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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

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Sumati Bhalla's picture
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Authors:  

1.    Dr. Namrata C. Gill, MDS

Senior Lecturer

Department of Pedodontics

Dr. H.S.J. Institute of Dental Sciences & Hospital

Panjab University, Chandigarh



2.    Dr. Sumati Bhalla, MDS

Senior Lecturer

Public Health Dentistry

Dr. H.S.J. Institute of Dental Sciences & Hospital

Panjab University, Chandigarh

 

Introduction

Mind of a child is a blank slate on which experience writes its lessons. Negative dental experiences are major causes of long-standing fear and anxiety towards dental treatment. Pediatric dentists have long sought to provide dental care to their child patients in a manner which will promote excellence in quality of care and concurrently induce a positive attitude in them toward dental treatment. This aim can only be fulfilled if children receive safe and effective pain control. A range of techniques are available, comprising four overlapping categories: behavioral techniques, local anesthesia (LA), conscious sedation, and general anesthesia (GA). Vast majority of patients are amenable to satisfactory treatment using behavior management & LA alone. However, American Academy of Pediatric Dentistry (AAPD) recognizes that a population of patients, because of their need for extensive treatment, acute situational anxiety, uncooperative age-appropriate behavior, immature cognitive functioning, disabilities, or medical conditions, would benefit from deep sedation or general anesthesia.

Use of these pharmacological methods for managing uncooperative child can be done after all other management modalities have proved unsuccessful and safety of patient & practitioner justifies their use. Since the use of Pediatric chair-side general anesthesia is still not popular because of the stigmas attached to it, this paper tries to highlight the correct indications, contraindications, proper preoperative preparation, protocol for dental treatment under General anesthesia and postoperative care.

According to the degree of CNS depression, these pharmacological management techniques can be graded as:

·         Conscious Sedation

·         Deep Sedation

·         General Anesthesia

Definitions

Sedation is a technique where one or more drugs are used to depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surroundings.

General Anesthesia is a drug-induced loss of consciousness during which patients cannot be aroused, even by painful stimulation. Under GA, the ability to independently maintain ventilatory function is often impaired, patients may 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 and cardiovascular function may be impaired.

The decision to use GA is complicated by the knowledge that there is a finite risk of serious morbidity such as psychological trauma & even death (3-4 per million).  A vast majority of patients are amenable to satisfactory treatment using behavior management & LA alone or LA with conscious sedation therefore no child should be submitted to GA without consideration of potentially devastating outcome. Consider all available management techniques including acceptable restraints & sedation before deciding to use GA.

Indications for the use of chair-side GA in children

·         Patients with certain physical, mental or medically compromising conditions.

·         Patients with dental restorative or surgical needs for whom LA is ineffective because of acute infection, anatomic variations or allergy.

·         Extremely uncooperative, fearful, anxious, physically resistant or uncommunicative child or adolescent with substantial dental needs for whom there is no expectation that the behavior will soon improve.

·         Patients who have sustained extensive orofacial or dental trauma.

·         Patients requiring dental care for whom use of GA may protect the developing psyche & / or reduce medical risks.

Contraindications

·         Patient with medical contraindications to GA

·         Healthy & cooperative patients with minimal dental needs

Outpatient Vs Inpatient General Anesthesia

Outpatient- Child or adolescent free of medical disorders or well controlled chronic systemic disorders (categorized as ASA I or II)

Inpatient- child or adolescent can be considered if they fall in the category ASA III, If a medical condition exists that requires close follow up, or if child lives outside the general area of hospital and parents demonstrate questionable ability to comply with preoperative & post operative instructions

Steps in patient selection & preparation 

Pre-procedure

·         Observation & recording of child’s behavior

·         Obtain detailed medical history

·         Thorough intra-oral examination

·         Evaluate current medical status and possibility of any complications

Informed consent

Parent or legal guardian must agree to the use of GA. Parent should be provided with  complete information regarding foreseeable risks and benefits associated with particular technique and agents being used. Explanation should be provided in clear, concise terms. Information regarding alternative methods available should be provided.

