Guidelines For The Management Of Children Referred For ...dentalanaesthesia.org.uk/wp-content/uploads/2016/08/full_guideline… · the British Society of Paediatric Dentistry; the

Guidelines For The Management Of Children Referred For Dental Extractions Under General

Anaesthesia

August 2011 Review Date: 2016

TheAssociationofPaediatric

AnaesthetistsofGreatBritain&

Ireland

TheRoyalCollegeofAnaesthetists

http://www.bspd.co.uk/

http://www.rcn.org.uk/

http://www.fgdp.org.uk/

www.aagbi.org

www.dentalanaesthesia.org.uk

www.rcoa.ac.uk

www.apagbi.org.uk

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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]

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GuidelinesForTheManagementOfChildrenReferredForDentalExtractionsUnderGeneralAnaesthesia

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TABLEOF CONTENTS

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.ConditionsRequiringSpecialConsiderationInChildrenReferredForDentalExtractionsUnderGeneralAnaesthesia...............................................................................................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

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13.1‘Hospitalsetting’(38)......................................................................................................................28

13.2‘Criticalcarefacilities’(38)............................................................................................................29

14.PerioperativeCare.................................................................................................................................30

14.1Generalprinciplesofcare...........................................................................................................30

14.2Procedureonarrivalattheward/admissionarea.........................................................31

14.3Minimumstandardsforseniorityandcompetenceofanaesthetistandanaestheticassistant...............................................................................................................................31

14.4Anaestheticconsiderations........................................................................................................32

14.5Traininginpaediatricresuscitation.......................................................................................32

14.6Minimumstandardsforperioperativemonitoring..........................................................33

14.7Intravenousaccess.........................................................................................................................34

14.8Managementoftheuncooperativechildwhorequiresgeneralanaesthesiafordentalextractions.....................................................................................................................................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.ukIII. ConsultationandpeerreviewprocessIV. AGREEchecklistV. AuditmarkersandresearchideasVI. UsefuldocumentationVII. UsefulwebsitelinksVIII. Relevantarticlespublishedaftertheendoftheliteraturesearchperiodand

notformallyassessedbytheGuidelineDevelopmentGroupIX. ConflictofInterestDeclarations(available on request from [email protected])

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1.INTRODUCTION

Theseguidelineswerecommissionedby theAssociationofPaediatricAnaesthetistsofGreatBritainandIreland,incollaborationwiththeAssociationofDentalAnaesthetists;the British Society of Paediatric Dentistry; the Royal College of Anaesthetists; theAssociation of Anaesthetists of Great Britain and Ireland and the Royal College ofNursing.Theyaredesignedtoprovideevidence‐basedinformationonthemanagementof children and young people who are referred for dental extractions under generalanaesthesia.

The guidelines were prepared by a committee of healthcare professionals, with theassistanceofapatientrepresentative.Prior topublication, therewasaperiodofopenconsultation duringwhich suggestions were received from representatives of patientgroups and professional organisations. The target users of these guidelines includedentists, anaesthetists, registered nurses, dental nurses and operating departmentassistants / practitioners. Some sections of the document may also be of interest toparents/carers.BarrierstoimplementationandhealtheconomicswerenotwithintheremitoftheseguidelinesandwerenotconsideredbytheGuidelineDevelopmentGroup.

Inthisdocumenttheterm“outpatient”isusedtodescribeshort‐stayambulatorycare.Itis acknowledged that the facilities and organisation of such services vary widelythroughout the United Kingdom; however, general anaesthesia for dental extractionsmustbeprovidedwithinahospital settingasdefinedbelow. It isalsorecognised thatmany hospitals now incorporate their paediatric dental service within a day‐casesurgical service, which may allow the safe management of more complex cases. It isemphasisedthat,whateverthelengthofstay,childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofcareaschildrenundergoinggeneralanaesthesiaforanyotherprocedure.

