hospital dental services for children and the use of general anesthesia
DESCRIPTION
“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. Cardiovascular function may be impaired.TRANSCRIPT
الرحيم الرحمن الله بسم
Hospital Dental Services for Children
and the Use of General Anesthesia
Definition 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. Cardiovascular function may be impaired.
American Academy of Pediatric Dentistry ( AAPD)
Definition General anesthesia”:
American Academy of Pediatric Dentistry ( AAPD)
a drug-induced state loss of consciousness
patients : not arousable (even by painful stimulation)
Ventilatory function : impaired require positive-pressure ventilation
maintaining a patent airway
Cardiovascular function : impaired.
rationale for using general anesthesia in the behavior management
the medical condition of the patient • e.g.: need of pre- operative blood transfusion
the child needs extensive dental work • e.g.: the procedure more safely in the hospital
setting The negative dental behavior
provide safe and comprehensive dental care for the pediatric patient with behavior, medical, or other problems that preclude treatment in the office setting by eliminating cognitive, sensory, and skeletal motor activity in order to facilitate the delivery of quality comprehensive diagnostic, restorative, and /or other dental services.
Goals of General anesthesia”:
Goals of General anesthesia”:
• provide safe and comprehensive dental care• Patients: behavior or medical problemsCANT do treatment in office settingBY eliminating cognitive + sensory + skeletal
motor activity
delivery of quality comprehensive diagnostic + restorative dental services
Indication of General anesthesia”:
• Patients with certain physical, mental, or medically
compromising conditions.• Patients whom local anesthesia is ineffective.• The extremely uncooperative, fearful, anxious,
physically resistant or uncommunicative child.• Patients who have extensive orofacial and/or dental
trauma• Patients with immediate comprehensive dental needs.
Contraindication of General anesthesia”:
• General anesthesia risk• Respiratory infection• Active systemic disease with elevated
temperature• NPO guideline violation• A healthy cooperative patient with
minimal dental needs
Psychological effects of hospitalization on children
20 – 50 % of children : behavior changes
after hospitalization.
Main factor: separation from
parents
Minimize negative behavior:
• Operative room tour.• Favorite doll.• Pre-induction sedation.• Nonthreatening environment.• Post- procedure sedation.• Join the parents in the
recovery
Selection of Operating Room Facility
OUT – PATIENT (day surgery)
IN-PATIENT (hospital setting)
Selection of Operating Room Facility
out –PATIENT ( day- surgery)
Patient selection
Healthy, ASA I/II
advantages •more efficient•better tolerated by family•more patient friendly
In-PATIENT (hospital setting)
• ASA III and above•children from remote areas with rampant decay•questionable parental compliance with pre and post instructions•possible need for 24 hours admission
Patient selection
Dental rehabilitation underGENERAL ANESTHESIA1. MEDICAL AND DENTAL HISTORY
2. PRE OPERATIVE DENTAL EXMINAITION.
3. PARENTAL CONSULTATION
4. PEDIATRIC CONSULTATION
5. PRE OPERATIVE ANESTHESIA EXAMINATION
6. ONE WEEK BEFORE APPOINTMENT (CONSENT FORM)
7. PREOPERATIVE ORDERS
8. PATIENT ADMISSION
9. EQUIPMENT PREPARATION
10. ANESTHESIA INDUCTION
11. RESTOARTIVE PROCEDURE
12. POST OPERATIVE PROCEDURE
13. DISCHARGE AND FOLLOW UP CARE
1- MEDICAL AND DENTAL HISTORY
Medical and dental history
Family and social history
Chief complain
Medical History
1. Disease or abnormalities.2. Allergies or adverse drug reactions.3.Current medications, dose, time,route and site
of administration.4.Previous hospitalization5.History of general anesthesia or sedations.6.Family history.7.Review of body system.8.Age and body weight.