Medical clearance

A comprehensive medical history should always be obtained followed by a complete physical, hematologic and urine examination. After this the due clearance should be obtained from the anesthetist and the date for procedure should be decided.

Pre-anesthetic dietary guidelines (should be provided in written to the patients)

 Clear liquids                                              up to 2- 3 hours before surgery

 Breast milk                                                up to 4 hours before surgery

 Infant formula & non human milk              up to 6 hours before surgery

 Light meal                                                  up to 6-8 hours before surgery

A pre scheduled dental procedure under GA may at times be cancelled due to sudden patient illness like productive cough, rhinitis, wheezing, in cases of risks related to co-exiting diseases or a failure to comply to preoperative instructions.

Hospital admission

In patient should be admitted one day before the surgery and the parents should fulfill the formalities beforehand. Dentist & anesthetist should ideally visit the patient an evening before the surgery. NPO guidelines should be followed. On the day of the procedure dentist & staff should be in the operating room 30 minute before the start of the procedure.

Dentist should evaluate:

 - how the child  spent the previous evening

 - check that preanesthetic medicine has been given

 - NPO status

 - makes written notes

Operating room protocol

·         All persons involved in the operating room must follow OSHA guidelines

·         Barrier  technique should be followed  to prevent cross- contamination

Anesthetic agents

Inhalation anesthesia is preferred in children as compared to intravenous as children are fearful of needles.

Properties of inhalation general anesthetics:

·         All inhalation anesthetic agents produce anesthesia by depressing specific areas of the brain

·         Modern inhaled anesthetics are extremely potent. Induction of anesthesia occurs quickly, & passage through the stages is quite rapid.

Inhalation anesthetics include- Nitrous oxide, Halothane, Enflurane, Isoflurane, Deslurane, Sevoflurane.

Stages of General Anesthesia

Induction – Halothane has remained most popular inducing agent for many decades. At present sevoflurane is the most popular choice. As compared to halothane, sevoflurane produces more rapid induction and emergence, less myocardial depression & less respiratory problems.

Maintenance – halothane, sevoflurane, desflurane & isoflurane are all acceptable maintenance agents.

Anesthetic preparation of child- Always allow the parent to accompany the child to cope with anesthesia induction.

ASA I or II patients requiring short 2-10 min procedure e.g. Extraction- Occasional pre-medication with Benzodiazepene may be required. Anesthetic vapour (sevoflurane) in N2O mixture via face mask is used for induction and face mask exchanged with nose mask or laryngeal mask during maintenance.

Outpatient ASA I or II patients that require dental treatment that lasts more than 10 mins, e.g. removal of supernumeraries, odontomes, extensive conservative dentistry/ Inpatient ASA III- Induction is similar to short case except intubation being preferred instead of face mask. Nasotracheal intubation is preferred over orotracheal intubation to ensure good access to oral cavity and short acting neuromuscular agent needs to be used to help insert intubation.

Role of Anesthesiologist

·         Starting IV line

·         Securing necessary monitoring equipment

·         Performing intubation

·         Stabilizing  nasotracheal tube

·         Ensure pt is stable & equipment is functioning properly

Role of Dental Assistant and dentist

Instruments & material should be neatly arranged in a trolley, preoperative radiographs should be obtained before scrubbing.

Peri-oral cleaning - Before dental procedure is begun, perioral area is cleansed with three sterile 4x 4 inch guaze pads- 1st gauze pad saturated with bacteriostatic cleaning agent , 2nd gauze pad with sterile saline, 3rd with alcohol. The purpose is not to sterilize but remove gross debris.

Draping- Surgical sheet should be placed over body to maintain body temperature & to provide a clear field. Head should be draped with three towels to form triangular access space for mouth.

