or small pieces of tissue from entering the lungs.
Maintain a clear surgical field: By absorbing fluids, it keeps the surgical area clean and visible.

Question 13

What are the stages of anesthesia?

Answer 13

 Stage 1: Induction
 Stage 2: Excitement
 Stage 3: Surgical Anaesthesia
 Stage 4: Respiratory Paralysis/ Overdose

Question 14

What phase is very dangerous to enter?

Answer 14

stage 4 - respiratory paralysis/overdose

Question 15

What are GA indications?

Answer 15

 Child needs to be asleep for treatment because there is a belief 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
OR
 Dentist needs patient to be guaranteed to be completely still, operation is complex i.e. the surgeon needs the child to be fully anaesthetised

Question 16

What are GA contraindications?

Answer 16

risks of procedure do not outweigh the benefits

Question 17

What are the major risks of GA?

Answer 17

 Serious outcome/ major adverse event 1:400,0000, 3 in a million
 Death, will not wake up again, brain damage

Question 18

What are the minor/common risks of GA?

Answer 18

 Common
 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 restorations, restorations may be lost/ fail/wear through, stitches

Question 19

What are potential complications that may occur due to GA?

Answer 19

 Damage to mouth/ oropharynx from intubation
 Minor idiosyncratic/ allergic reactions- nausea and vomiting
 Malignant hyperpyrexia (rare! But VERY important to ask re FH of this!!! Needs specific care)
 Slow recovery from anaesthetic
 Prolonged apnoea after muscle relaxant (suxamethonium)
 “awareness”- paralysed but not effective anaesthesia
 Laryngospasm
 Coughing/moving during procedure- anaesthetic too light during stimulation e.g. extractions
 Prolonged bleeding intra- operatively or bleeding post-op

Question 20

What documentation must be completed for safety?

Answer 20

WHO Surgical Safety Checklist
 Brief before list, debrief after
 For every patient every time:
 Sign in
 Time Out
 Sign Out

Question 21

Why is dental treatment on the lower arch during GA more difficult?

Answer 21

During dental treatment (especially extractions on lower arch) mandible can easily fall or be pushed backwards and the chin onto the chest—obstructing airway!!!!!! Dentist must be aware of this and lift mandible or anaesthetist/ assistant may help to hold mandible forward

Question 22

What medicial conditions require careful work up for GA?

Answer 22

sickle cell disease
down’s syndrome
bleeding disorders
cardiac conditions
renal disease
diabetes
liver disease
cystic fibrosis
severe asthma
epilepsy

Question 23

What is the discharge criteria for post-op

Answer 23

 Fully conscious, able to maintain clear airway, exhibits protective
reflexes
 Satisfactory oxygenation and respiration
 CVS stable- no unexplained cardiac irregularities, no persistent bleeding, pulse and BP acceptable, adequate peripheral perfusion
 Pain, nausea and vomiting controlled
 Temperature in normal limits
 Eaten, drunk, been to toilet

Question 24

What are the satisfactory respiration values?

Answer 24

 2-5yrs 24-30 breaths/min
 5-12yrs 20-24 breaths/min

Question 25

What is the satisficatory heart rate and BP?

Answer 25

 Heart rate 2-10yrs mean 80 beat/min

 BP for 1-10yrs= 90+ 2x age in yrs.

Question 26

What are the post-op instructions?

Answer 26

 Pain control
 Travel home
 Rest / quiet play
 Monitoring
 What to look out for – pain, bleeding etc
 Next day off school/nursery (GA remains in fat for a while)
 Extraction advice
 Soft diet
 Prevention
 Follow up
 Discharge letters

Question 27

Who can consent for children

Answer 27

mother
father is married to mother at time of child’s conception
unmarried father if named on birth certificate (04/05/2006)
adoptive parents
married step-parents can aquire
legally appointed guardian

Question 28

Can consent be given by a child under the age of 16?

Answer 28

Consent to medical treatment can be given by a child under the age of 16 if ‘Gillick competent’

children under the age of 16 can consent to medical treatment if they have sufficient maturity and judgement to enable them fully to understand what is proposed.

Question 29

When should consent be taken and how?

Answer 29

First stage of consent should 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, post-op care and pain control

For GA MUST have written consent

Question 30

What should the referral letter state?

Answer 30

 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

Question 31

What must the referral letter include?

Answer 31

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

Question 32

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.

True/False

Answer 32

False

Question 33

Step parents automatically gain parental responsibility when they marry a child’s biological parent.

True/False

Answer 33

False

Question 34

Adoptive parents have parental responsibility following completion of the adoption process

True/False

Answer 34

True