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Guidelines For The Management Of Children Referred For Dental Extractions Under General Anaesthesia TheAssociationof Paediatric Anaesthetistsof GreatBritain& Ireland TheRoyalCollegeof Anaesthetists August 2011 Review Date: 2016 Main Authors: Dr Lola Adewale, Dr Neil Morton, Dr Michael Blayney Date Published: August 2011 Review date 2016 These guidelines are published in good faith by the Association of Paediatric Anaesthetists of Great Britain and Ireland, on behalf of the endorsing organisations listed on page 5. SIGN methodology was used and the Guideline Development group included nominated representatives from stakeholders, as detailed on page 6. The members of the Guideline Development Group have agreed the process and outcomes of their deliberations. The guidelines have been peer reviewed by all the relevant stakeholder organisations, as well as representatives of children, young people and families. If there are any inaccuracies, please contact the Chair of the Guideline Committee via either the email address below or the APA website: http://www.apagbi.org.uk/ The APA supports the Guideline Development Group with expenses for travel, secretarial and librarian support to help produce the guidelines and for any material required for dissemination of the guidelines. There is no other remuneration to individual members of the Guideline Development Group. Please address any comments to: Chair, Guideline Committee Association of Paediatric Anaesthetists of Great Britain and Ireland 21 Portland Place, London W1B 1PY [email protected] 1| GuidelinesForTheManagementOf ChildrenReferredForDental ExtractionsUnderGeneral Anaesthesia 2| TABLEOFCONTENTS ExecutiveSummary............................................................................................................................................ 1.Introduction...................................................................................................................................................5 2.Committee.......................................................................................................................................................6 3.MethodologyAndEvidenceGrading....................................................................................................7 3.1Levelsofevidence(www.sign.ac.uk)...........................................................................................7 3.2Gradesofrecommendations(www.sign.ac.uk)......................................................................8 4.DefinitionOfAGuideline..........................................................................................................................9 5.MedicolegalStatusOfGuidelines.......................................................................................................10 6.AimsAndRemit.........................................................................................................................................11 7.KeyQuestions.............................................................................................................................................12 8.ASuggestedCarePathway....................................................................................................................13 9.KeyRecommendations...........................................................................................................................14 9.1Referral..................................................................................................................................................14 9.2Assessmentandpreparation........................................................................................................14 9.3Appropriatesiteandfacilities.....................................................................................................16 9.4Perioperativecare............................................................................................................................16 9.5Perioperativeanalgesia..................................................................................................................18 9.6Recoveryanddischarge.................................................................................................................18 10.ApplicationOfTheseGuidelines......................................................................................................20 11.ConditionsRequiringSpecialConsiderationInChildrenReferredForDental ExtractionsUnderGeneralAnaesthesia...............................................................................................21 12.Referral,AssessmentAndPreparation.........................................................................................22 12.1Referral...............................................................................................................................................22 12.2Assessmentandpreparation.....................................................................................................23 12.2.1Separateassessmentvisit.......................................................................................................23 12.2.2Consent...........................................................................................................................................24 12.2.3Dentalassessment......................................................................................................................25 12.2.4Anaestheticassessment...........................................................................................................26 13.AppropriateSiteAndFacilities(AsDefinedByTheDepartmentOfHealth)................27 3| 13.1‘Hospitalsetting’(38)......................................................................................................................28 13.2‘Criticalcarefacilities’(38)............................................................................................................29 14.PerioperativeCare.................................................................................................................................30 14.1Generalprinciplesofcare...........................................................................................................30 14.2Procedureonarrivalattheward/admissionarea.........................................................31 14.3Minimumstandardsforseniorityandcompetenceofanaesthetistand anaestheticassistant...............................................................................................................................31 14.4Anaestheticconsiderations........................................................................................................32 14.5Traininginpaediatricresuscitation.......................................................................................32 14.6Minimumstandardsforperioperativemonitoring..........................................................33 14.7Intravenousaccess.........................................................................................................................34 14.8Managementoftheuncooperativechildwhorequiresgeneralanaesthesiafor dentalextractions.....................................................................................................................................34 14.9Traininginsafeguardingofchildren......................................................................................35 15.PerioperativeAnalgesia.......................................................................................................................36 15.1Analgesicregimensfordentalextractionsinchildren...................................................38 16.Recoveryanddischargehome..........................................................................................................40 16.1Equipmentandstaffinglevelsintherecoveryarea.........................................................40 16.2Dischargecriteria...........................................................................................................................42 16.2.1CriteriaforDischarge................................................................................................................42 16.2.2Careafterdischarge...................................................................................................................44 17.References.................................................................................................................................................45 18.Appendices(seewebsitefileforappendices)............................................................................50 I. Literaturesearchstrategies (available on request from [email protected]) II. Evidencetablesseewww.apagbi.org.uk III. Consultationandpeerreviewprocess IV. AGREEchecklist V. Auditmarkersandresearchideas VI. Usefuldocumentation VII. Usefulwebsitelinks VIII. Relevantarticlespublishedaftertheendoftheliteraturesearchperiodand notformallyassessedbytheGuidelineDevelopmentGroup IX. ConflictofInterestDeclarations(available on request