The presentation gives details of induction procedures, pre-medications, anesthetic drugs, post-operative instructions.

1. GENERAL ANAESTHESIA
S.L.L.JAYASRI
I MDS

2. Contents
 Introduction
 ASA Classification
 Stages of GA
 Preoperative evaluation of
the child
 Medical history
 Preparation of the child
 Premedication
 Induction of anaesthesia
 GA in Paediatric dentistry
 Postoperative instructions
 Conclusion
 References

3. Introduction
 General anesthesia: a drug-induced loss of consciousness during
which patients are not arousable, even by painful stimulation.
 The ability to independently maintain ventilatory function is often
impaired
 Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of
depressed spontaneous ventilation or drug-induced depression of
neuromuscular function.

4.  General anaesthesia = Hypnosis + Analgesia + Relaxation
 Hypnosis = suppression of consciousness
 Analgesia = suppression of physiological responses to pain
stimuli
 Relaxation = suppression of muscle tone and relaxation

5.  A controlled reversible state of:
– Amnesia (with loss of consciousness)
– Analgesia
– Akinesia (skeletal muscle relaxation)
– Autonomic and sensory reflex blockade
 Called the “4 A’s” of General Anaesthesia.
 In practice these effects are produced with a combination of drugs
rather than with a single anaesthetic agent

6. Advantages of GACLASSIFICATION SYSTEM:
1. Patients cooperation in not absolutely essential for the success
of GA.
2. Patient is unconscious.
3. Patient does not respond to pain.
4. Amnesia is present.
5. GA may be the only technique that will prove successful for
certain patients.
6. Rapid onset of action.

7. Disadvantages of GA
1. The patient is unconscious.
2. Protective reflexes are depressed.
3. Advanced training is required.
4. An ‘‘anaesthesia team’’ is required.
5. Special equipment is required wherever general anaesthesia.
6. A recovery area must be available for the patient.
7. Post anaesthetic complications are more i.e., Laryngospasm

8. ASA Classification

12. Ask the Medical history

15. Upper respiratory tract infections
 2 week waiting period
 Preoperative salbutamol
 IV Hydration
 Anticholinergics

16. Anaemia
Hematocrit > 25%

17.  SECONDARY SMOKING (ETS)

ASTHMA
ATOPIC ECZEMA
HAY FEVER

18. Preparation of the child for surgery

22. Route of administration

23. Benzodiazepines
 Calmness in children
 Diminishes recall of Peri anaesthetic events
MIDAZOLAM
 0.025 – 0.1 mg/kg IV
 0.1 – 0.2 mg/kg IM
 0.25 – 0.75 mg/kg orally
 0.2 mg/kg Nasally
 1mg/kg Rectally
 Onset of action:
within 5 min , peak in 15-20min

24. Factors alter the Blood concentration of
midazolam
INCREASE
 Erythromycin
 Protease inhibitors
(Antiretroviral drugs)
 Calcium channel blockers
DECREASE
 Anticonvulsants (phenytoin
and carbamazepine)
 Rifampicin
 Glucocorticoids
 Barbiturates
 St. John’s wort

25. DIAZEPAM
 Used in older Children
 Should not be used in Infants and preterm neonates (immature hepatic function).
 0.1 -0.3 mg/kg orally
 1 mg/kg Rectally
LORAZEPAM
 Used in older children
 0.005 mg/kg orally
 Advantages over diazepam : more reliable amnesia
less tissue irritation.
 Disadvantages over diazepam : Slow onset of action
 Prolonged duration

26. Barbiturates
 Infrequently used.
Methohexital / Thiopental
 30 mg / kg – Rectally
 Onset of action : within 15 min
Disadvantages:
 Sedation is profound
 Airway obstruction and laryngospasm
 Apnoea in child with meningomyelocele
Precautions :
 Child should be closely monitored
 Adequate Oxygen and ventilator support


27. Non barbiturates
 Chloral hydrate & Triclofos – Orally
Disadvantages:
 Slow onset
 Long acting
 Irritating to skin , mucous membrane and GIT
Opioids
 Produce Analgesia and sedation in child with preoperative pain.
Disadvantages:
 Respiratory depression
 Dysphoria
 Precautions : child should be carefully monitored with pulse
oximetry.

28. Opioids
Morphine sulphate: 0.05 – 0.1 mg/kg IV
 Given for children with preoperative pain.
Sufentanil: 1.5 – 3 mg /kg Nasally
Ketamine: 2 mg/kg IM
 5 – 6 mg/kg alone sedates children within 12min
 10mg/kg – child with burns
 Oral ketamine 3mg/kg + Oral midazolam 0.5mg/kg
 Nasal ketamine 6mg/kg
 Rectal ketamine 5mg/kg

29. Alpha 2 agonists
Clonidine 4mg/kg
Dexmedetomidine 2- 4 µg/kg orally
2- 3 µg/kg Intra nasally
 Children with burns 2µg/kg intra nasally + 0.5 mg/kg
oral midazolam.
Antihistamines
Hydroxyzine : Antiemetic, antihistaminic and antispasmodic.
 0.5-01mg/kg IM
Diphenhydramine : mild sedative and anti muscarinic effect
 oral diphenhydramine 0.25mg/kg + oral midazolam 0.5mg/kg

