General Anesthesia in Pediatric Dentistry

The presentation gives details of induction procedures, pre-medications, anesthetic drugs, post-operative instructions.

1. GENERAL ANAESTHESIA S.L.L.JAYASRI I MDS

2. Contents Introduction ASA Classification Stages of GA Preoperative evaluation of the child Medical history Preparation of the child Premedication Induction of anaesthesia GA in Paediatric dentistry Postoperative instructions Conclusion References

3. Introduction General anesthesia: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.

4. General anaesthesia = Hypnosis + Analgesia + Relaxation Hypnosis = suppression of consciousness Analgesia = suppression of physiological responses to pain stimuli Relaxation = suppression of muscle tone and relaxation

5. A controlled reversible state of: – Amnesia (with loss of consciousness) – Analgesia – Akinesia (skeletal muscle relaxation) – Autonomic and sensory reflex blockade Called the “4 A’s” of General Anaesthesia. In practice these effects are produced with a combination of drugs rather than with a single anaesthetic agent

6. Advantages of GA CLASSIFICATION SYSTEM: Patients cooperation in not absolutely essential for the success of GA. Patient is unconscious. Patient does not respond to pain. Amnesia is present. GA may be the only technique that will prove successful for certain patients. Rapid onset of action.

7. Disadvantages of GA The patient is unconscious. Protective reflexes are depressed. Advanced training is required. An ‘‘anaesthesia team’’ is required. Special equipment is required wherever general anaesthesia. A recovery area must be available for the patient. Post anaesthetic complications are more i.e., Laryngospasm

8. ASA Classification

9. Ask the Medical history

10. Upper respiratory tract infections 2 week waiting period Preoperative salbutamol IV Hydration Anticholinergics

11. Anaemia Hematocrit > 25%

12. SECONDARY SMOKING (ETS) ASTHMA ATOPIC ECZEMA HAY FEVER

13. Preparation of the child for surgery

14. Route of administration

15. Benzodiazepines Calmness in children Diminishes recall of Peri anaesthetic events MIDAZOLAM 0.025 – 0.1 mg/kg IV 0.1 – 0.2 mg/kg IM 0.25 – 0.75 mg/kg orally 0.2 mg/kg Nasally 1mg/kg Rectally Onset of action: within 5 min , peak in 15-20min

16. Factors alter the Blood concentration of midazolam INCREASE Erythromycin Protease inhibitors (Antiretroviral drugs) Calcium channel blockers DECREASE Anticonvulsants (phenytoin and carbamazepine) Rifampicin Glucocorticoids Barbiturates St. John’s wort

17. DIAZEPAM Used in o lder Children Should not be used in Infants and preterm neonates (immature hepatic function). 0.1 -0.3 mg/kg orally 1 mg/kg Rectally LORAZEPAM Used in older children 0.005 mg/kg orally Advantages over diazepam : more reliable amnesia less tissue irritation. Disadvantages over diazepam : Slow o nset of action Prolonged duration

18. Barbiturates Infrequently used. Methohexital / Thiopental 30 mg / kg – Rectally Onset of action : within 15 min Disadvantages: Sedation is profound Airway obstruction and laryngospasm Apnoea in child with meningomyelocele Precautions : Child should be closely monitored Adequate Oxygen and ventilator support

19. Non barbiturates Chloral hydrate & Triclofos – Orally Disadvantages: Slow onset Long acting Irritating to skin , mucous membrane and GIT Opioids Produce Analgesia and sedation in child with preoperative pain . Disadvantages : Respiratory depression Dysphoria Precautions : child should be carefully monitored with pulse oximetry. continuously monitored with Pulse oximetry

20. Opioids Morphine sulphate: 0.05 – 0.1 mg/kg IV Given for children with preoperative pain. Sufentanil : 1.5 – 3 mg /kg Nasally Ketamine: 2 mg/kg IM 5 – 6 mg/kg alone sedates children within 12min 10mg/kg – child with burns Oral ketamine 3mg/kg + Oral midazolam 0.5mg/kg Nasal ketamine 6mg/kg Rectal ketamine 5mg/kg

21. Alpha 2 agonists Clonidine 4mg/kg Dexmedetomidine 2- 4 µg/kg orally 2- 3 µg/kg Intra nasally Children with burns 2 µg/kg intra nasally + 0.5 mg/kg oral midazolam. Antihistamines Hydroxyzine : Antiemetic, antihistaminic and antispasmodic. 0.5-01mg/kg IM Diphenhydramine : mild sedative and anti muscarinic effect oral diphenhydramine 0.25mg/kg + oral midazolam 0.5mg/kg