Theseguidelineshavebeenofficiallyendorsedbyalltheorganisationslistedbelow:

AssociationofPaediatricAnaesthetistsofGreatBritainandIreland

AssociationofDentalAnaesthetists

AssociationofAnaesthetistsofGreatBritain&Ireland

BritishSocietyofPaediatricDentistry

RoyalCollegeofAnaesthetists

RoyalCollegeofNursing

FacultyofGeneralDentalPractice(UK)

TheguidelinesarealsoofficiallysupportedbytheRoyalCollegeofPaediatricsandChildHealth.

Thedocumentwillbereviewedeveryfiveyears.

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www.apagbi.org.uk

http://www.dentalanaesthesia.org.uk/

www.aagbi.org

http://www.bspd.co.uk/

www.rcoa.ac.uk

http://www.rcn.org.uk/

http://www.fgdp.org.uk/

http://www.rcpch.ac.uk/

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2.COMMITTEE

DrLolaAdewale ConsultantPaediatricAnaesthetist(Chair)

DrChristineArnold SpecialistinSpecialCareDentistry(AssociationofDentalAnaesthetists)

DrMichaelBlayney ConsultantAnaesthetist(RoyalCollegeofAnaesthetists)

DrWilliamHamlin ConsultantAnaesthetist(AssociationofDentalAnaesthetists)

ProfessorMarieThereseHosey Consultant Paediatric Dentist (British Society ofPaediatricDentistry)

DrNeilMorton ReaderinPaediatricAnaesthesia&PainManagement(AssociationofAnaesthetistsofGreatBritainandIreland)

DrGrantRodney ConsultantAnaesthetist(AssociationofPaediatricAnaesthetistsofGreatBritainandIreland)

DrAnna‐MariaRollin ConsultantAnaesthetist(RoyalCollegeofAnaesthetists)

DrKenRuiz ConsultantAnaesthetist(AssociationofDentalAnaesthetists)

MrsAnnSeymour Lay Representative (Association of PaediatricAnaesthetistsofGreatBritainandIreland)

MrsJulieSpice SeniorNurse(RoyalCollegeofNursing)

Declaration

TheGuidelineDevelopmentGroup is editorially independentandmembershad travelexpensesreimbursedbytheAPAGBIaccordingtoitspublishedexpensespolicy.

TherewerenoConflictsofInterest(available on request from [email protected] ).

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3.METHODOLOGYANDEVIDENCEGRADING

Electronicandmanualsearcheswereperformedof thepublished literatureupto31stOctober 2010 (See Appendix I) Included were English language meta‐analyses,systematic reviews, randomised controlled trials, clinical trials, cohort studies, caseseriesandstudiesinpatientsaged0–18years.MembersoftheGuidelineDevelopmentGroupalsoperformedmanualsearchesofguidelinespublishedbyrelevantprofessionalregulatorybodies, associations andRoyalColleges.TheGuidelineDevelopmentGroupreviewed some of the literature relating to adult patients, particularly where resultscould reasonably be extrapolated to the care of older children and adolescents. Casereportswereexcluded,togetherwitharticlespublishedinforeignlanguagesandthosedescribingtheuseofdrugsortechniquesthatwerenotapplicabletopracticewithintheUnitedKingdom.

Evidencewasassessed,usingSIGNmethodologyanddefinitions,aslevel1–4accordingto the criteria below. Recommendationswere graded A – D according to the level ofevidenceusedtocompilethem.Forareaswherepublishedevidencewasinsufficienttomake a formal recommendation, Good Practice Points (GPP) are provided. The latterindicate best clinical practice, based on the clinical experience and opinion of theGuidelineDevelopmentGroup.MandatoryrecommendationsarelegalrequirementsorstandardsagreedbytheGeneralMedicalCounciland/orGeneralDentalCouncil.