from [email protected]) 4| 1.INTRODUCTION These guidelines were commissioned by the Association of Paediatric Anaesthetists of GreatBritainandIreland,incollaborationwiththeAssociationofDentalAnaesthetists; the British Society of Paediatric Dentistry; the Royal College of Anaesthetists; the Association of Anaesthetists of Great Britain and Ireland and the Royal College of Nursing.Theyaredesignedtoprovideevidence‐basedinformationonthemanagement of children and young people who are referred for dental extractions under general anaesthesia. The guidelines were prepared by a committee of healthcare professionals, with the assistance of a patient representative. Prior to publication, there was a period of open consultation during which suggestions were received from representatives of patient groups and professional organisations. The target users of these guidelines include dentists, anaesthetists, registered nurses, dental nurses and operating department assistants / practitioners. Some sections of the document may also be of interest to parents/carers.Barrierstoimplementationandhealtheconomicswerenotwithinthe remitoftheseguidelinesandwerenotconsideredbytheGuidelineDevelopmentGroup. Inthisdocumenttheterm“outpatient”isusedtodescribeshort‐stayambulatorycare.It is acknowledged that the facilities and organisation of such services vary widely throughout the United Kingdom; however, general anaesthesia for dental extractions must be provided within a hospital setting as defined below. It is also recognised that many hospitals now incorporate their paediatric dental service within a day‐case surgical service, which may allow the safe management of more complex cases. It is emphasisedthat,whateverthelengthofstay,childrenundergoinggeneralanaesthesia fordentalextractionsshouldreceivethesamestandardofcareaschildrenundergoing generalanaesthesiaforanyotherprocedure. Theseguidelineshavebeenofficiallyendorsedbyalltheorganisationslistedbelow: AssociationofPaediatricAnaesthetistsofGreatBritainandIreland AssociationofDentalAnaesthetists AssociationofAnaesthetistsofGreatBritain&Ireland BritishSocietyofPaediatricDentistry RoyalCollegeofAnaesthetists RoyalCollegeofNursing FacultyofGeneralDentalPractice(UK) TheguidelinesarealsoofficiallysupportedbytheRoyalCollegeofPaediatricsandChild Health. Thedocumentwillbereviewedeveryfiveyears. Return to ToC 5| 2.COMMITTEE DrLolaAdewale ConsultantPaediatricAnaesthetist(Chair) DrChristineArnold SpecialistinSpecialCareDentistry(Associationof DentalAnaesthetists) DrMichaelBlayney ConsultantAnaesthetist(RoyalCollegeof Anaesthetists) DrWilliamHamlin ConsultantAnaesthetist(AssociationofDental Anaesthetists) ProfessorMarieThereseHosey Consultant Paediatric Dentist (British Society of PaediatricDentistry) DrNeilMorton ReaderinPaediatricAnaesthesia&Pain Management(AssociationofAnaesthetistsof GreatBritainandIreland) DrGrantRodney ConsultantAnaesthetist(AssociationofPaediatric AnaesthetistsofGreatBritainandIreland) DrAnna‐MariaRollin ConsultantAnaesthetist(RoyalCollegeof Anaesthetists) DrKenRuiz ConsultantAnaesthetist(AssociationofDental Anaesthetists) MrsAnnSeymour Lay Representative (Association of Paediatric AnaesthetistsofGreatBritainandIreland) MrsJulieSpice SeniorNurse(RoyalCollegeofNursing) Declaration The Guideline Development Group is editorially independent and members had travel expensesreimbursedbytheAPAGBIaccordingtoitspublishedexpensespolicy. TherewerenoConflictsofInterest(available on request from [email protected] ). Return to ToC 6| 3.METHODOLOGYANDEVIDENCEGRADING Electronicandmanualsearcheswereperformedofthepublishedliteratureupto31st October 2010 (See Appendix I) Included were English language meta‐analyses, systematic reviews, randomised controlled trials, clinical trials, cohort studies, case seriesandstudiesinpatientsaged0–18years.MembersoftheGuidelineDevelopment Groupalsoperformedmanualsearchesofguidelinespublishedbyrelevantprofessional regulatory bodies, associations and Royal Colleges. The Guideline Development Group reviewed some of the literature relating to adult patients, particularly where results could reasonably be extrapolated to the care of older children and adolescents. Case reportswereexcluded,togetherwitharticlespublishedinforeignlanguagesandthose describingtheuseofdrugsortechniquesthatwerenotapplicabletopracticewithinthe UnitedKingdom. Evidencewasassessed,usingSIGNmethodologyanddefinitions,aslevel1–4according to the criteria below. Recommendations were graded A – D according to the level of evidenceusedtocompilethem.Forareaswherepublishedevidencewasinsufficientto make a formal recommendation, Good Practice Points (GPP) are provided. The latter indicate best clinical practice, based on the clinical experience and opinion of the GuidelineDevelopmentGroup.Mandatoryrecommendationsarelegalrequirementsor standardsagreedbytheGeneralMedicalCounciland/orGeneralDentalCouncil. 3.1LEVELSOFEVIDENCE(WWW.SIGN.AC.UK) 1++ Highqualitymeta‐analyses,systematicreviewsofrandomisedcontrolledtrials (RCTs),orRCTswithaverylowriskofbias 1+ Well‐conductedmeta‐analyses,systematicreviews,orRCTswithalowriskof bias 1‐ Meta‐analyses,systematicreviews,orRCTswithahighriskofbias 2++ Highqualitycasecontrolorcohortstudieswithaverylowriskofconfounding orbiasandahighprobabilitythattherelationshipiscausal 2+ Well‐conductedcasecontrolorcohortstudieswithalowriskofconfoundingor biasandamoderateprobabilitythattherelationshipiscausal 2‐ Casecontrolorcohortstudieswithahighriskofconfoundingorbiasanda significantriskthattherelationshipisnotcausal 3 Non‐analyticstudies,e.g.casereports,caseseries 4 Expertopinion 7| 3.2GRADESOFRECOMMENDATIONS(WWW.SIGN.AC.UK) [A] Atleastonemeta‐analysis,systematicreview,orRCTratedas1++,anddirectly applicabletothetargetpopulation;orabodyofevidenceconsistingprincipally ofstudiesratedas1+,directlyapplicabletothetargetpopulation,and demonstratingoverallconsistencyofresults [B] Abodyofevidenceincludingstudiesratedas2++,directlyapplicabletothe targetpopulation,anddemonstratingoverallconsistencyofresults;or extrapolatedevidencefromstudiesratedas1++or1+ [C] Abodyofevidenceincludingstudiesratedas2+,directlyapplicabletothetarget populationanddemonstratingoverallconsistencyofresults;orextrapolated evidencefromstudiesratedas2++ [D] Evidencelevel3or4,orextrapolatedevidencefromstudiesratedas2+ Return to ToC 8| 4.DEFINITIONOFAGUIDELINE TheScottishIntercollegiateGuidelinesNetwork(www.sign.ac.uk)intheirGuideline DevelopersHandbook(SIGN50)statesthat: Clinical practice guidelines have been defined as “systematically developed statements to assistpractitionerandpatientdecisionsaboutappropriatehealthcareforspecificclinical circumstances”. They are designed to help practitioners assimilate, evaluate and implement the ever increasing amount of evidence and opinion on best current practice. Clinical guidelines are intended as neither cookbook nor textbook but where there is evidence of variation in practice, which affects patient outcomes, and a strong research baseprovidingevidenceofeffectivepractice,guidelinescanassisthealthcareprofessionals inmakingdecisionsaboutappropriateandeffectivecarefortheirpatients. Return to ToC 9| 5.MEDICOLEGALSTATUSOFGUIDELINES SIGNhasclarifiedthestatusofguidelinesasfollows: Clinical guidelines do not rob clinicians of their freedom, nor relieve them of their responsibilitytomakeappropriatedecisionsbasedontheirownexperienceandaccording to the particular circumstances of each patient. It is stressed that the standard of care required by law derives from customary and accepted practice rather than from the impositionofpracticesthroughclinicalguidelines. To be liable for clinical negligence, it must be established that the course the healthcare professional has adopted “is one which no professional man of ordinary skill would have takenifhehadbeenactingwithordinarycare”.Thistest,fromacaseHuntervHanleyin 1955wasdevelopedfurtherbytheBolamtest,i.e.ahealthcareprofessionalisnotguiltyof negligence if “he has acted in accordance with a practice accepted as proper by a responsible body of men skilled in that particular art”. A healthcare professional may thereforedefendachargeofnegligencewithevidencethat(s)heactedinconformitywith thepracticeacceptedbyanotherbodyofopinion.ThetestappliedbytheCourtistherefore basedonwhatisactuallydoneinpracticeratherthanonaprescriptionofwhatshouldbe done as proposed by guidelines. Customary and accepted practice will be established in court by introduction of expert testimony. Although clinical guidelines will not be introduced as a substitute for expert testimony, they may be referred to by an expert witnessasevidenceofsuchcustomaryandacceptedpractice. Itisimportanttoemphasisethatguidelinesareintendedasanaidtoclinicaljudgmentnot to replace it. Guidelines do not provide the answers to every clinical question, nor guarantee a successful outcome in every case. The ultimate decision about a particular clinicalprocedureortreatmentwillalwaysdependoneachindividualpatient’scondition, circumstancesandwishes,andtheclinicaljudgmentofthehealthcareteam. Guidelines are, however, intended to address variation in practice. While there is no compulsion to implement any guideline or individual recommendations, NHS Boards, clinical teams, and individual practitioners in primary and secondary care should all be abletodefinethestandardofcarewhichtheyprovide,andtojustifyifnecessarywhythese donotmeetnationallyagreedrecommendations. Return to ToC 10| 6.AIMSANDREMIT Todevelopanevidence‐basedconsensusonthecarepathwayfromreferralto dischargeforchildrenandyoungpeoplewhoarereferredfordentalextractions undergeneralanaesthesia. Return to ToC 11| 7.KEYQUESTIONS 7.1Whatistheoptimalintegratedcarepathwayforchildrenandyoungpeoplewhomay requiregeneralanaesthesiafordentalextractions? 