22. Anticholinergics Atropine 0.01- 0.02 mg /kg Scopolamine 0.005 – 0.010 mg/kg Glycopyrrolate – 0.01mg/kg Topical anaesthetics

23. Corticosteroids Children who are taking long term steroid therapy Hydrocortisone 1-2mg/kg IM/IV Dexamethasone 0.05 – 0.1 mg/kg

24. Antacids, H2-Receptor Antagonists, and Gastrointestinal Motility Drugs

25. Child with special needs Autism Premedication

26. Parental presence during induction COMFORT & SUPPORT THE CHILD HOLD THE CHILD’S HAND

27. Induction of anaesthesia

28. Inhalation anaesthesia Sevoflurane 8 % Halothane 5%

29. IV Induction

30. Propofol 1-6 months old : 3 + 0.2mg/kg 10 – 16 years old : 2.4 + 0.1 mg/kg Unpremedicated children : 2.5 -3 mg/kg ADVANTAGES Reduced airway problems More rapid emergence Reduced nausea and vomiting DISADVANTAGES Pain at injection site

31. Ketamine 1-2mg/kg Uses Cardiovascular instability patients Hypovolemic patients

32. Reversal agents Physostigmine dosage: 0.5 to 2 mg slow IV Flumazenil dosage: 0.1 to 1mg IV. Neostigmine dosage: 0.05 to 0.07 mg/kg Naloxone 0.4mg initially followed by 0.1mg-0.2mg every 2-3min for children under 20 kg and dose for children over 20 kg is 2mg.

33. GA in Paediatric dentistry INDICATIONS: Very young individuals Extreme anxiety Mental disability Physical disability Acute infection Allergy to LA Extensive Maxillofacial surgery CONTRAINDICATIONS: A young child with incipient carious lesions. Non- compliance with NIL PER ORAL instructions. Unwilling parents PURPOSE : To allow Total Oral Rehabilitation

34. Procedures performed are: Extraction Pulpal treatment Stainless steel crowns Amalgam / Composite restorations PFS SURGICAL RESTORATIVE PREVENTIVE

35. GA in Dentistry Dental chair anaesthesia Day care anaesthesia In patient anaesthesia

36. Physical and intraoral examination PHYSICAL EXAMINATION General Head Neck Lateral facial profile INTRAORAL EXAMINATION Lips Tongue Floor of the mouth Buccal mucosa Hard and soft palate Oropharynx Periodontium Oral habits

37. Child’s record Name Age Gender Chief complaint & History of present illness Past medical history Present medications ( Dosages and timings) Results of Laboratory tests Documentation of informed consent and physical examination R equirement for GA ASA Classification of the child No. of Decayed teeth Procedures completed before Treatment plan ASK THE PARENT ABOUT MIC: Major illness certificate DI: Disability identification card Finally Dentist’s signature

38. Postoperative instructions After treatment, the first drink should be sips of plain water, sweet drinks can be given next. Food or drinks are preferred in small quantities at frequent intervals rather in large quantities at one time. Aerated drinks should not be given in first 24 hours. For elevated body temp- antipyretics and fluids can be given.

39. 5 . Patients should seek advice if there is persistent vomiting beyond 4 hours , increased temp above 101F, difficulty in breathing, excessive drowsiness, any matter of concern. 6 . 24 hour contact number of dental surgeon/ pedodontist should be given to parents. 7 . Emphasize on checkup on the following day and essentials of regular follow up.

40. Conclusion Thorough Knowledge about the child’s medical history and preoperative fasting time. Have good rapport with the child before anaesthesia to enhance the trust of both the child and the parent.

41. References A practice of anaesthesia for infants and children Cote and Lerman’s Textbook, 6 th edition. Manual of Paediatric Anaesthesia Lerman and Cote. Tsai CL, Tsai YL, Lin YT, Lin YT. A retrospective study of dental treatment under general anaesthesia of children with or without a chronic illness and/or a disability. Chang Gung Med J. 2006;29(4):412-418 . Naveen Malhotra, General Anaesthesia for Dentistry, Indian Journal of Anaesthesia 2008;52:Suppl (5): 725-737. Sigston PE, Jenkins AM, Jackson EA, Sury MR, Mackersie AM, Hatch DJ. Rapid inhalation induction in children: 8% sevoflurane compared with 5% halothane.  Br J Anaesth . 1997;78(4):362-365. doi:10.1093/ bja /78.4.362.

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