3.1LEVELSOFEVIDENCE(WWW.SIGN.AC.UK)

1++ Highqualitymeta‐analyses,systematicreviewsofrandomisedcontrolledtrials(RCTs),orRCTswithaverylowriskofbias

1+ Well‐conductedmeta‐analyses,systematicreviews,orRCTswithalowriskofbias

1‐ Meta‐analyses,systematicreviews,orRCTswithahighriskofbias

2++ Highqualitycasecontrolorcohortstudieswithaverylowriskofconfoundingorbiasandahighprobabilitythattherelationshipiscausal

2+ Well‐conductedcasecontrolorcohortstudieswithalowriskofconfoundingorbiasandamoderateprobabilitythattherelationshipiscausal

2‐ Casecontrolorcohortstudieswithahighriskofconfoundingorbiasandasignificantriskthattherelationshipisnotcausal

3 Non‐analyticstudies,e.g.casereports,caseseries

4 Expertopinion

http://www.sign.ac.uk/

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3.2GRADESOFRECOMMENDATIONS(WWW.SIGN.AC.UK)

[A] Atleastonemeta‐analysis,systematicreview,orRCTratedas1++,anddirectlyapplicabletothetargetpopulation;orabodyofevidenceconsistingprincipallyofstudiesratedas1+,directlyapplicabletothetargetpopulation,anddemonstratingoverallconsistencyofresults

[B] Abodyofevidenceincludingstudiesratedas2++,directlyapplicabletothetargetpopulation,anddemonstratingoverallconsistencyofresults;orextrapolatedevidencefromstudiesratedas1++or1+

[C] Abodyofevidenceincludingstudiesratedas2+,directlyapplicabletothetargetpopulationanddemonstratingoverallconsistencyofresults;orextrapolatedevidencefromstudiesratedas2++

[D] Evidencelevel3or4,orextrapolatedevidencefromstudiesratedas2+

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http://www.sign.ac.uk/

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4.DEFINITIONOFAGUIDELINE

TheScottishIntercollegiateGuidelinesNetwork(www.sign.ac.uk)intheirGuidelineDevelopersHandbook(SIGN50)statesthat:Clinicalpracticeguidelineshavebeendefinedas“systematicallydevelopedstatementstoassistpractitionerandpatientdecisionsaboutappropriatehealthcareforspecificclinicalcircumstances”. They are designed to help practitioners assimilate, evaluate andimplement theever increasingamountofevidenceandopiniononbestcurrentpractice.Clinical guidelines are intended as neither cookbook nor textbook but where there isevidenceofvariation inpractice,whichaffectspatientoutcomes,anda strong researchbaseprovidingevidenceofeffectivepractice,guidelinescanassisthealthcareprofessionalsinmakingdecisionsaboutappropriateandeffectivecarefortheirpatients.

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5.MEDICOLEGALSTATUSOFGUIDELINES

SIGNhasclarifiedthestatusofguidelinesasfollows:Clinical guidelines do not rob clinicians of their freedom, nor relieve them of theirresponsibilitytomakeappropriatedecisionsbasedontheirownexperienceandaccordingto theparticular circumstances of eachpatient. It is stressed that the standard of carerequired by law derives from customary and accepted practice rather than from theimpositionofpracticesthroughclinicalguidelines.Tobe liable forclinicalnegligence, itmustbeestablished that thecourse thehealthcareprofessionalhasadopted“isonewhichnoprofessionalmanofordinaryskillwouldhavetakenifhehadbeenactingwithordinarycare”.Thistest,fromacaseHuntervHanleyin1955wasdevelopedfurtherbytheBolamtest,i.e.ahealthcareprofessionalisnotguiltyofnegligence if “he has acted in accordance with a practice accepted as proper by aresponsible body ofmen skilled in that particular art”. A healthcare professionalmaythereforedefendachargeofnegligencewithevidencethat(s)heactedinconformitywiththepracticeacceptedbyanotherbodyofopinion.ThetestappliedbytheCourtisthereforebasedonwhatisactuallydoneinpracticeratherthanonaprescriptionofwhatshouldbedoneasproposedbyguidelines.Customaryandacceptedpracticewillbe established incourt by introduction of expert testimony. Although clinical guidelines will not beintroduced as a substitute for expert testimony, theymay be referred to by an expertwitnessasevidenceofsuchcustomaryandacceptedpractice.Itisimportanttoemphasisethatguidelinesareintendedasanaidtoclinicaljudgmentnotto replace it. Guidelines do not provide the answers to every clinical question, norguaranteea successfuloutcome in every case.Theultimatedecisionaboutaparticularclinicalprocedureortreatmentwillalwaysdependoneachindividualpatient’scondition,circumstancesandwishes,andtheclinicaljudgmentofthehealthcareteam.Guidelines are, however, intended to address variation in practice.While there is nocompulsion to implement any guideline or individual recommendations, NHS Boards,clinical teams,and individualpractitioners inprimaryand secondary care shouldallbeabletodefinethestandardofcarewhichtheyprovide,andtojustifyifnecessarywhythesedonotmeetnationallyagreedrecommendations.