7.2Towhichchildrenandyoungpeoplewilltheseguidelinesapply? 7.3Whatassessmentandpreparationarerequired? 7.4 How can the requirement for general anaesthesia, especially repeat general anaesthesia,bereduced? 7.5Whatshouldbetheminimumstandardsforseniorityandcompetenciesofstaff? 7.6Whataretheminimumstandardsforperioperativemonitoring? 7.7Isintravenousaccessnecessary? 7.8 What are the implications of various anaesthetic techniques for perioperative care andpostoperativeadverseeffects? 7.9Whatistheoptimalanalgesicregimen? 7.10Whatequipmentandstaffinglevelsarerequiredforrecovery? 7.11Whatshouldbethecriteriaandproceduresfordischargehome? 7.12Whatadviceshouldbegivenaboutpostoperativecarefollowingdischarge? Return to ToC 12| 8.ASUGGESTEDCAREPATHWAY ReferringDentist PrimaryCareSetting Childrequiringdentalextractions notmanageablewithingeneral dentalpracticesetting Referralguidelinesandproforma Setting‐ dependentonlocal facilities AssessmentAppointment (DentistwithexperienceinPaediatric Dentistry) Dentalandmedicalhistory Dentalexamination&radiology Definitivetreatmentplanning GAnotconsideredtobethebest option,i.e.suitablefortreatment underlocalanaesthesia+/‐ inhalationalsedation(butGDPunable toprovide) Agreementonthemost appropriateformofpainand anxietymanagement Extractionsarrangedbydental assessor Generalanaesthesiarequired Preliminaryanaestheticassessment performedbyassessingdentist Accesstotheopinionofan anaesthetist,ifrequired Patientpreparation.Requirementfor sedativepremedicationconsidered. Verbal&writteninformation provided GAisconsideredtobethebest option,butnotsuitablefor ‘outpatient’setting(e.g.significant medicalconditionorcomplexdental problem) Seeparagraph11–Conditions requiringspecialconsideration Linktohospitaldaycare,inpatientand paediatricservices, includingaccesstoConsultantin PaediatricDentistry Acquisitionofinformedconsent Suitablefor‘outpatient’GA HospitalAppointment HospitalSetting* (Routinenon‐emergencycases) Assessmentbyanaesthetist Confirmationofconsent Dentalextractionsperformed *Asdefinedby:AConsciousDecision:Areviewofthe useofgeneralanaesthesiaandconscioussedationin primarydentalcare.DOH2000(6).General anaesthesiafordentaltreatmentinahospitalsetting withcriticalcarefacilities.CDOletterDoH;2001(29). 13| 9.KEYRECOMMENDATIONS 9.1REFERRAL Recommendation1 Dentalextractionsshouldonlybeperformedundergeneralanaesthesiawhenthisis consideredtobethemostclinicallyappropriatemethodofmanagement. (MANDATORY) Recommendation2 Allservicesshoulddevelopalocalreferralproforma,distributedwithappropriate guidancetoallreferrers.Thereferrallettershouldclearlyjustifytheuseofgeneral anaesthesia,thoughtheultimatedecisiononwhethergeneralanaesthesiais administeredshouldbemadeattheassessmentappointment. (GRADED) 9.2ASSESSMENTANDPREPARATION Recommendation3 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesame standardofassessmentandpreparationaschildrenadmittedforanyotherprocedure undergeneralanaesthesia. (GRADED) Recommendation4 Optionsforthedentalextractions,includingwhethertheyareperformedunderlocal anaesthesia,localanaesthesiasupplementedwithconscioussedation,orgeneral anaesthesia,shouldbeexplainedtotheparent/carerandchild(whereappropriate), allowingadequatetimeforeachoptiontobeconsidered.Theassociatedbenefitsand risksofeachtechniqueshouldalsobediscussed. (MANDATORY) Return to ToC 14| Recommendation5 Unlessthereisanurgentclinicalneedfortreatment,assessmentshouldideallybe undertakenataseparateappointment.Thisshouldincludetheformationofatreatment plan,preparationfortheprocedureandassociatedgeneralanaesthesia,assessmentof theneedforsedativepremedication,informationsharing,dischargeplanningandan explanationoffastinginstructionstogetherwithanappropriateregimenforanalgesia. Sufficienttimeshouldbeprovidedtoallowtheparent/carerandchildtoarriveata consideredopinionandtogiveinformedconsent. (GRADED) Recommendation6 Theassessingdentistshouldideallybeaspecialistinpaediatricdentistry,oradentist whocandemonstratethenecessarycompetenciestocarryoutcomprehensive treatmentplanningforchildrenwhorequiregeneralanaesthesia.Thedentistshouldbe trainedandexperiencedinthebehaviouralmanagementofchildren,including conscioussedation(particularlyinhalationalsedation).Thedentistshouldalsobe conversantwithallclinicalguidelinesrelevanttotheassessment,diagnosis,treatment planningandmanagementofchildrenrequiringdentalextractionsundergeneral anaesthesia.Relevantradiologicalinvestigationsshouldbeavailableattheassessment appointment. (GRADED) Recommendation7 Attheassessmentappointment,writteninformationshouldbeprovidedinsuitable formatsforthechildandtheparent/carer.Thisshouldincludedetailsabout: Preoperativepreparation,includingpreoperativefasting Theproposedtreatmentplan,includingbenefitsandrisks Theavailabilityofalternativetreatmentoptions Theprocessofgeneralanaesthesia,includingpotentialsideeffectsand complications Appropriateescortsforthechildonthedayoftheprocedure Postoperativearrangements,includingsuitabletransporthome Postoperativecareandanalgesia. (GRADED) Return to ToC 15| Recommendation8 Theopinionofanappropriatelytrainedandexperiencedanaesthetistshouldbe available,ifrequired,priortothetreatmentappointment.Dentalandrelevantmedical caserecordsshouldalsobeavailable. (GRADED) 9.3APPROPRIATESITEANDFACILITIES Recommendation9 Childrenrequiringgeneralanaesthesiafordentalextractionsshouldbemanagedina child‐centred,family‐friendlyhospitalsetting.Thisshouldprovidethespace,facilities, equipmentandappropriatelytrainedpersonnelrequiredtoenableresuscitationand criticalcaretobeimmediately,efficientlyandeffectivelyundertaken,shouldtheneed arise.Agreedprotocolsandappropriatecommunicationlinksmustbeinplace,bothto summonadditionalassistanceinanemergencysituationandforthetimelytransferof paediatricpatientstodedicatedareassuchashighdependencyunits(HDUs)or intensivecareunits(ICUs),ifnecessary. (MANDATORY) 9.4PERIOPERATIVECARE Recommendation10 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesame standardofcareaschildrenadmittedforanyotherprocedureundergeneral anaesthesia.Thisshouldincludeanopportunitytovisitthedepartmentbeforetheday oftheprocedure,aswellasaccesstopreoperativepreparationbyregisteredchildren’s nursesand/orplayspecialists.Ifsuchstaffarenotemployedwithinthedepartment, arrangementsshouldbemadetoensureappropriateavailabilityonaflexiblebasis. (GRADED) Recommendation11 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbecaredforina family‐orientatedenvironment.Thisshouldallowtheparent/carertoaccompanythe childduringinductionofgeneralanaesthesia,whereappropriate.Treatmentrooms shouldbechild‐friendly,withsuitableplayandrecreationalequipmentinthewaiting areas.Thereshouldbephysicalseparationfromadultpatients,aswellasadequate spacetoaccommodatetheequipmentrequiredtomeettheneedsofthechildwith physicaldisabilities. (GRADED) Return to ToC 16| Recommendation12 Parents and carers should be informed of the potential adverse effects of general anaesthesia, including the timescale of these. Advice should be given about return to school and normal activities, as well as the management of behavioural changes at home. (GRADEC) Recommendation13 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbemanagedby staffwhohavereceivedappropriatetraining,andwhoarecompetentinpaediatric anaesthesiaandpaediatricresuscitation.Regularupdatesinresuscitationtechniques, togetherwithpracticeasateaminthemanagementofsimulatedemergencies,are essentialtomaintainskillsandoptimiseeffectiveteamworkinginagenuinecrisis. (GRADED) Recommendation14 Whenevergeneralanaesthesiaisadministeredtoachild,clinicalobservationshouldbe supplementedbyminimumstandardsofmonitoring.Thesestandardsshouldbe uniformirrespectiveoftheduration,locationormodeofanaesthesia. (GRADED) Recommendation15 Intravenousaccessshouldbeconsideredforeverypatient.Topicallocalanaesthetic cream(Ametop®/EMLA®/LMX4®)shouldbeappliedpreoperativelytopotential sitesforvenepuncture,whereappropriate. (GPP) Recommendation16 AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct2004 (oritsequivalent),therightsofthechild,safeguardingofchildren/childprotectionand theprocessofobtainingconsent.Allmembersofstaffwhocareforchildrenshouldbe awareoflocalpoliciesconcerningthemanagementofuncooperativechildren. (GPP) Return to ToC 17| Recommendation17 Allclinicalstaffcaringforchildrenshouldhavethenecessarylevelofcompetenceinthe safeguardingofchildren/childprotection.