Alya Elgamri

October 2019
What is general anaesthesia?

Anaesthetic drugs are injected

into a vein, or anaesthetic gases
GA is a state of controlled
are inhaled into the lungs, and
unconsciousness during which
they are then carried to the brain
you feel nothing and can be
by the blood. They stop the brain
described as ‘anaesthetized’.
recognizing messages coming
from the nerves in the body.
• Anaesthetic unconsciousness is
different from unconsciousness
due to disease or injury and is
different from sleep.
• As the anaesthetic drugs wear
off, consciousness starts to
return.
 Risks
Major risks are rare
associated
with
The real risk of a serious outcome is probably
general
less than one in 400000, although it is not
possible to estimate this properly because of
the lack of data.
anaesthesia
The main concern of parents is that a
child who has been anaesthetized will
either not wake up again or wake up
with brain damage.
Major
This is a real, but vanishingly small, risk
risks
that is associated with past times when
GA for dental treatment in children was
carried out in general dental surgeries.
• Pain

• Headache

• Sore nose
Minor
• Sore throat

• Nausea and vomiting

risks
• Upset

• Greater anxiety about future dental treatment

Requirements for G.A

The general
anaesthetic must be
Nowadays, it is
administered by a
mandatory in the UK
consultant trained in
for all GA to be carried
paediatric aspects of
out in a hospital setting
GA, the anaesthetic
with immediate access
assistant, operating
or transfer to a
theatre nurses,
paediatric critical care
recovery staff, and the
unit.
dentist and dental
nurse.
Indications for general anaesthesia

1. The child needs to be put completely to sleep because there is a

belief that he/she is too young, too anxious, or too uncooperative
to accept treatment by any other method of pain control. An
example of this is a child with early childhood caries, especially
when there are painful, unrestorable teeth in multiple quadrants.
2. The dental surgeon needs a guarantee of a completely still
patient, usually because the planned dental procedure is complex
and requires full ‘cooperation’ as the operation is surgically
challenging. Complete stillness is required to ensure satisfactory
operating conditions. An example of this is a child who needs the
surgical removal of a supernumerary.
Once a primary care dentist has
determined that dental
treatment under GA is the most
clinically appropriate method of
management, they will
normally refer the child to a
local GA service provider.

Referral
The referral letter should
clearly justify the need for the
use of GA.
The assessment process at the GA
service

• Dental—to check and confirm the treatment plan. This will

probably be undertaken by a specialist in paediatric dentistry.

• Medical—to determine fitness to undergo a general

anaesthetic.
Pre- GA appointment

Dental examination, including

radiographs if appropriate, will
be performed and options for The associated benefits and
the dental treatment, risks of each technique will
including LA, conscious
sedation, or GA, will be also have to be discussed.
explained.
Treatment planning for GA
• The general principle to be applied is that greater effort needs to

be made to ensure that the treatment procedure carried out has

a reliable and clear prognostic outcome.

• This is so that the patient is not faced with the possibility of

having a second general anaesthetic to repeat or undo failed

dental treatment.
 • For example, the high level of

extractions in cardiac cases or in an

For example immune compromised child is to
ensure that no potential focus of
infection remains.
Consent for dental treatment under GA
The information leaflet should include:
• Preoperative preparation including fasting
• Overview of the proposed treatment including benefits and minor and major
Risks
• The general anaesthetic procedure
• An adult escort should bring the child patient—no other child should
Accompany them
• Postoperative arrangements including the need for suitable transport home
• Postoperative care and pain control.
What is day surgery?

• The term ‘day surgery’ is used to describe short-stay ambulatory

care which does not involve the use of a hospital bed overnight.

• Whatever the length of stay, children undergoing GA for dental

treatment receive the same standard of care and have a similar

pathway as those undergoing medical procedures
Induction of GA
• The objective is to ensure that sufficient
anaesthetic enters the blood stream to enable
controlled loss of consciousness.

• This is commonly achieved by the delivery of a

gaseous mix of oxygen and nitrous oxide which
carries an anaesthetic inhalation adjunct such as
sevoflurane.
 Once
anaesthesia is A pulse oxi-
established, meter is used to
steps are taken measure blood
to ensure patient oxygenation.
safety. Monitoring
Many GA procedures
A cuff for blood machines also
pressure and an have the facility
electrocardiogra to monitor the
m (ECG). carbon dioxide
output.
 The child can go home after normal bodily
functions are restored (e.g. they can walk
unaided, swallow, and go to the toilet).
Discharge
after GA However, it takes approximately 2 days for
cognition to return fully, even after a short
general anaesthetic. Therefore postoperative
care is needed during this recovery time (e.g.
the child may need time away from school).
Follow-up

• Arrangements need to be made for the child to be seen in a few

weeks, usually with the GDP. This may be to check that

postoperative healing has taken place and that preventive
advice is being followed and reinforced.

• Occasionally, it may be necessary to remove sutures

Summary
• The best way to manage child dental anxiety is to
avoid its occurrence in the first place through
prevention of dental disease, good behaviour
management, pain-free operative care, and
treatment planning that is tailored to the needs and
developmental stage of each individual child.
• When GA is considered a thorough assessment is required.
• This includes psychological assessment, confirmation of the plan
of treatment, together with preparation for the procedure
including information sharing, fasting instructions if required,
discharge planning, and postoperative pain management.
• The parent and child need time and information to consider the
treatment options and to give informed consent.