Throat pack- Mouth should be opened with bite blocks. Pharyngopalatine area needs to be sealed off with moist strip of 3 inch wide sterile guaze 12 to 18 inches long. Packing reduces the escape of anesthetic agents and prevents any material from entering the pharynx. Throat pack should be tightly sealed.    Thorough intraoral examination should be performed to formulate a final treatment plan. Written documentation of throat pack placement and removal very important

Treatment in the operating room

Treatment sequence- Additional Radiographs, Dental prophylaxis, Endodontic treatment, Restorative treatment & Stainless Steel crown placement, followed by extractions.

 

General considerations

·         LA should be administered  to minimize pain & bleeding and rubber dam for quadrant isolation

·         Place restorations that provide the greatest longevity, with least maintenance, e.g.,  SS crowns instead of large amalgam restorations

·         Any incipient  interproximal  carious lesions  should be restored

·         When in doubt about pulpal status  & the treatment choice perform more radical one. eg pulpectomy instead of pulpotomy

·         Restorative care under GA allows excellent patient compliance , therefore increases quality & quantity of dental care .

Completion of the procedure

Anesthetist should be informed 10 minutes prior to completing procedure so that child can begin to be aroused & preparations can be made for extubation. Recovery personnel also need to be informed. On completion oral cavity is thoroughly debrided, throat pack removed carefully. At this point anesthetist assumes responsibility for the child. Dentist remains in operating room during extubation and helps in transportation to recovery room. Child is then handed over to recovery room staff and dentist gives instructions, if any special care is required e.g. extraction has been done, where to apply gauze packs. Prescription is written for pain control, antibiotics, and antiemitics. After confirming airway patency, vital signs are stable & child is recovering well dentist meets the parents to give brief report. Approximate time in which child would be shifted to ward (in patient) or be ready for discharge (out patient) is informed.

Recovery

Out patient - Once the child is awake, displays appropriate behavior, maintains airway, has stable vital signs,  has no uncontrolled bleeding or pain, is voiding, has no retention of liquids, decision is made to discharge.

In patient- Appropriate instructions written on medical chart are handed over. Patient is kept under observation for a day or two. Discharge summary, prescription & necessary post operative instructions are given to parent at the time of release.

Conclusion

“Primum nor curarum- first do no harm” - No child should be submitted to GA without consideration of potentially devastating outcomes. Use of any drug carries some degree of risk. Available evidence suggests that use of appropriate sedative & anesthetic drugs in the dental office by appropriately trained professionals has remarkable safety. But use of pharmacological methods for managing uncooperative child should be done after all other management modalities have proved unsuccessful.

References

1.    American Academy of Pediatric Dentistry: Guidelines for the elective use of conscious sedation and general anesthesia in pediatric patients. Pediatric Dentistry 7(4):334-37, 1985.

2.    Collins VJ: Principles of anesthesiology, general and regional anesthesia. Vol.1 3rd ed, Lea and Febinger,Philadelphia,1993.

3.    Foster T, Perinpayangam H,Pfaffenbach A, Certo M. Recurrence of early childhood caries after comprehensive treatment with general anesthesia and follow up. JDent Child 73 (1): 25-30, 2006.

4.    Koirala B, Pandey RK, Saksen AK, Kumar R, Sharma S. A comparative evaluation of new sedatives in conscious sedation. J Clin Pediatr Dent. 30(4): 273-6, 2006.

5.    Saxen MA, Wilson S, Paravchio R: Anesthessia for Pediatric Dentistry. Dental Clinics of North America, 43(2) 231-245, 1999.

6.    Keitch J, Macpherson A. Current state of sedation/ analgesia care in dentistry. Curr Opin Aaesthisiol 20(4):384-7, 2007.

7.    Allen K, Tandon S: Pharmacologic means of Patient management in Textbook of Pedodontics Shobha Tandon, 2nd ed. Paras Medical Publisher, Hyderabad, 157-168, 2009.