* (MANDATORY) *Thisshouldbeaminimumof“Level2Competence”,asoutlinedbytheIntercollegiateDocumenton SafeguardingChildrenandYoungPeople(2010).75 9.5PERIOPERATIVEANALGESIA Recommendation18 Unlesscontraindicated,non‐steroidalanti‐inflammatorydrugs(NSAIDs)and/or paracetamolshouldbeusedtoprovideanalgesiafordentalextractionsundergeneral anaesthesia.Thesedrugsmaybecombinedorgivenseparatelybefore,duringorafter surgery.Opioidsarenotroutinelyrequiredforuncomplicateddentalextractions. (GRADEB) Recommendation19 Infiltrationofalocalanaestheticagentcombinedwithavasoconstrictoragentmayhave aroleinachievinghaemostasis,withpossiblysomebenefitintermsofanalgesiainthe olderchildwhoisabletounderstandthesensationofnumbness. (GRADEB) Recommendation20 Thestandardsforrecoveryanddischargefollowinggeneralanaesthesiafordental extractionsinchildrenshouldbethesameasthosefollowinggeneralanaesthesiafor anyotherprocedure. (GPP) Recommendation21 Childrenshouldbemanagedinadedicatedandappropriatelyequippedchildren’s recoveryarea,onaone‐to‐onebasis,bydesignatedmembersofstaffwhoreceive regulartraininginpaediatricresuscitation.Aregisteredchildren’snursemustbe availabletoprovidecareforpaediatricpatientsandtosuperviseothernursingstaffwho maybeinvolvedinthecareofchildren.Amemberofstaffwhoistrainedandcompetent inadvancedpaediatriclifesupportshouldbeavailableuntilthechildisdischargedfrom thedepartment. (GRADED) Return to ToC 18| 9.6RECOVERYANDDISCHARGE Recommendation22 Facilitiesshouldallowparents/carerstobepresentassoonastheirchildemerges fromgeneralanaesthesia.Adequatetimeshouldbeallowedforthesecondstageof recoveryandappropriatefacilitiesshouldbeprovidedforthechildwhorequires prolongedrecoveryformedical,nursing,orsocialreasons. (GPP). Recommendation23 Dischargeortransferofthepatientshouldbebasedonspecifiedcriteria,irrespectiveof thetimetakentoachievethese. (GPP) Recommendation24 Suitabletransporthomeshouldbearranged.Thechildmustbeaccompaniedbya responsibleadult. (GPP) Recommendation25 Writtenandverbaladviceaboutpostoperativecareshouldbeprovidedfortheparent/ carer.Aresponsibleadultmustbeavailableforcareofthechildathome.Clear informationshouldalsobeprovidedonappropriatelinesofcommunicationintheevent ofanysubsequentqueriesorpostoperativeproblems. (GPP) Return to ToC 19| 10.APPLICATIONOFTHESEGUIDELINES Theseguidelinesareintendedtoapplytochildrenandyoungpeopleaged1–18 years. Return to ToC 20| 11.CONDITIONSREQUIRINGSPECIALCONSIDERATIONIN CHILDRENREFERREDFORDENTALEXTRACTIONSUNDER GENERALANAESTHESIA Anatomicalorfunctionalabnormalitiesoftheairway Severeorpoorlycontrolledasthma Cardiacdiseasewhichissymptomatic,requirestreatmentorhasnotbeen investigated Asymptomaticheartmurmurs Coagulopathy,anti‐coagulanttherapyoranti‐platelettherapy AbnormalBodyMassIndex(<18.5or>30)(1‐5) Gastro‐oesophagealrefluxwhichrequirestreatment Impairedrenalorhepaticfunction Unstablemetabolicorendocrinedisorders Congenitalsyndromesorconditionsassociatedwithincreasedanaestheticrisk Historyofsignificantproblemoccurringundergeneralanaesthesia Familyhistoryofsignificantproblemoccurringundergeneralanaesthesia Previousabnormalreactiontoanaestheticagents Significantneurologicalorneuromusculardisorders Significantskinorconnectivetissuedisorders Activesystemicinfection Haemoglobinopathies Significantlearningdisabilitiesorbehaviouralabnormalities Severeanxietyorhistoryofunsatisfactoryexperienceassociatedwithgeneral anaesthesia Requirementforsedativepremedication Return to Toc 21| 12.REFERRAL,ASSESSMENTANDPREPARATION 12.1REFERRAL Dentalproceduresshouldonlybeperformedundergeneralanaesthesiawhenthelatter isjudgedtobeclinicallynecessarytodelivertherequiredtreatment(6).Clear justificationfortheuseofgeneralanaesthesiashouldbemadeinthereferralletter(7). (EvidenceLevel4) Recommendation1 Dentalextractionsshouldonlybeperformedundergeneralanaesthesiawhenthis isconsideredtobethemostclinicallyappropriatemethodofmanagement. (MANDATORY) Guidelinesonthereferralprocessandacceptancecriteriashouldbeissuedtoall referrers.Astandardreferralproformashouldbeusedtoobtainessentialinformation forpatienttriage(8‐12).(EvidenceLevel2+) Inaccordancewithexistingguidelines,thereferrershouldspecifyanyindicationsfor theuseofgeneralanaesthesiatoperformthedentalextractions.Theultimatedecision onwhethergeneralanaesthesiaisadministeredshould,however,bemadebythe serviceproviderwhenthepatientattendstheassessmentappointment.(6,7,13,14) (EvidenceLevel4) Recommendation2 Allservicesshoulddevelopalocalreferralproforma,distributedwith appropriateguidancetoallreferrers.Thereferrallettershouldclearlyjustifythe useofgeneralanaesthesia,thoughtheultimatedecisiononwhethergeneral anaesthesiaisadministeredshouldbemadeattheassessmentappointment. (GRADED) Return to ToC 22| 12.2ASSESSMENTANDPREPARATION Dentalextractionsinchildrenareoftenperformedintheprimarydentalcaresetting, usinglocalanaesthesiaeitherwithorwithoutsedation.Generalanaesthesiamaybe requiredifthesetechniquesarenotsuitable,particularlyiftheyhavebeenpreviously unsuccessful.Otherfactorstobeconsideredinclude: Thepotentialinabilityofthechildtocooperate,determinedbyage,development, languageordisability Theexistenceofanypsychologicaldisorder Thepresenceofacutedentalinfection Therequirementforextractionsinmultiplequadrants Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesame standardofassessmentandpreparationaschildrenadmittedforanyotherprocedure undergeneralanaesthesia.(GPP) Priorassessmenthasbeendemonstratedtofacilitatethepatientpathwayonthedayof surgery(15).(EvidenceLevel4) Recommendation3 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethe samestandardofassessmentandpreparationaschildrenadmittedforanyother procedureundergeneralanaesthesia. (GRADED) 12.2.1SEPARATEASSESSMENTVISIT Assessmentshouldideallyoccurataseparatevisitandincorporatedental,medical,and preliminaryanaestheticassessments(14,16‐18).(EvidenceLevel2+,4)Special considerationmayberequiredinurgentclinicalcasesorwheretherearegeographical and/orsociallimitations. Aseparateassessmentappointmentmayallow: Confirmationoftheneedfortreatment Modificationstotheproposedtreatmentplan Opportunityfordetaileddiscussionandconsiderationofalternativetreatment options,togetherwiththeassociatedrisks.Optionsforthedentalextractions include:localanaesthesia,localanaesthesiasupplementedwithconscioussedation, orgeneralanaesthesia(19). Assessmentofthedegreetowhichtheexplanationsareunderstoodbytheparent /carerandthechild(6,7,14,17).(EvidenceLevel2+,4) 23| Reductionintherequirementforgeneralanaesthesiabyusingalternativemethods ofpainandanxietymanagement(16),(EvidenceLevel2+) Reductionintherequirementforrepeatgeneralanaesthesiathroughappropriate treatmentplanning(16,20).(EvidenceLevel2+) Identificationofanymedicalproblemsthatmayrequiretheadviceofan anaesthetist.(21).(EvidenceLevel4) Supportforthechildandparent/carerduringpreparationforgeneralanaesthesia Assessmentoftherequirementforsedativepremedication Discussionof:fastinginstructions,appropriateescortsforthechildonthedayofthe procedure,painmanagement,dischargeadvice,suitabletransporthomeandreturn tonormalactivities Recommendation4 Optionsforthedentalextractionsincludingwhethertheyareperformedunder localanaesthesia,localanaesthesiasupplementedwithconscioussedation,or generalanaesthesia,shouldbeexplainedtotheparent/carerandchild(where appropriate),allowingadequatetimeforeachoptiontobeconsidered.The associatedbenefitsandrisksofeachtechniqueshouldalsobediscussed. (MANDATORY) 12.2.2CONSENT Inchildren,theprocessofobtainingconsentfordentalextractionsundergeneral anaesthesiashouldbethesameasobtainingconsentforanyotherdiagnosticor therapeuticprocedure. Informedconsentmustbeobtainedinwritingfromaparentorguardianwithparental responsibilityinaccordancewiththeChildrenAct2004(oritsequivalent),aswellas otherprofessionalguidelinesonobtainingconsent.(22‐26)Childrenwhoarecompetent shouldbeinvitedtotakepartintheconsentprocess.Inordertoprovideinformed consenttoexaminationortreatment,childrenandtheirparents/carersshouldreceive verbalandwritteninformationaboutthefollowing(25,27,28): Detailsoftheproposedtreatmentplan,includingbenefitsandrisks Availabilityofalternativetreatmentoptions Theprocessofgeneralanaesthesia,includingpotentialsideeffectsand complications Preoperativefasting,appropriateescortsforthechildonthedayoftheprocedure, suitabletransporthome,postoperativecareandanalgesia(7,29) (EvidenceLevel4) 24| The decision to perform the procedure should involve the provision of information, acquisitionofinformedconsentandmaintenanceofconfidentiality (30).Informationfor theparent/carershouldbeprovidedinanappropriateandeasilyunderstoodformat. Similarly,informationforthechildshouldbeprovidedinasuitable formatandwhere possible,thechild’sunderstandingshouldalsobeestablished(27, 28).Whentreatmentis notconsideredtobeanemergency,obtainingconsentshouldbeseenasaprocessand nottheisolatedeventofsecuringasignatureimmediatelypriortotheprocedurebeing performed.Theconsentprocessshouldinvolveadiscussionoftreatmentoptionswith theprovisionofsufficientinformationtotheparent/carerandthechild.Appropriate timeshouldthenbeprovidedtoallowaninformeddecisiontobereached.Information about the potential side effects and complications of general anaesthesia should be discussedearlyinthisprocess.