2-PRE – OPERATIVE DENTAL EXAMNATION
2-Pre- operative dental examination
Clinical examination
Extra- oral (head and
neck physical examination)
Intra- oral
Soft tissu
e
Hard tissu
e
Radiographic Examination
lips
tongue
Floor of the mouth
Buccal mucosa
Hard/soft palate
oropharynx
peridontium
Soft tissue
caries
Eruption sequence
Occlusion
Hard tissue
3-PARENTAL CONSULTATIONexplain to the parents:
• Discuss the reason/need for G.A• Risks/benefits with G.A.• Anticipated post-operative behavior.• Need for a physical examination• Need for laboratory tests.• Need for medical consultation (if indicated).• Admission process to the hospital/ one day surgery.• Pre-surgical and post-surgical dietary precautions.
4-PEDIATRIC CONSULTATION
PEDIATRIC CONSULTATION
PEDIATRIC Evaluation
Medical history
Review of body
system
ASA classificati
on
Request the needed laboratory investigations
Pediatric Review of the laboratory result
ASA Physical Status Classification System
ASA I A normal healthy patient
ASA II A patient with MILD systemic disease
ASA III A patient with SEVERE systemic disease
ASA IV A patient with SEVERE systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes
Request the needed laboratory investigation
CBC,PT,PTT,INR coagulation, sickle cell screen,
HGsAg
thyroid function tests
5-Pre operative anesthesia examination
Tonsillar size classification.The anesthetic recommendation:• Cleared for the operation after the
pediatric clearance.• Fasting from the midnight the day
before the surgery• Preoperative medication (Midazolam)
Tonsillar size classification
Classify +3 (more than 50% pharyngeal area occupied by tonsils) ↑ risk airway obstruction
Mallampati classification
Mallampati classificationClass 1: Full visibility of tonsils, uvula
and soft palate
Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula
Class 3: Soft and hard palate and base of the uvula are visible
Class 4: Only Hard Palate visible
6-ONE WEEK BEFORE APPOINTMENT
LEGAL CONSENT IS SIGNED
consent form for blood transfusion in case of emergency is signed
The date of the operation.
Informed consent
• Verbal and Written.• wittiness.• Explain benefits +
risks + alternatives to general
anesthesia.
7 -PREOPERATIVE ORDERS
Diet description and restrictions Laboratory studies needed for
anesthesia and surgery clearance Preoperative Medication Consultations requests as needed Oncall for operating rooms
Dietary precautions NPO guild line
Ingested Material Minimum Fasting Period (h)
Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee
2
Breast milk 4
Infant formula 6
Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, theamount ingested must be considered when determining an appropriate fasting period
6
Light meal: 6
Diet instructions
1.No milk or solids for 6-8 hours .2.Clear liquids up to 3hours
before the procedure.
Reasons for diet instructions
Prevent emesis during or immediately after a sedative procedure.
uptake is maximized when the stomach is empty.
8-PATIENT ADMISSION
Admission order • admit the patient for dental rehabilitation under
general anesthesia.• Laboratory investigations.• History and Physical examination.• Notify the anesthesiology for pre operative
evaluation.• Medications.• consultations
9-EQUIPMENT PREPARATION
Operating room protocol • Follow occupational safety and health
administration ( OSHA) guidelines.• Standard scrub technique for sterile procedure.• sterile gown + sterile gloves + protective
barriers.
Intra oral dental procedure is a CLAEN procedure rather than sterile procedure
9-EQUIPMENT PREPARATION
9-ANESTHESIA INDUCTION
Properties of inhalation anesthesia
• In children; induce anesthesia
Inhalation of halogenated volatile anesthetic agents by : Face mask
Effect: depressing specific areas of the brain
Anesthetic potency :
Definition Concentration of the agent required to inhibit response to a standard surgical stimulus.