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6.AIMSANDREMIT

Todevelopanevidence‐basedconsensusonthecarepathwayfromreferralto

dischargeforchildrenandyoungpeoplewhoarereferredfordentalextractions

undergeneralanaesthesia.

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7.KEYQUESTIONS

7.1Whatistheoptimalintegratedcarepathwayforchildrenandyoungpeoplewhomayrequiregeneralanaesthesiafordentalextractions?

7.2Towhichchildrenandyoungpeoplewilltheseguidelinesapply?

7.3Whatassessmentandpreparationarerequired?

7.4 How can the requirement for general anaesthesia, especially repeat generalanaesthesia,bereduced?

7.5Whatshouldbetheminimumstandardsforseniorityandcompetenciesofstaff?

7.6Whataretheminimumstandardsforperioperativemonitoring?

7.7Isintravenousaccessnecessary?

7.8Whatare the implicationsofvariousanaesthetic techniques forperioperativecareandpostoperativeadverseeffects?

7.9Whatistheoptimalanalgesicregimen?

7.10Whatequipmentandstaffinglevelsarerequiredforrecovery?

7.11Whatshouldbethecriteriaandproceduresfordischargehome?

7.12Whatadviceshouldbegivenaboutpostoperativecarefollowingdischarge?

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ReferringDentist

Childrequiringdentalextractionsnotmanageablewithingeneraldentalpracticesetting

Referralguidelinesandproforma

AssessmentAppointment

(DentistwithexperienceinPaediatricDentistry)

DentalandmedicalhistoryDentalexamination&radiologyDefinitivetreatmentplanning

Agreementonthemostappropriateformofpainandanxietymanagement

Generalanaesthesiarequired

Preliminaryanaestheticassessmentperformedbyassessingdentist

Accesstotheopinionofananaesthetist,ifrequired

Patientpreparation.Requirementforsedativepremedicationconsidered.Verbal&writteninformationprovided

Acquisitionofinformedconsent

Suitablefor‘outpatient’GA

HospitalAppointment

(Routinenon‐emergencycases)

Assessmentbyanaesthetist

Confirmationofconsent

Dentalextractionsperformed

GAnotconsideredtobethebestoption,i.e.suitablefortreatmentunderlocalanaesthesia+/‐inhalationalsedation(butGDPunabletoprovide)

Extractionsarrangedbydentalassessor

GAisconsideredtobethebestoption,butnotsuitablefor‘outpatient’setting(e.g.significantmedicalconditionorcomplexdentalproblem)Seeparagraph11–Conditionsrequiringspecialconsideration

Linktohospitaldaycare,inpatientandpaediatricservices,includingaccesstoConsultantinPaediatricDentistry

PrimaryCareSetting

Setting‐ dependentonlocalfacilities

HospitalSetting*

8.ASUGGESTEDCAREPATHWAY

*Asdefinedby:AConsciousDecision:Areviewoftheuseofgeneralanaesthesiaandconscioussedationinprimarydentalcare.DOH2000(6).Generalanaesthesiafordentaltreatmentinahospitalsettingwithcriticalcarefacilities.CDOletterDoH;2001(29).

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9.KEYRECOMMENDATIONS

9.1REFERRAL

Recommendation1

Dentalextractionsshouldonlybeperformedundergeneralanaesthesiawhenthisisconsideredtobethemostclinicallyappropriatemethodofmanagement.