(EvidenceLevel4) If general anaesthesia is required for the dental extractions, the process of consent should begin before the patient meets the anaesthetist. It is neither practical nor desirable for all the information to be provided to children and parents /carers at the preoperativemeetingwiththeanaesthetist.Otherthaninexceptionalcircumstances,it is not acceptable to provide children or parents / carers with new information at the timeofgeneralanaesthesia(26).EvidenceLevel4) Preoperative preparation for children and parents / carers should employ a range of media and pre‐treatment programmes, with contributions from all members of the multidisciplinaryteam(30).(EvidenceLevel4) Recommendation5 Unlessthereisanurgentclinicalneedfortreatment,assessmentshouldideallybe undertakenataseparateappointment.Thisshouldincludetheformationofa treatmentplan,preparationfortheprocedureandassociatedgeneral anaesthesia,assessmentoftheneedforsedativepremedication,information sharing,dischargeplanningandanexplanationoffastinginstructionstogether withanappropriateregimenforanalgesia.Sufficienttimeshouldbeprovidedto allowtheparent/carerandchildtoarriveataconsideredopinionandtogive informedconsent. (GRADED) 12.2.3DENTALASSESSMENT Dentalassessmentshouldideallybeperformedbyaspecialistinpaediatricdentistry(17, or a dentist who can demonstrate the necessary competencies to carry out comprehensivetreatmentplanningforchildrenwhorequiregeneralanaesthesia.Where theassessingdentistisnotaspecialist,supportfromaspecialistorconsultantshouldbe readily available, if required, through established clinical networks. Access to other specialties,suchasorthodontics,oralsurgeryandmaxillofacialsurgeryshouldalsobe availableforallchildren. 31), 25| The assessing dentist should be trained and experienced in the behavioural management of children and the use of conscious sedation techniques, particularly inhalationsedation(32).(Evidencelevel4) The assessing dentist should also be conversant with all clinical guidelines relevant to theassessment,diagnosis,treatmentplanningandmanagementofchildrenwhorequire dentalextractionsundergeneralanaesthesia.(33,34)(EvidenceLevel4) Familiarity with the management of anxious children is also important in determining the requirement for sedative premedication. The opinion of a suitably trained and experienced anaesthetist should be available prior to the treatment appointment, if required, with dental and relevant medical case records also made available. (21) (EvidenceLevel4) Comprehensive assessment, including radiography should facilitate the treatment planningprocessandmayreducetherequirementforrepeatgeneralanaesthesia (14,35). (EvidenceLevel4) Recommendation6 Theassessingdentistshouldideallybeaspecialistinpaediatricdentistry,ora dentistwhocandemonstratethenecessarycompetenciestocarryout comprehensivetreatmentplanningforchildrenwhorequiregeneralanaesthesia. Thedentistshouldbetrainedandexperiencedinthebehaviouralmanagementof children,includingconscioussedation(particularlyinhalationalsedation).The dentistshouldalsobeconversantwithallclinicalguidelinesrelevanttothe assessment,diagnosis,treatmentplanningandmanagementofchildrenrequiring dentalextractionsundergeneralanaesthesia.Relevantradiologicalinvestigations shouldbeavailableattheassessmentappointment. (GRADED) 12.2.4ANAESTHETICASSESSMENT Althoughquestionnairesmaybeusedfortheinitialscreeningprocesspriortogeneral anaesthesia, there should always be access to the opinion of a suitably trained and experiencedanaesthetist.Theanaesthetistisultimatelyresponsiblefortheanaesthetic assessment and the adequacy of the information provided for each child and parent /carer prior to general anaesthesia (21, 26, 36). The dental case records and relevant medical case records should be made available at the time of the anaesthetic assessment.(EvidenceLevel4) Accepted guidance(21, 36) emphasises the importance of preoperative assessment to ensurethat:‐ Patientsarefitforgeneralanaesthesia Resultsofanyrelevantinvestigationsareavailableatthetimeoftreatment 26| Childrenandparents/carersaregivenanopportunitytoexpressanyconcernsthey mayhaveaboutgeneralanaesthesiaandtheproposedtreatmentplan. All patients requiring general anaesthesia must be seen by an anaesthetist preoperatively(21).Theanaesthetistisresponsiblefordecidingwhetherornotapatient isfitforgeneralanaesthesia,howeveritiscommonforotherprofessionalgroupstobe involvedintheassessmentprocess.(EvidenceLevel4) It is inappropriate for a particular type of premedication, technique of anaesthesia or methodofpainmanagementtobeagreedwithoutconsultationwithananaesthetist. (21) (EvidenceLevel4) Written material may improve the information acquired by parents / carers and may enhance satisfaction. The timing of delivery of this information is also important.(37) (EvidenceLevel2+) Parents / carers and children should be advised that they will meet the anaesthetist priortotreatment,withtheopportunityforfurtherdiscussionandexplanation. Recommendation7 Attheassessmentappointment,writteninformationshouldbeprovidedin suitableformatsforthechildandtheparent/carer.Thisshouldinclude detailsabout: Preoperativepreparation,includingpreoperativefasting Theproposedtreatmentplan,includingbenefitsandrisks Theavailabilityofalternativetreatmentoptions Theprocessofgeneralanaesthesia,includingpotentialsideeffectsand complications Appropriateescortsforthechildonthedayoftheprocedure Postoperativearrangements,includingsuitabletransporthome Postoperativecareandanalgesia. (GRADED) Recommendation8 Theopinionofasuitablytrainedandexperiencedanaesthetistshouldbe available,ifrequired,priortothetreatmentappointment.Dentalandrelevant medicalcaserecordsshouldalsobeavailable. (GRADED) Return to ToC 27| 13.APPROPRIATESITEANDFACILITIES(ASDEFINEDBY THEDEPARTMENTOFHEALTH) General anaesthesia for dental extractions should only be administered within a ‘hospitalsetting’.Theterm‘hospitalsetting’wasdefinedintheDepartmentofHealth document ‘A Conscious Decision’ (2001) as … “any institution for the reception and treatment of persons suffering illness or any injury or disability requiring medical or dentaltreatment,whichhascriticalcarefacilitiesonthesamesiteandincludesclinicsand outpatient departments in connection with any such institution” (7). The terms ‘hospital setting’and‘criticalcarefacilities’werefurtherclarifiedbytheDepartmentofHealthin May2001.(38) 13.1‘HOSPITALSETTING’ (38) Children requiring general anaesthesia should be treated within an age‐appropriate, child‐centred and family‐friendly hospital setting. The ‘hospital setting’ should be at least equivalent to that of a hospital within the NHS, including clinics and day care facilitiesassociatedwiththoseinstitutions,where: Surgeryorprocedureswhichinvolvetheuseofgeneralanaesthesia,withorwithout localanaesthesia,areregularlyundertaken, Trained personnel are immediately available to assist the anaesthetist with the resuscitation of a collapsed patient so that the patient’s airway, breathing and circulationarefullysupportedwithoutdelay, Facilities and staff are able to support and maintain a collapsed patient pending recoveryorsupervisedtransfertoahighdependencyunit(HDU)orintensivecare unit(ICU)thatmay,insomeinstances,beonaseparatehospitalsite. This does not necessarily mean that general anaesthesia for dental extractions should only be provided in what might be considered the main operating suite of those institutions. Usually, the clinics and day care facilities described above would be situatedwithinthegroundsofthehospitalandeitherwithin,orcloseto,themainbody ofthehospital.Agreedprotocolsandappropriatecommunicationlinksmustbeinplace tosummonextrahelpandalsoforthetimelytransferofpatientstodedicatedareassuch asHDUsorICUs,shouldtheneedoccur. Usually, it is self‐evident whether or not a particular site for the provision of general anaesthesia for dental extractions is part of the hospital setting. In cases of doubt, decisionsonwhetheraproposedsiteisacceptableshouldbemadebytheresponsible commissioningandhealthcareproviderorganisationsonasite‐by‐sitebasistakinginto account: Thebuilding,equipmentandfacilitiesavailable, 28| Thearrangementsmadefortheimmediateprovisionofcriticalcare(seebelow) attheproposedsite.Thisshouldincludeeasyaccessforemergencyservicesand forapatientonastretcher, ThearrangementsinplaceforthetimelytransferofthepatienttoHDUsorICUs, shouldthisbenecessary. 13.2‘CRITICALCAREFACILITIES’ (38) A‘criticalcarefacility’inthiscontextisanareaorroomwhichhasthespace,equipment and appropriately trained personnel to enable critical care and resuscitation to be efficiently and effectively undertaken, should the need arise. The space required could be the existing operating area, if this is of sufficient size. Of paramount importance however,istheimmediate,efficientandeffectivemanagementofthecollapse.