8.    Weddell  JA, Jones JE: Hospital Dental Services for Children and the use of General Anesthesia in Dentistry for the child and adolescent.9th ed. Dean JA , Avery DR, McDonald, Elseviers, Missouri, 277-295, reprint 2011.

 

 

 

 

 

 

 

 

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

 good write up dr sumati bhalla. keep it up

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

Healthy children under 36 months of age, presenting early childhood caries were randomly assigned to receive protective stabilization plus: combined oral midazolam (0.5 mg/kg) and ketamine (3 mg/kg) (MK), or oral midazolam (1.0 mg/kg) (MS), or no sedative (PS).
The combination of oral midazolam and ketamine is efficacious for guiding the behaviour of children under 3 years old. (International Journal of Paediatric Dentistry)

 

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

Exposure to common antibacterial chemicals and preservatives found in soap, toothpaste, mouthwash and other personal-care products may make children more prone to a wide range of food and environmental allergies, according to new research from Johns Hopkins Children's Center.
Results of the NIH-funded study are published online ahead of print June 18 in the Journal of Allergy and Clinical Immunology.
Using existing data from a national health survey of 860 children ages 6 to 18, Johns Hopkins researchers examined the relationship between a child's urinary levels of antibacterials and preservatives found in many personal-hygiene products and the presence of IgE antibodies in the child's blood. IgE antibodies are immune chemicals that rise in response to an allergen and are markedly elevated in people with allergies.
"We saw a link between level of exposure, measured by the amount of antimicrobial agents in the urine, and allergy risk, indicated by circulating antibodies to specific allergens," said lead investigator Jessica Savage, M.D., M.H.S., an allergy and immunology fellow at Hopkins.
The researchers caution that the findings do not demonstrate that antibacterials and preservatives themselves cause the allergies, but instead suggest that these agents play a role in immune system development.
The investigators say their findings are also consistent with the so-called hygiene hypothesis, which has recently gained traction as one possible explanation behind the growing rates of food and environmental allergies in the developed world. The hypothesis suggests that early childhood exposure to common pathogens is essential in building healthy immune responses. Lack of such exposure, according to the theory, can lead to an overactive immune system that misfires against harmless substances such as food proteins, pollen or pet dander.
"The link between allergy risk and antimicrobial exposure suggests that these agents may disrupt the delicate balance between beneficial and bad bacteria in the body and lead to immune system dysregulation, which in turn raises the risk of allergies," Savage added.
In the study, those with the highest urine levels of triclosan -- an antibacterial agent used in soaps, mouthwash and toothpaste -- had the highest levels of food IgE antibodies, and therefore the highest allergy risk, compared with children with the lowest triclosan levels. Children with the highest urinary levels of parabens -- preservatives with antimicrobial properties used in cosmetics, food and medications -- were more likely to have detectable levels of IgE antibodies to environmental allergens like pollen and pet dander, compared with those with low paraben levels.
The team initially zeroed in on seven ingredients previously shown to disrupt endocrine function in lab and animal studies. These compounds were bisphenol A -- found in plastics -- and triclosan, benzophenone-3 and propyl, methyl, butyl and ethyl parabens, found in personal-hygiene products and some foods and medications. Interestingly, triclosan and propyl and butyl parabens, all of which have antimicrobial properties, were the only ones associated with increased allergy risk in the current study, the researchers noted.
"This finding highlights the antimicrobial properties of these agents as a probable driving force behind their effect on the immune system," said senior investigator Corinne Keet, M.D., M.S., an allergist at Johns Hopkins Children's Center.
Children with the highest urine levels of triclosan had nearly twice the risk of environmental allergies as children with the lowest urinary concentrations. Those with highest levels of propyl paraben in the urine had twice the risk of an environmental allergy. Food allergy risk was more than twice as pronounced in children with the highest levels of urinary triclosan as in children with the lowest triclosan levels. High paraben levels in the urine were not linked to food allergy risk.
To clarify the link between antimicrobial agents and allergy development, the researchers are planning a long-term study in babies exposed to antibacterial ingredients at birth, following them throughout childhood.
he research was funded by the National Institutes of Health training grant number T32AI007056-31.
Co-investigators on the research were Elizabeth Matsui, M.D., M.H.S., and Robert Wood, M.D., both of Hopkins.

