Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehab

Resident: Adam J. Bottrill
Date: 26JAN11
Region: Providence
Article title: Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehabilitation
Author(s): Watts, Amy K. DDS, MS
Journal: Pediatric Dentistry
Page #s: 414-419
Vol:No Date: 31:5, SEP/OCT 2009
Major topic: Local Anesthesia, General Anesthesia, Children
Minor topic(s): NA
Type of Article: Randomized, parallel-design study
Main Purpose: The purpose of this article was to evaluate the use of intraoperative local anesthetics in pediatric outpatient dental surgery. It assessed physiological stability, as defined by fluctuations in end-tidal CO2, HR, RR and subsequent anesthesiologist intervention.

Key points in the article discussion:

I. General:
A. Pain is both a real emotional and physiological respoonse
B. Research suggests that the use of regional anesthesia can reduce the amount of required inhaled general anesthesia.
C. LA, in conjunction with GA can produce a more hemodynamically stable patient AND control pain in the immediate post-operative period.
D. IDEAL ANESTHETIC AGENT: immobility, amnesia, , sedation, analgesia/nociception, arousal blockade with a pharmacological profile that possesses a wide margin of safety.
E. Currently, no guidelines by either the ASA or the ADA for use of local anesthesia during GA dental rehab. AAPD states that LA "may be used" to reduce pain in post-op period.


II. Methods:
A. Pilot study was conducted for feasability purposes
B. 48 children (mean age of 3.87) undergoing GA
C. Inclusion Criteria
1. 12-84 mo
2. at least one maxillary extraction.
3. rubber dam clamp in maxilla
4. at least one primary tooth needing pulp/crown
5. ASA I or ASA II
D. One dental anesthesiologist used for all GA's
E. Two groups: LA and NON-LA
F. LA administered prior to procedures (for LA group)
G. 2% xylocaine was given in the LA group
H. No patient exceeded 4.4mL of LA
I. Vital sign changes recorded 30 seconds after each procedure.
J. Anesthesiologist intervention was with 10 mg boluses of propofol
K. Intervention if: movement, breath holding, 20% increase in vital signs, ETCO2 <40mm Hg
B. Two groups: LA and NON-LA
C. LA administered prior to procedures (for LA group)
D. Vital sign changes recorded 30 seconds after each procedure.

III. Results/Discussion: (pooled data)
A. NON-LA group: changes in vital signs were statistically significant for two parameters.
1. Post extraction ETCO2
2. Post extraction HR
B. Interference: Different patients have different tolerability for changes in vital signs from baseline.
C. Weaknesses:
1. The exact amount of anesthesia received by each tooth was not able to be controlled.
2. Order of procedures was decided by the dentist.

IV. Conclusions:
A. Patients who were not given intraoperative local anesthesia were more likely to experience vital sign fluctuation requiring anesthesiologist intervention.

Assessment of article: I thought it was an efffective, thorough study. I wish there was more statistical significance to some of the other parameters and procedures. The conclusions seemed to only follow what is already known anecdotally. Despite this fact, it is nice to have an actual article backing up existing practice.

Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.

Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Department of Pediatric Dentistry

Lutheran Medical Center

 

Resident’s Name:  Chad Abby                                    Date: 5/29/2009

Article title:  Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Author(s): Howard Needleman, Sandhya Harpavat, Sam Wu, Elizabeth Allred, Charles Berde

Journal:  Pediatric Dentistry

 Volume (number): Vol. 30, No. 2

Month, Year:  2008

Major topic:  General Anesthesia

 Minor topic(s:  Postoperative pain of dental rehabilitation performed on children under GA

Type of Article:  Scientific Article

Main Purpose:  The purpose of this study was to determine the prevalence, severity and variables influencing postoperative pain and other sequelae in children undergoing dental rehabilitation under general anesthesia. 

Methods:  Healthy children scheduled for dental rehabilitation having treatment only on primary teeth were included in the study.  General anesthesia protocol was standardized and patients did not receive local anesthesia intraoperatively.  Pain and other postoperative sequelae were recorded for seven days postoperatively. 

Findings:  95% of the 90 children had postoperative pain which was moderate in intensity and highest immediately postoperatively.  Children who had an extraction or were at least 4 years old and had more then 12 procedures experienced, increased postoperative pain.  The most common postoperative symptoms other than pain were agitation, need for analgesics, and sleepiness.  Longer operative times resulted in increased postoperative sleepiness.  Children whose tracheal intubations were traumatic were more likely to report sore throats.  Children who were at least 4 years old required more analgesics, experienced more postoperative sleepiness and had nausea more frequently.  All postoperative problems significantly decreased by day 2 postoperatively and ceased by day four to five. 

Key points/Summary :  Children undergoing dental rehabilitation under general anesthesia commonly experience postoperative symptoms such as pain, agitation, need for analgesics, and sleepiness.  Children who have longer operative times are more likely to experience postoperative sleepiness.  This study used no intraoperative local anesthesia nor were there any standard orders for the use of postoperative analgesics to be given in the recovery room, which may explain why the children in this study had the highest rate of reported pain compared with other previous studies.  It was also found that children of less-educated parents were more likely to report pain in both the preoperative and PACU periods. 