‘Critical carefacilities’inthecontextofthisguidancearenotnecessarilydedicatedareassuchas HDUsorICUs. If there is a sudden and serious collapse of a patient during general anaesthesia for dental extractions, the overriding need is to provide swift and expert medical care. Additional skilled personnel must be immediately available, together with emergency drugsandequipmentincludingdefibrillationfacilities. Allpersonnelinvolvedwiththeadministrationofgeneralanaesthesiamusthaveup‐to‐ date skills in advanced life support. The additional skilled support required should be providedbypersonnelwhoaretrainedspecificallyasateamtomanagelife‐threatening situations.Thelevelofcareprovidedshouldbebasedontheneedsofthepatientandat least equivalent to “Level 2 Critical Care”, as defined for adults by the Department of Health.(39) Agreed protocols and appropriate communication links must be in place, both to summon additional assistance in an emergency situation, as well as for the timely transferofpaediatricpatientstodedicatedareassuchasHDUsorICUs,shouldtheneed occur. Recommendation9 Childrenrequiringgeneralanaesthesiafordentalextractionsshouldbemanaged inachild‐centred,family‐friendlyhospitalsetting.Thisshouldprovidethespace, facilities,equipmentandappropriatelytrainedpersonnelrequiredtoenable resuscitationandcriticalcaretobeimmediately,efficientlyandeffectively undertaken,shouldtheneedarise.Agreedprotocolsandappropriate communicationlinksmustbeinplace,bothtosummonadditionalassistanceinan emergencysituationandforthetimelytransferofpaediatricpatientsto dedicatedareassuchashighdependencyunits(HDUs)orintensivecareunits (ICUs),ifnecessary. (MANDATORY) Return to ToC 29| 14.PERIOPERATIVECARE 14.1GENERALPRINCIPLESOFCARE Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesame standard of care as children admitted for any other procedure under general anaesthesia.Thisincludesthecompletionofanappropriatepreoperativechecklist(40‐46). (EvidenceLevel4) Anopportunityshouldbeprovidedforthechildrento visitthedepartmentbeforethe day of the procedure. There should also be access to preoperative preparation by registered children’s nurses and / or play specialists (40, 41, 43‐46). If such staff are not employeddirectlywithinthedepartment,flexibleoptionsshouldbeconsideredinorder toensureappropriateavailabilityonasessionalbasis.(EvidenceLevel4) Recommendation10 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethe samestandardofcareaschildrenadmittedforanyotherprocedureunder generalanaesthesia.Thisshouldincludeanopportunitytovisitthedepartment beforethedayoftheprocedure,aswellasaccesstopreoperativepreparationby registeredchildren’snursesand/orplayspecialists.Ifsuchstaffarenot employedwithinthedepartment,arrangementsshouldbemadetoensure appropriateavailabilityonaflexiblebasis. (GRADED) Children requiring general anaesthesia for dental extractions should be managed in a safe,family‐orientatedandchild‐friendlyenvironment,separatefromadultpatients (47, 48). This should allow parents / carers to accompany their child during induction of generalanaesthesia,whereappropriate.Suitableequipment,toysandgamesshouldbe provided,togetherwithaplayareatoreduceanxietyandimproverecovery (49,50).The emotionalandphysicalrequirementsofchildrenshouldbereflectedinthedesignofthe operatingtheatredepartment,theappearanceoftheanaestheticandrecoveryareas,as well as the working practices of the staff involved (48, 50, 51). There should also be adequatespacetoaccommodatetheequipmentrequiredtomeettheneedsofthechild withphysicaldisabilities (41, 47, 51, 52).Aregisteredchildren’snursemustbeavailableto supervise other nursing staff who may be involved in the care of children. Play specialistsshouldalsobeavailable.(50).(EvidenceLevel4) 30| Recommendation11 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbecared forinafamily‐orientatedenvironment.Thisshouldallowtheparent/carerto accompanythechildduringinductionofgeneralanaesthesia,whereappropriate. Treatmentroomsshouldbechild‐friendly,withsuitableplayandrecreational equipmentinthewaitingareas.Thereshouldbephysicalseparationfromadult patients,aswellasadequatespacetoaccommodatetheequipmentrequiredto meettheneedsofthechildwithphysicaldisabilities. (GRADED) 14.2PROCEDUREONARRIVALATTHEWARD/ADMISSIONAREA Planned arrival times should allow adequate time for preparation of the child, whilst considering that strategies to reduce anxiety should include the shortest safe fasting timesandminimalwaitingtimes(30)(EvidenceLevel4). It is essential to confirm that fasting instructions have been followed. Baseline measurements and observations should be recorded (e.g. weight, temperature and pulse)forcomparisonwiththoseobtainedpostoperatively. Afinaldentalandanaestheticassessmentshouldbemadeandtopicallocalanaesthetic cream (EMLA® / Ametop® / LMX4®) applied, if appropriate. If the requirement for sedative premedication becomes apparent at this stage, having previously been unrecognised, it may be appropriate to reschedule the procedure to allow a planned strategyforanxietymanagement. Parents / carers should be given appropriate support to reassure and comfort their childduringinductionandrecovery. 14.3MINIMUMSTANDARDSFORSENIORITYANDCOMPETENCEOF ANAESTHETISTANDANAESTHETICASSISTANT Irrespective of the setting, children undergoing general anaesthesia for dental extractions should receive the same standard of care as those undergoing general anaesthesia for any other procedure. They should be anaesthetised by a consultant anaesthetist on the specialist register, who in addition to undertaking regular and relevant paediatric practice sufficient to maintain core competencies, possesses dedicated training and skills in paediatric dental general anaesthesia, and undertakes appropriatecontinuingprofessionaldevelopment(CPD).(13,51,53,54)Childrenmayalsobe anaesthetised by a Staff Grade or Associate Specialist (SAS) anaesthetist, or Specialty Doctor (SD), provided that he or she satisfies the same criteria and that there is a nominated supervising consultant anaesthetist with appropriate experience (51) . Trainees anaesthetising children should always be appropriately supervised by a consultantwithrelevantexperience(51).(EvidenceLevel4) The anaesthetist should be assisted by staff (anaesthetic nurses or operating department practitioners/assistants) with specific training in paediatrics and skills relevanttopaediatricdentalgeneralanaesthesia(13,51).(EvidenceLevel4) 31| The anaesthetist should be assisted by staff (anaesthetic nurses or operating department practitioners/assistants) with specific training in paediatrics and skills relevanttopaediatricdentalgeneralanaesthesia(13,51).(EvidenceLevel4) In the immediate post‐anaesthetic recovery period, management of the patient should beinaccordancewithexistingguidelines.(36,51,55,56)(EvidenceLevel4)Thechildshould bemanagedintherecoverywardorpost‐anaesthesiacareunit,onaone‐to‐onebasis, byadesignatedtrainedmemberoftherecoveryteamwhohasappropriatetrainingin paediatricresuscitation(55).Aregisteredchildren’snursemustbeavailabletosupervise other nursing staff who may be involved in the care of children. A member of staff trainedandcompetentinadvancedpaediatriclifesupportshouldbepresentwhenever generalanaesthesiaisadministeredtoachild.(51)(EvidenceLevel4) 14.4ANAESTHETICCONSIDERATIONS Parents / carers should be advised that general anaesthesia may have short‐term adverse effects such as headache, sore throat, sickness, dizziness and mild allergic reaction(28, 29, 57). The risk of serious complications should also be explained(57). Information should be provided on the effects of general anaesthesia on the child’s cognition and behaviour. These usually resolve within 48 hours, however they may persist for up to 2 weeks, with effects on the child’s performance at school as well as care of the child at home.(58, 59) (Evidence Level 3) There is some evidence that intravenous anaesthesia produces fewer such effects and also reduces postoperative vomiting.(60,61)(EvidenceLevel2+) Recommendation12 Parentsandcarersshouldbeinformedofthepotentialadverseeffectsofgeneral anaesthesia,includingthetimescaleofthese.Adviceshouldbegivenaboutreturn toschoolandnormalactivities,aswellasthemanagementofbehaviouralchanges athome. (GRADEC) 14.5TRAININGINPAEDIATRICRESUSCITATION Childrenundergoinggeneralanaesthesiashouldbemanagedbystaffwhohavereceived appropriate training and who are competent in paediatric anaesthesia and paediatric resuscitation (51).Regularupdatesinresuscitationtechniques,togetherwithpracticeas ateaminthemanagementofsimulatedemergencies,areessentialtomaintainskillsand optimiseeffectiveteamworkinginagenuinecrisis(13).Trainingshouldfollowguidance outlinedbytheResuscitationCouncil(UK)(62).(EvidenceLevel4) 32| Specifically, anaesthetists administering general anaesthesia for dental extractions in children should be trained according to the most recent guidelines in advanced life supportforchildrenandshouldmaintainthenecessaryskills(13,36,51,62‐65).Allmembers of the anaesthesia team should have experience in managing clinical emergencies, includingpaediatriclifesupport.Recoverystaffshouldalsoreceiveregulartrainingin paediatric resuscitation. A member of staff trained and competent in advanced paediatric life support should be present for all sessions during which general anaesthesiaisadministeredtochildren(36,51).