 

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

Young children with allergies to milk and egg experience reactions to these and other foods more often than researchers had expected, a study reports. The study also found that severe and potentially life-threatening reactions in a significant number of these children occur and that some caregivers are hesitant to give such children epinephrine, a medication that reverses the symptoms of such reactions and can save lives.
"This study reinforces the importance of doctors, parents and other caregivers working together to be even more vigilant in managing food allergy in children," said Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.
The study results appear online in the June 25 issue of Pediatrics and are the latest findings from the Consortium of Food Allergy Research (CoFAR), a network established by NIAID to conduct clinical trials, observational studies and basic research to better understand and treat food allergy.
The research is part of an ongoing CoFAR observational study that enrolled 512 infants aged 3 to 15 months who at study entry were allergic to milk or egg, or who were likely to be allergic, based on a positive skin test and the presence of moderate-to-severe eczema, a chronic skin condition. The investigators are carefully following these children to see whether their allergies resolve or if new allergies, particularly peanut allergy, develop. The study is ongoing at research hospitals in Baltimore; Denver; Durham, N.C.; Little Rock, Ark.; and New York City.
CoFAR investigators advised parents and caregivers to avoid giving their children foods that could cause an allergic reaction. Study participants also received an emergency action plan, describing the symptoms of a severe allergic reaction to food and what to do if a child has one, along with a prescription and instructions on how to give epinephrine if a severe reaction occurred.
Data compiled from patient questionnaires and clinic visits over three years showed that 72 percent of the children had a food-allergic reaction, and that 53 percent of the children had more than one reaction, with the majority of reactions being to milk, egg or peanut. This translated into a rate of nearly 1 food-allergic reaction per child per year. Approximately 11 percent of the reactions were classified as severe and included symptoms such as swelling in the throat, difficulty breathing, a sudden drop in blood pressure, dizziness or fainting. Almost all of the severe reactions were caused by ingestion of the allergen rather than inhalation or skin contact.
In only 30 percent of the severe reactions did caregivers administer epinephrine, a drug that alleviates the symptoms of severe reactions by increasing heart rate, constricting blood vessels and opening the airways. Investigators found that caregivers did not give children epinephrine for a number of reasons: the drug was not available, they were too afraid to administer it, they did not recognize the symptoms as those of an allergic reaction, or they did not recognize the reaction as severe.
"This study documenting the natural history of allergic reactions to three of the major food allergens in pre-school children provides important new information for parents, caregivers and health care workers because of the large number of children involved and the rigorous follow-up," said Daniel Rotrosen, M.D., director of the NIAID Division of Allergy, Immunology and Transplantation, which oversees CoFAR. "The findings not only reveal that food-allergic reactions occur at a much higher rate in young children than we thought, they also suggest that more vigilance and increased use of epinephrine is needed."
Almost 90 percent of allergic reactions to egg, milk or peanut occurred after a child accidentally ate the food. The reasons for the accidental exposures included caregivers misreading food labels, not checking a food for an allergen, and unintentionally allowing a food allergen to come into contact with other foods (cross-contamination).
The study also found that approximately 11 percent of allergic reactions to egg, milk or peanut occurred after a caregiver -- most often a parent -- provided a child the allergenic food intentionally.
"Intentional exposures to allergenic food are typically reported in teenagers, who tend to take more risks or who might be embarrassed about their food allergy," says David Fleischer, M.D., the lead study author. "What is troubling is that in this study we found that a significant number of young children received allergenic foods from parents who were aware of the allergy."
CoFAR investigators are exploring possible reasons for these intentional exposures, but they speculate that it could reflect parents' at-home tests to determine if children have outgrown the food allergy. Because giving children allergenic foods could possibly result in life-threatening reactions, such testing should only be conducted under the direct supervision of a health care professional trained in performing food challenges. The study findings reinforce the importance of caregivers working closely with their doctors to understand how to effectively manage a child's food allergy.

