2005 Annual Scientific Meeting - CLICK FOR PROGRAMME

No more “Magic gas” for out patient dental extractions in children

Dr. S Vijayaraghavan

Bishop Auckland General Hospital.

Introduction

General anaesthesia for dental extraction in children should be simple, effective, short lived with no side effects. The child should recover immediately and able to go home within an hour.

“Simple removal of teeth may take one or two minutes. Recovery will occur quickly, usually within five minute. After very short operations children can usually go home in one hour. It is common for children to feel dizzy and a bit sick for few hours and to occasionally be sick especially if they have swallowed a little blood”.(Information leaflet RCA & AAGBI_June2004)

Aim

To find out of GA and TIVA is best suited for dental extraction in children. It is a retrospective analysis of the anaesthetic I administered for out patient dental extractions in children from 1998 onwards.

Materials and methods

A total of 1332 children were anaesthetised. All children after a preoperative check up, had local anaesthetic cream applied to facilitate IV cannulation, this procedure explained to the parents. If the children were cooperative ECG, SPO₂, NIBP were instituted. In uncooperative child only pulse oximeter was monitored. Intra venous cannulation attempted in all children with a 22G cannula. If the IV cannulation failed in 2 attempts or the parents/children preferred inhalational induction, then the IV cannula was inserted after they were anaesthetised by inhalational induction. Post extraction pain was treated with Paracetamol or ibuprofen orally.

Two different anaesthetic techniques were used.

General anaesthesia

1. Volatile Induced Maintained Anaesthesia (VIMA)

2. Propofol 3-4mg/kg IV bolus followed by oxygen, nitrous oxide and sevoflurane for maintenance (GA).

Intravenous anaesthesia

1. Propofol 3-5mg/kg IV bolus, oxygen in air for maintenance (PROPOFOL)

2. Propofol 3-5 mg/kg IV and remifentanil IV 1µg/kg over 30secs bolus, oxygen in air for maintenance (TIVA). If needed, half of the original dose is repeated.

1mg of remifentanil dissolved in 100ml of 0.9% N-saline. 1 ml of this solution gives 10µg of remifentanil.

Intra op monitoring, airway maintenance, duration of the procedure and the complications encountered were recorded. The amount of anaesthetics used was noted. Post operative nausea and vomiting were observed in the ward.

 Results:

 Discussion:

General anaesthesia becomes a necessity for needle phobic parents/children and who need extensive dental extractions. Sharing the airway with the dentist and coping with dental packs and dental debris are well known hazards. This can be averted by inserting a laryngeal mask airway (LMA). With venous access and appropriate use of short acting drugs such as propofol and remifentanil, fast recovery can be assured.¹

Because of the shared airway eleven children got lighter during the general anaesthetic. Lighter plane of anaesthesia leads to Laryngospasm. Significantly this did not happen with TIVA (p=0.05).

Arrhythmias are less common with sevoflurane anaesthesia.² The heart rate was more than 150/minute in 25 children in the general anaesthesia group (p<0.01).

The duration of the procedure was less in TIVA group 4.2 minutes, compared to GA group 7.2 minutes, (P=0.001). This is because there was no competition for the airway, relaxed jaw and no chances the children getting lighter.

Volatile anaesthetics increase the incidence of post operative nausea and vomiting(PONV), six children in GA group suffered PONV compared to one child in TIVA group (p<0.01). (3).

The lowest recorded SPO₂ at induction was lower in TIVA group compared to that of GA.

There was no significant difference in oxygen saturation during the procedure.

The average amount of sevoflurane to do a session of ten children is approximately 150ml. 250 ml of sevoflurane costs £125. On top of it one needs at least 5-7 ampoules of propofol for induction costing £2.33 per ampoule. The amount of sevoflurane required increases if one need to do all children with inhalational induction. 1mg of remifentanil costs £5, 100ml of 0.9% sodium chloride costs £2 and 5-7 ampoules of propofol (£2.33 per ampoule). It works out cheaper to use TIVA rather than GA.

Last but not least theatre pollution with TIVA does not occur at all.

Conclusions:

 References:

1. Suri, Paediatric anaesthesia for non-surgical procedures outside theatres, 10RC1, European Society of Anaesthesiologist 2003.
2. Paris et al, Comparison of sevoflurane and halothane for outpatient dental anaesthesia in children. Br.J.Anaesth 1997;79:280-4.
3. Sneyd et al, A Meta analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents, Eur.J.Anaesthesiol 1998; 15:433-45.