(EvidenceLevel4) Recommendation13 Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbe managedbystaffwhohavereceivedappropriatetraining,andwhoarecompetent inpaediatricanaesthesiaandpaediatricresuscitation.Regularupdatesin resuscitationtechniques,togetherwithpracticeasateaminthemanagementof simulatedemergencies,areessentialtomaintainskillsandoptimiseeffective teamworkinginagenuinecrisis. (GRADED) 14.6MINIMUMSTANDARDSFORPERIOPERATIVEMONITORING Nationally accepted guidelines on minimum standards of monitoring for general anaesthesiahavebeenpublishedbytheAssociationofAnaesthetistsofGreatBritainand Ireland (AAGBI) (66). Clinical observation must be supplemented by core standards of monitoring whenever a child is anaesthetised, in order to monitor the patient’s physiological state and depth of anaesthesia, as well as the functioning of anaesthetic equipment.Theseminimumstandardsshouldbeuniformirrespectiveoftheduration, location,ormodeofanaesthesia. Thefollowingmonitoringdevicesmustalwaysbeavailabletoensurethesafeconductof generalanaesthesia: Pulseoximeter Non‐invasivebloodpressuremonitor Electrocardiogram Airwaygasmonitor(oxygen,carbondioxideandvolatileagent) Airway pressure monitor (whenever intermittent positive pressure ventilation isemployed) A nerve stimulator (if a neuromuscular blocking agent has been administered) and meansofmeasuringthepatient’stemperaturemustalsobeavailable. Inchildren,itmaynotalwaysbepossibletoattachallmonitoringbeforetheinduction of anaesthesia due to lack of, or potential loss of, cooperation. Monitoring should howeverbecommencedassoonaspossible,andthereasonsforanydelayrecordedin thepatient’scase‐records.Adetailedsummaryoftheanaesthetictechniqueemployed 33| should be clearly recorded, together with the information provided by the monitoring devices. Monitoring should be maintained postoperatively until the child has fully recovered from general anaesthesia (i.e. has reached the end of Stage 1 Recovery), with clinical observations being supplemented by the following monitoring devices, where appropriate: Pulseoximeter Non‐invasivebloodpressuremonitor Thefollowingmustalsobeimmediatelyavailable: Electrocardiogram NerveStimulator(ifaneuromuscularblockingagenthasbeenadministered) Temperaturemeasuringdevice Capnograph Recommendation14 Whenevergeneralanaesthesiaisadministeredtoachild,clinicalobservation shouldbesupplementedbyminimumstandardsofmonitoring.Thesestandards shouldbeuniformirrespectiveoftheduration,locationormodeofanaesthesia. (GRADED) 14.7INTRAVENOUSACCESS Recent national surveys have demonstrated that it is widely considered to be good practice to establish intravenous access during the course of general anaesthesia for dentalextractionsinchildren (67‐69).Intravenousaccessshouldbeconsideredforevery patient. Topical local anaesthetic cream (Ametop® / EMLA®/ LMX4®) should be applied preoperatively to potential sites for venepuncture, where appropriate. (EvidenceLevel4) Recommendation15 Intravenousaccessshouldbeconsideredforeverypatient.Topicallocal anaestheticcream(Ametop®/EMLA®/LMX4®)shouldbeapplied preoperativelytopotentialsitesforvenepuncture,whereappropriate. (GPP) 34| 14.8MANAGEMENTOFTHEUNCOOPERATIVECHILDWHOREQUIRES GENERALANAESTHESIAFORDENTALEXTRACTIONS AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct2004 (oritsequivalent),therightsofthechild,safeguardingofchildren/childprotectionand theprocessofobtainingconsent (22, 25, 26, 51,53,54,70‐75).Allmembersofstaffwhocarefor children should be aware of local policies for the management of uncooperative children.(70‐72).(EvidenceLevel4) Recommendation16 AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct 2004(oritsequivalent),therightsofthechild,safeguardingofchildren/child protectionandtheprocessofobtainingconsent.Allmembersofstaffwhocarefor childrenshouldbeawareoflocalpoliciesconcerningthemanagementof uncooperativechildren. (GPP) 14.9TRAININGINSAFEGUARDINGOFCHILDREN The safety of the child is paramount. Specific guidance for anaesthetists has been developed jointly by the Association of Paediatric Anaesthetists of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, and the Royal College of Anaesthetists(74). Detailed guidance for the dental team is also available from the Department of Health(76). All clinical staff who have any contact with children, young people and / or parents / carers should have a minimum of “Level 2” competence in safeguardingchildren/childprotection,inaccordancewiththecompetencyframework outlined in the Intercollegiate Document on Safeguarding Children and Young People (2010)(75).EvidenceLevel4 Recommendation17 Allclinicalstaffcaringforchildrenshouldhavethe necessary level of competenceinthesafeguardingofchildren/childprotection.* (MANDATORY) *Thisshouldbeaminimumof“Level2Competence”,asoutlinedbytheIntercollegiateDocumenton SafeguardingChildrenandYoungPeople(2010).75 35| 15.PERIOPERATIVEANALGESIA The available evidence on perioperative analgesia in children has recently been summarisedbytheAssociationofPaediatricAnaesthetistsofGreatBritainandIreland (77). Children undergoing dental extractions should be subject to the same generic principles of pain management as children undergoing any other surgical procedure. These principles include the need for age appropriate pain scoring, consideration of a range of analgesia techniques, together with information and instructions for parents aboutpostoperativepainmanagement (77).Thereshouldbeappropriatepost‐operative pain assessment and management policies, usually supported by a pain team(30).(EvidenceLevel4) Dental extractions are known to be associated with pain that can persist for up to 72 hoursandanalgesictreatmentisfrequentlyrequired(78,79).(EvidenceLevel2+)Younger children and those having multiple extractions are more likely to experience pain and distress(80).(EvidenceLevel3) Children undergoing dental extractions should receive adequate analgesia based on widely accepted principles of pre‐emptive, multi‐modal analgesia and a modern understanding of analgesic pharmacology. Analgesic therapy should preferably start beforesurgeryandbecontinuedforaslongasrequiredpostoperatively (77).(Evidence Level4) Non‐steroidal anti‐inflammatory drugs (NSAIDs) provide satisfactory analgesia for dental extractions. Diclofenac or ibuprofen, either alone or in combination with paracetamol, each provides more effective analgesia than paracetamol alone (80, 81). (EvidenceLevel2++) Opioidanalgesicsarenotusuallyrequiredtoprovideanalgesiaforuncomplicateddental extractions. They demonstrate no analgesia benefit over NSAIDs and may prolong recoveryandincreasesedation (82‐84).(EvidenceLevel2++)However,opioidanalgesics may be considered for multiple or difficult extractions. They may also be required as rescueanalgesiawhenNSAIDsandparacetamolarecontraindicatedorhaveprovedto beinsufficient. Recommendation18 Unlesscontraindicated,non‐steroidalanti‐inflammatorydrugs(NSAIDs)and/or paracetamolshouldbeusedtoprovideanalgesiafordentalextractionsunder generalanaesthesia.Thesedrugsmaybecombinedorgivenseparatelybefore, duringoraftersurgery.Opioidsarenotroutinelyrequiredforuncomplicated dentalextractions. (GRADEB) 36| Evidence suggests that, in children, when dental extractions are performed under general anaesthesia in the presence of systemic analgesia, the use of local anaesthesia foradditionalanalgesiaisofminimalbenefit. (85‐90).Traumatothelip,cheekortongue may occur following the use of local anaesthesia, particularly in small children. The sensation of numbness may also cause distress in younger children. Nevertheless, the combination of a local anaesthetic agent with a vasoconstrictor agent may be useful, primarily to reduce bleeding, with possibly some benefit in terms of analgesia in the olderchildwhoisabletounderstandthesensationofnumbness.(EvidenceLevel2++) Recommendation19 Infiltrationofalocalanaestheticagentcombinedwithavasoconstrictoragent mayhavearoleinachievinghaemostasis,withpossiblysomebenefitintermsof analgesiaintheolderchildwhoisabletounderstandthesensationofnumbness. (GRADEB) 37| 15.1ANALGESICREGIMENSFORDENTALEXTRACTIONSINCHILDREN Analgesic drugs may be administered preoperatively, intraoperatively or postoperatively, via the oral, intravenous or rectal route as appropriate. The following dosage guidelines (Table 1, and accompanying notes) are based on recommendations from the British National Formulary for Children (BNFC) and the publication by the Association of Paediatric Anaesthetists of Great Britain and Ireland entitled ‘Good PracticeinPostoperativeandProceduralPain’(2008).