Measure by : Minimum alveolar concentration ( MAC)
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Heart rate , blood pressure , Respiratory rate
stages of anesthesia
Stage 1
Relative + total analgesia
Stage 2
Excitement
Stage 3
Surgical anesthesia
Stage 4
Respiratory paralysis
Inhalation anesthesia agent:
Nitrous oxide
halothane
Isoflurane
sevoflurane
Sevoflurane;• Agent of choice for
inhalation induction• Rapid induction• Less respiratory
problems
Inhalation
anesthesia
sevofluran
e
Maintenance anesthesia
halothane
sevoflurane
isoflurane
Patient is in a stable anesthetic condition andready for the dental procedure
Perioral cleaning , draping and placement of throat pack
Intra oral examination
Dental prophylaxis
Taking radiographs
Formulate the final treatment plan
11-RESTOARTIVE PROCEDURE
Perioral cleaning , draping and placement of pharyngeal throat
pack
• Clean the perioral area with three sterile 4x4 inch gauze pads
(remove gross debris)
• Cover the patient` body by surgical sheet
maintain the body temperature
provide clean field
• Draped the head by three towels
• Form triangular access space
• expose the mouth• Expose the
nasotracheal tube
Throat pack
Technique Seal the pharngoplataine area by moist sterile gauze ( 12 to 18 inch long )
Documentation
Written documentation for time of placementWritten documentation for time of removal
Function 1. Reduce the escape of anesthetic agent.2. Prevent any material from entering the pharynx
Requirement The gauze must be tightly packed around the tube
Ensure good seal
Operating room positions of the staff while performing the necessary dental procedures
• use mouth prop• NOT impinge on
lips/tongue
Restorative dentistry in the operating room
• use of local anesthesia• Quadrant isolation by rubber dam.
• Topical application of fluoride for each quadrant.
• Place restoration of GREATEST LONGEVITY with the LEAST amount of maintenance.
• E.g : SSC > MOD filling
Advantages of restorative dental care under general anesthesia
Excellent patient
compliance
Increase quality and quantity of dental care.
Decrease anxiety level
Intra operative complication Dislodge/obstruct
endotracheal tube
IV infiltrate/ disconnect
Nasal bleeding
Lip/tongue bleeding
Completion of the procedure
• Notify the anesthesiologist 10 minutes before complete the procedure.
• Notify the recovery room.• Debride the oral cavity.• Remove the throat pack.
12-POST OPERATIVE CARE
• Inform the nurse of post surgical instructions.
• Establish ; potent airway + stable vital signs.
• give the parents a brief report of the treatment.
Written prescriptions
Pain control (acetaminophen
)
Antibiotics (Amoxicillin )
Antiemtics (Zofranel)
Post operative order
outpatient order
Inpatient order
Operative report
Post instructions to the parents
OUT patient orders
• Monitor vital signs until stable.• Disconnect IV when release from recovery.• Start clear liquids in day surgery.• Recall appointment.• Analgesic prescription.• Discharge from day surgery when meet
discharge criteria.
IN patient orders
• IV solution (e.g. ;5 % dextrose with ½ normal saline) at rate (e.g. 40 ml/hr)
• Monitor vital signs q 15 minutes until stable then routine.
• Elevate head 30 degree.• Apply ice packs ( swelling)• Apply pressure pack ( homeostasis)• Start clear liquids as patient tolerated.• Medications.
Operative report
• Type of dental procedure.• Type of intubation.• Teeth restored.• Teeth extracted.• Dental prophylaxis and topical fluoride
application.• Summary (length of the procedure, blood loss,
complications)• Prognosis.• Dentist name and signature.
Post instructions to the parents
Discussing The diagnosis and the treatment plan completed in the operating room
Discussing the Nature of the restoration placed
OHI, preventive programs Diet counseling Post operative medications Recall visit after 1 week
Post operative complication
Fever Nausea
Vomiting hypoxia
Bleeding
13-DISCHARGE AND FOLLOW UP CARE The patient is alert , fully awake Normal vital signs records The patient can drink and eat well No bleeding No severe pain Restorations intact and in place
Recommended Discharge Criteria1. Cardiovascular function and airway patency :
satisfactory + stable
2. The patient is easily arousable.
3. protective reflexes: intact.
4. The patient can talk + sit up unaided
5. very young or handicapped children: return to he pre -sedation level of responsiveness
6. The state of hydration : adequate.