Assessment of article:  Dentists often have limited contact with children immediately following treatment under general anesthesia so it is important to explain to parents what to expect and how to manage and reduce children’s postoperative emotional and physical distress.  The results were somewhat surprising to me considering how few parents tell us there children have postoperative pain or nausea following dental rehabilitation after general anesthesia.  Possibly parents feel more comfortable expressing pain or discomfort on questionnaires they fill out?  This is something the article mentioned in that the type of pain scale used was more of a self assessment scale. 

Reasons for Repeat Dental Treatment Under GA

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Anna Haritos Date: May 22, 2009
Article title: Reasons for Repeat Dental Treatment Under General Anesthesia for the Healthy Child
Author(s): Sheller, et al
Journal: Pediatic Dentistry
Volume (number): 25:6
Month, Year: Nov-Dec, 2003
Major topic: Repeat GA-based dental treatment
Minor topic(s): n/a
Type of Article: Research
Main Purpose: to investigate the reasons why healthy children required repeat dental treatment under GA
Overview of method of research: A retrospective chart review of 23 patients (ASA I, II, two GA-dental tx) was conducted between Jan 19990 and Mar 2000; these charts were labeled subjects and were matched demographically with 23 ‘control’ charts of one-time GA-dental tx patients; Parents/guardians of these subjects and controls were recruited for questionnaire/interview session – 11 subject parents and 9 control parents participated;
Findings: The chart review found that repeat patients were mostly male, with mean age of first GA-treatment at 2.6 yrs, and mean age second GA-treatment 4.7 years. For both subjects and controls, Medicaid was the most common method of payment. At the initial visit, prior to any GA, no subjects cooperated for radiographs, while 40% of controls cooperated for radiographs. All of the subjects received central incisor treatment under GA while 76% of the controls received central incisor treatment. 7% of subjects versus 43% of controls returned for post-op visits. 39% of subjects developed caries on previously untreated/unerupted teeth versus 2% of the controls. Success of SSC were similar in both groups. Interview responses by parents revealed that subject patients had a hard time with injections in the medical setting versus controls; At the time of the first GA, more subjects than controls were bottle-fed with non-water fluids. All controls had an adult brushing their teeth at the time of the first GA versus 55% of the subjects. After the first GA treatment, 45% of subjects continued to use non-water bottle-feeding at nap and bedtime versus 11% of controls. Both subject and control parents did not change frequency of type of snacks given to their child before versus after GA treatment.
Key points/Summary: patient factors associated with need for second session of GA-dental treatment: 1)100% involvement of maxillary central incisors at time of initial GA; 2)continued use of the bottle at the time of GA; 3)poor cooperation in the medical/dental setting; 4) difficult personality as described by parent; 5) parents not brushing child’s teeth; 6) parent/child had dysfunctional social situation; 7) parents failed to bring child back for post-op visit;
Assessment of article : very good article

Perioperative Approach To Children

Department of Pediatric Dentistry
Lutheran Medical Center
Date: 05/22/2009
Article title: Perioperative Approach To Children
Author(s): Zuckerberg Aaron L.
Journal: Pediatric Anesthesia
Volume (number): 41 number 1
Month, Year: Feb 1994
Major topic: Pediatric Anesthesia
Minor topics: Outpatient surgery
Type of Article: Professional Paper

Main Purpose:
Review the importance of child management in the perioperative period.
Overview of method of research: Professional paper with review of literature.

Findings:
The current trend toward treating pediatric patients under general anesthesia in outpatient clinics means that anesthesiologists often have little contact with the patient outside of the OR. Therefore, the responsibility of the perioperative care falls on the pediatrician and referring doctor. Psychological preparation of the child and family is extremely important.

Key points/Summary :
Parental Anxieties: many things that are routine to health care providers can be very frightening to parents. It’s important to establish trust with parents and provide them factual help to allay fears.

Childhood anxieties: children have many strange ideas about what may happen to them when they are in surgery. Being “put to sleep” also has negative connotations for children ranging from punishment to their pet’s euthanasia. Using play and imagination to help the child manage the situation can be helpful.

Psychological consequences of anesthesia and surgery
acute: emergence can range from calm to very wild. Data show that children who have a calm induction are more likely to emerge quietly.
chronic: some children can experience behavior changes after surgery and anesthesia. This is not a concern unless it persists beyond 2 weeks. Anxiety is the most common behavior changes, but regression, interpersonal disturbances, sleep anxiety and eating disturbances have all been recognized.

Advantages of outpatient surgery: cost, minimal parent-child separation, rapid return to daily life, restoration of parental control, reduction of nosocomial infections.

The limitations of outpatient surgery: parents struggle to take time off work and may be poor at providing post-operative care. Fear of the unknown is less because the child spends more time in the hospital.

Induction: in most settings, parents are present for induction. Having the parent wear a gown and hat can help the child wear his own gown and hat. The anesthesiologist can also use time before the induction to create a relationship with the child. The author recommends puppet shows, magic tricks and creation of balloon animals.

Perioperative sedation: in the past nearly every child was premedicated. Having parent present for induction basically obviates the need for premedication. Also you want a good airway for induction, which is another reason not to premedicate. The anesthesiologists should also tailor the induction to account for any limiting factors.

Postoperative period: parents want to be with their children as soon as they come out of surgery to verify to themselves that the child has survived and to support the child in recovery. Usually parents are allowed to be involved once anesthesia has turned the child over to PACU. Adequate post surgery analgesia must also be accounted for.

Assessment of article: Good review of many factors involved in taking care of patients when any level of sedation is involved.