(77,91)(EvidenceLevel4) Table1.SuggestedAnalgesiaRegimensforDentalExtractionsinChildren PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE OPTION1 OralParacetamol 20mg/kg,1hrpre‐ operatively ‐‐‐‐‐‐‐‐ OralIbuprofen 5–10mg/kg,PRN OPTION2 OralParacetamol 20mg/kg,1hrpre‐ operatively Diclofenac 1mg/kgperrectum (PR)afterinduction* ‐‐‐‐‐‐‐‐‐ OralParacetamol 20mg/kg andoralIbuprofen 5‐10mg/kg,1hrpre‐ operatively ‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐ OPTION4 Oral Ibuprofen 5‐10mg/kg,1hrpre‐ operatively ‐‐‐‐‐‐‐‐ OralParacetamol 20mg/kg,PRN OPTION5 Oral Ibuprofen 5‐10mg/kg,1hrpre‐ operatively IV Paracetamol 15mg/kg** ‐‐‐‐‐‐‐‐‐ OPTION6 IV Paracetamol 15mg/kg** OralIbuprofen 5‐10mg/kg,PRN OPTION3 38| NOTES(toaccompanyTable1): 1. Unlesscontraindicated,allchildrenshouldreceiveapreparationof Paracetamoland/orNSAIDperioperatively. If Paracetamol or NSAIDs have not been administered either preoperatively or intraoperatively, either oral Paracetamol 20mg/kg or oral Ibuprofen 5 – 10mg/kg maybeadministeredintherecoveryperiod 2. Rectalpreparations* Diclofenac 1 mg/kg per rectum (PR) may be administered after induction of anaesthesia and following documented consent (if preoperative NSAIDs have not been administered). There is evidence that rectal diclofenac is more rapidly absorbed than oral NSAIDs, giving higher plasma levels (92). (NB. Rectal Paracetamol is not recommended due to high dosage requirements (up to 45mg/kg),slowabsorptionandvariableplasmaconcentrations(93,94)). 3. Intravenouspreparations** IVParacetamol15mg/kgmaybeadministeredasanalternativetotheoralroute for children over 1 year old. This should be infused over a period of 15 minutes, whichmaylimititsuseforsomeverybriefdentalextractions. IV Diclofenac may be considered as an alternative but is not licensed for use in children(95). 4. Opioids Opioidsarenotroutinelyrequiredforuncomplicateddentalextractions,butmaybe administered intraoperatively for children undergoing multiple or difficult extractions(e.g.Fentanyl0.5–1.0mcg/kgIVorTramadol1–2mg/kgIV) (84,96).If anopioidisusedthenanantiemeticagentshouldbeconsidered(pleaserefertothe APAGBI guidelines for evidence‐based advice on prevention and treatment of postoperativenauseaandvomiting).(97) FollowingtheadministrationofParacetamolandanNSAIDeitherpreoperativelyor intraoperatively, the treatment of pain experienced during the immediate post‐ anaesthetic recovery period may require an opioid as rescue analgesia (e.g. Codeine0.5–1mg/kgorally,orTramadol1–2mg/kgorally). 5. Localanaesthesia Local anaesthetic agents may be administered by the dental surgeon. However, thereislimitedevidenceforanybenefitintermsofanalgesiainchildrenundergoing general anaesthesia in the presence of systemic analgesia. Younger children may becomedistressedbythesensationofnumbness.Thereisalsotheriskoftraumato thetongue,lipsandcheeks. Return to ToC 39| 16.RECOVERYANDDISCHARGEHOME Recoveryfromgeneralanaesthesiacanbedividedintothreestages (98).(EvidenceLevel 4) FirstStageRecovery Thisstagelastsuntilthepatientisawake,protectivereflexeshavereturnedand painiscontrolled. SecondStageRecovery Thisstagebeginsattheendofstageoneandendswhenthepatientisreadyfor dischargefromhospital. LateRecovery This phase is very variable and ends when the patient has made a full physiologicalandpsychologicalrecoveryfromthesurgicalprocedure. The anaesthetic technique employed should be designed to maximise the speed and quality of recovery in the first and second stages, and so facilitate discharge from hospital(98). 16.1EQUIPMENTANDSTAFFINGLEVELSINTHERECOVERYAREA Recoveryfromgeneralanaesthesiafordentalextractionsinchildrenrequiresthesame standardsofmonitoringandstaffingasrecoveryfromanyotherprocedureperformed undergeneralanaesthesia(55,66). Thereshouldbeaseparaterecoveryareaforchildren,allowingparents/carerstobe present as soon as their child has emerged from general anaesthesia. This should be withinanage‐appropriatechild‐friendlyenvironment(51,55).(EvidenceLevel4) The recovery area should have appropriate equipment for management of the paediatric airway. Resuscitation equipment should also be immediately available. Children should be managed on a one‐to‐one basis, by designated trained members of therecoverystaff,whoreceiveregulartraininginpaediatricresuscitation.Aregistered children’s nurse must be available to provide care for paediatric patients and to superviseothernursingstaffwhomaybeinvolvedinthecareofchildren.Amemberof staff who is trained and competent in advanced paediatric life support should be available until the child is discharged from the department(51). No fewer than two members of staff should be present when a child who does not fulfil the criteria for dischargeremainswithintherecoveryarea(55).(EvidenceLevel4) Standards of monitoring during recovery from dental extractions under general anaesthesia should be the same as those for any other procedure performed under 40| general anaesthesia. Clinical observations should be supplemented by use of a pulse oximeter and non‐invasive blood pressure monitor, where appropriate. An electrocardiogram and capnograph should also be available, together with a nerve stimulatorandadevicetomeasurethepatient’stemperature(66).(EvidenceLevel4) Recommendation20 The standards for recovery and discharge following general anaesthesia for dental extractions in children should be the same as those following general anaesthesiaforanyotherprocedure. (GPP) Recommendation21 Childrenshouldbemanagedinadedicatedandappropriatelyequippedchildren’s recoveryarea,onaone‐to‐onebasis,bydesignatedmembersofstaffwhoreceive regulartraininginpaediatricresuscitation.Aregisteredchildren’snursemustbe available to provide care for paediatric patients and to supervise other nursing staffwhomaybeinvolvedinthecareofchildren.Amemberofstaffwhoistrained and competent in advanced paediatric life support should be available until the childisdischargedfromthedepartment. (GRADED) 41| 16.2DISCHARGECRITERIA Dischargefromtherecoveryroom(andultimately,dischargehome)istheresponsibility oftheattendingclinicians,howevertheadoptionofstrictdischargecriteriaallowsthis decisiontobedelegatedtotherecoverystaff(55). Scoring systems exist to aid in the assessment of recovery, for example the Post‐ Anaesthesia Score modified for Day Surgery(99, 100) or the Post‐anaesthesia Discharge ScoringSystem(101). The discharge process should create an environment in which parents / carers understand their roles and responsibilities for continuing care and therefore feel confidenttotaketheirchildhome. Whoevertakesresponsibilityforassessingthesuitabilityofachildfordischargeshould ensurethatthefollowingcriteriaarefulfilled: 16.2.1CRITERIAFORDISCHARGE Consciouslevelshouldbeconsistentwiththechild’spreoperativestate Cardiovascularandrespiratoryparametersshouldbestable Pain,nausea,vomitingandsurgicalbleedingshouldbeminimal Mobilityshouldbeatapreoperativelevel A responsible adult must be present to accompany the child home (this adult mustbeabletogivethechildhis/herundividedattentionduringthejourney home) Suitabletransporthomeshouldhavebeenarranged Inadditiontothesecriteriafordischarge,thefollowingshouldalsobeensured: Contact telephone numbers should be provided for both emergency and continuingcare Verbal and written instructions about the child’s recovery at home should be giventotheparent/carer,withconfirmationofthelevelofunderstanding Follow‐uparrangementsshouldbemadewhereappropriate Support and guidance on the administration of medication at home should be providedasnecessary A letter to the General Dental Practitioner should be posted or given to the parent/carer,dependingonthepolicyoftheunit Suitable home environment, with regard to supervision of the child as well as accesstofurtherhealthcareservices,ifrequired(102). Although discharge home is not time‐dependent, adequate time should be allowed for thesecondstageofrecovery.Appropriateinstructionsshouldbegiventotheparent/ carerandsuitabletransporthomeshouldbearranged(103,104).Aresponsibleadultmust accompany the child home and be available for subsequent care at home. Facilities 42| shouldbeavailableforthechildwhorequiresprolongedrecoveryformedical,nursing or social reasons. These facilities should allow the parent / carer to accompany their child,whereappropriate. Recommendation22 Facilitiesshouldallowparents/carerstobepresentassoonastheirchild emergesfromgeneralanaesthesia.Adequatetimeshouldbeallowedforthe secondstageofrecoveryandappropriatefacilitiesshouldbeprovidedforthe childwhorequiresprolongedrecoveryformedical,nursing,orsocialreasons. (GPP) Recommendation23 Dischargeortransferofthepatientshouldbebasedonspecifiedcriteria, irrespectiveofthetimetakentoachievethese. (GPP) Recommendation24 Suitabletransporthomeshouldbearranged.Thechildmustbeaccompaniedbya responsibleadult. (GPP) Recommendation25 Writtenandverbaladviceaboutpostoperativecareshouldbeprovidedforthe parent/carer.Aresponsibleadultmustbeavailableforcareofthechildathome. Clearinformationshouldalsobeprovidedonappropriatelinesofcommunication intheeventofanysubsequentqueriesorpostoperativeproblems. (GPP) 43| 16.2.2CAREAFTERDISCHARGE Postoperativeinstructions(14,35)shouldcover: Analgesia Postoperativenauseaandvomiting Residualeffectsofgeneralanaesthesia Bleeding Mouth‐care Detailsofanysuturesin‐situ Eating Returntoschoolornormalactivities Linesofcommunicationintheeventofpostoperativeproblems Preventionofcaries(35) Return to ToC 44| 17.REFERENCES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Nafiu OO, Reynolds PI, Bamgbade OA, et al. Childrens body mass index and perioperativecomplications.PaediatricAnaesthesia2007;17:426‐430. Lotia S, Bellamy MC. Anaesthesia and morbid obesity. 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