30. Anticholinergics
 Atropine 0.01- 0.02 mg /kg
 Scopolamine 0.005 – 0.010 mg/kg
 Glycopyrrolate – 0.01mg/kg
Topical anaesthetics

31. Corticosteroids
 Children who are taking long term steroid therapy
 Hydrocortisone 1-2mg/kg IM/IV
 Dexamethasone 0.05 – 0.1 mg/kg

32. Antacids, H2-Receptor Antagonists, and
Gastrointestinal Motility Drugs

33. Child with special needs
Autism Premedication

36. Parental presence during induction
COMFORT & SUPPORT
THE CHILD
HOLD THE CHILD’S
HAND

37. Induction of anaesthesia

38. Inhalation anaesthesia
Sevoflurane 8 %
Halothane 5%

42. IV Induction

44. Propofol
 1-6 months old : 3 + 0.2mg/kg
 10 – 16 years old : 2.4 + 0.1 mg/kg
 Unpremedicated children : 2.5 -3 mg/kg
ADVANTAGES
 Reduced airway problems
 More rapid emergence
 Reduced nausea and vomiting
DISADVANTAGES
 Pain at injection site

45. Ketamine
 1-2mg/kg
Uses
 Cardiovascular instability patients
 Hypovolemic patients

46. Reversal agents
Physostigmine
 dosage: 0.5 to 2 mg slow IV
Flumazenil
 dosage: 0.1 to 1mg IV.
Neostigmine
 dosage: 0.05 to 0.07 mg/kg
Naloxone
 0.4mg initially followed by 0.1mg-0.2mg every 2-3min for children
under 20 kg and dose for children over 20 kg is 2mg.

47. GA in Paediatric dentistry
INDICATIONS:
 Very young individuals
 Extreme anxiety
 Mental disability
 Physical disability
 Acute infection
 Allergy to LA
 Extensive Maxillofacial surgery
CONTRAINDICATIONS:
 A young child with incipient carious lesions.
 Non- compliance with NIL PER ORAL instructions.
 Unwilling parents
PURPOSE : To allow Total Oral Rehabilitation

48. Procedures performed are:
Extraction
Pulpal treatment
Stainless steel crowns
Amalgam / Composite restorations
PFS
SURGICAL
RESTORATIVE
PREVENTIVE

49. GA in Dentistry
 Dental chair anaesthesia
 Day care anaesthesia
 In patient anaesthesia

50. Physical and intraoral examination
PHYSICAL EXAMINATION
 General
 Head
 Neck
 Lateral facial profile
INTRAORAL EXAMINATION
 Lips
 Tongue
 Floor of the mouth
 Buccal mucosa
 Hard and soft palate
 Oropharynx
 Periodontium
Oral habits

51. Child’s record
 Name
 Age
 Gender
 Chief complaint & History of
present illness
 Past medical history
 Present medications ( Dosages and
timings)
 Results of Laboratory tests
 Documentation of informed
consent and physical examination
 Requirement for GA
 ASA Classification of the child
 No. of Decayed teeth
 Procedures completed before
 Treatment plan
 ASK THE PARENT ABOUT
 MIC: Major illness certificate
 DI: Disability identification card
 Finally Dentist’s signature

56. Postoperative instructions
1. After treatment, the first drink should be sips of plain water,
sweet drinks can be given next.
2. Food or drinks are preferred in small quantities at frequent
intervals rather in large quantities at one time.
3. Aerated drinks should not be given in first 24 hours.
4. For elevated body temp- antipyretics and fluids can be given.

57. 5. Patients should seek advice if there is persistent vomiting beyond
4 hours, increased temp above 101F, difficulty in breathing,
excessive drowsiness, any matter of concern.
6. 24 hour contact number of dental surgeon/ pedodontist should be
given to parents.
7. Emphasize on checkup on the following day and essentials of
regular follow up.

60. Conclusion
 Thorough Knowledge about the child’s medical history and
preoperative fasting time.
 Have good rapport with the child before anaesthesia to enhance the
trust of both the child and the parent.

61. References
 A practice of anaesthesia for infants and children Cote and
Lerman’s Textbook, 6th edition.
 Manual of Paediatric Anaesthesia Lerman and Cote.
 Tsai CL, Tsai YL, Lin YT, Lin YT. A retrospective study of dental
treatment under general anaesthesia of children with or without a
chronic illness and/or a disability. Chang Gung Med J.
2006;29(4):412-418.
 Naveen Malhotra, General Anaesthesia for Dentistry, Indian
Journal of Anaesthesia 2008;52:Suppl (5):725-737.
 Sigston PE, Jenkins AM, Jackson EA, Sury MR, Mackersie AM,
Hatch DJ. Rapid inhalation induction in children: 8% sevoflurane
compared with 5% halothane. Br J Anaesth. 1997;78(4):362-365.
doi:10.1093/bja/78.4.362.

62. THANK U …!