 

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

 Successful sedation in dentistry does not end when the patient departs the practice. Children, in particular, are sensitive to sedation, and as childhood caries rates remain high, the need for sedation will also persist.

Researchers from the department of pediatric dentistry at Louisiana State University Health Sciences Center (LSUHSC) School of Dentistry noticed the dearth of data about children's response to sedation after they have left the practice where the dental procedure took place. In a study published in Anesthesia Progress, the researchers compared the adverse events experienced by children administered meperidine and hydroxyzine versus midazolam eight hours and 24 hours after sedation (Summer 2013, Vol. 60:2, pp. 54-59).

Their results could help set expectations and inspire advice for parents as they prepare to take their children home.

"Sleeping in the car during the ride back home was observed in half of the sedated children in this study," wrote Priyanshi Ritwik, an associate professor in the department of pediatric dentistry, and colleagues. "This has the risk of airway obstruction."

The researchers also observed different reactions to the sedatives they compared. "Vomiting was seen in children sedated with meperidine and hydroxyzine but not in the children sedated with midazolam," they noted. "Prolonged sleep at home was significantly higher in the children sedated with meperidine and hydroxyzine." And most adverse effects were likely to occur in the first eight hours, although some took up to 24 hours to manifest.

 

The drive home

Sedatives often last longer than the duration of the dental appointment. Consequently, the trip home from the dental practice can be a hazardous one, involving vomiting or worse.

"It is critical to know the effects of these medications beyond the time spent by the child in the dental office, so that parents can be appropriately cautioned about the expected effects and how to distinguish them from any potential emergencies that may lead to airway obstruction," the researchers explained.

During a three-month period, the researchers called the parents of children undergoing sedation at LSUHSC who were willing to participate in a survey eight hours and 24 hours after the procedure. The children included in the study were generally healthy and sedated due to acute situational anxiety.

The eight-hour questionnaire asked predominantly "yes" or "no" questions about complaints of pain, vomiting, snoring, or sleeping in the car on the way home, sleeping at home arousability, irritability, the ability to eat and drink, the need for medications at home, and the need for additional medical care after the appointment. The questions at the 24-hour mark were similar.

The parents of 46 children participated in the study; 40 were sedated with a combination of meperidine and hydroxyzine while the remaining six were sedated with midazolam. In the former group, 16 children reported pain after eight hours and seven of them said it persisted at the 24-hour mark. Only two children in this group had a fever. One child in the midazolam group reported pain in the first eight hours and one child had a fever. There was no statistical difference in the proportion of patients experiencing pain (p = 0.647) or fever (p = 0.349) based on which sedative they were given.

Three children given meperidine and hydroxyzine vomited within eight hours of sedation; none from the midazolam group did. Half of the children from both groups slept in the car after departure. Of those who slept in the car, 13 from the meperidine-hydroxyzine group and one child from the midazolam group had a ride of less than 30 minutes to get home. Five children from the former group and one from the latter had a ride of more than 30 minutes.

"All children in the meperidine and hydroxyzine group exhibited prolonged sleep at home in the eight- to 24-hour period," the researchers noted. "Five children (13%) were difficult to wake up in this time period." In the other group, 67% of the children exhibited prolonged sleep and one of them was difficult to rouse.

The researchers noted that sleeping during the car ride home has the potential for airway obstruction because the children may tilt their head down to their chest. "It is, therefore, important to ask parents to bring another responsible adult to accompany their child in the car when planning sedations for pediatric patients," they concluded.

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Steal the child with a Sleepy wind: Pediatric chair-side general anesthesia

The thread was usefull.
For child Anasthesia it should be accomplished by a proffesional.

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