(MANDATORY)

Recommendation2

Allservicesshoulddevelopalocalreferralproforma,distributedwithappropriateguidancetoallreferrers.Thereferrallettershouldclearlyjustifytheuseofgeneralanaesthesia,thoughtheultimatedecisiononwhethergeneralanaesthesiaisadministeredshouldbemadeattheassessmentappointment.

(GRADED)

9.2ASSESSMENTANDPREPARATION

Recommendation3

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofassessmentandpreparationaschildrenadmittedforanyotherprocedureundergeneralanaesthesia.

(GRADED)

Recommendation4

Optionsforthedentalextractions,includingwhethertheyareperformedunderlocalanaesthesia,localanaesthesiasupplementedwithconscioussedation,orgeneralanaesthesia,shouldbeexplainedtotheparent/carerandchild(whereappropriate),allowingadequatetimeforeachoptiontobeconsidered.Theassociatedbenefitsandrisksofeachtechniqueshouldalsobediscussed.

(MANDATORY)

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Recommendation5

Unlessthereisanurgentclinicalneedfortreatment,assessmentshouldideallybeundertakenataseparateappointment.Thisshouldincludetheformationofatreatmentplan,preparationfortheprocedureandassociatedgeneralanaesthesia,assessmentoftheneedforsedativepremedication,informationsharing,dischargeplanningandanexplanationoffastinginstructionstogetherwithanappropriateregimenforanalgesia.Sufficienttimeshouldbeprovidedtoallowtheparent/carerandchildtoarriveataconsideredopinionandtogiveinformedconsent.

(GRADED)

Recommendation6

Theassessingdentistshouldideallybeaspecialistinpaediatricdentistry,oradentistwhocandemonstratethenecessarycompetenciestocarryoutcomprehensivetreatmentplanningforchildrenwhorequiregeneralanaesthesia.Thedentistshouldbetrainedandexperiencedinthebehaviouralmanagementofchildren,includingconscioussedation(particularlyinhalationalsedation).Thedentistshouldalsobeconversantwithallclinicalguidelinesrelevanttotheassessment,diagnosis,treatmentplanningandmanagementofchildrenrequiringdentalextractionsundergeneralanaesthesia.Relevantradiologicalinvestigationsshouldbeavailableattheassessmentappointment.

(GRADED)

Recommendation7

Attheassessmentappointment,writteninformationshouldbeprovidedinsuitableformatsforthechildandtheparent/carer.Thisshouldincludedetailsabout:

Preoperativepreparation,includingpreoperativefasting

Theproposedtreatmentplan,includingbenefitsandrisks

Theavailabilityofalternativetreatmentoptions

Theprocessofgeneralanaesthesia,includingpotentialsideeffectsandcomplications

Appropriateescortsforthechildonthedayoftheprocedure

Postoperativearrangements,includingsuitabletransporthome

Postoperativecareandanalgesia.

(GRADED)

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Recommendation8

Theopinionofanappropriatelytrainedandexperiencedanaesthetistshouldbeavailable,ifrequired,priortothetreatmentappointment.Dentalandrelevantmedicalcaserecordsshouldalsobeavailable.

(GRADED)

9.3APPROPRIATESITEANDFACILITIES

Recommendation9

Childrenrequiringgeneralanaesthesiafordentalextractionsshouldbemanagedinachild‐centred,family‐friendlyhospitalsetting.Thisshouldprovidethespace,facilities,equipmentandappropriatelytrainedpersonnelrequiredtoenableresuscitationandcriticalcaretobeimmediately,efficientlyandeffectivelyundertaken,shouldtheneedarise.Agreedprotocolsandappropriatecommunicationlinksmustbeinplace,bothtosummonadditionalassistanceinanemergencysituationandforthetimelytransferofpaediatricpatientstodedicatedareassuchashighdependencyunits(HDUs)orintensivecareunits(ICUs),ifnecessary.

(MANDATORY)

9.4PERIOPERATIVECARE

Recommendation10

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofcareaschildrenadmittedforanyotherprocedureundergeneralanaesthesia.Thisshouldincludeanopportunitytovisitthedepartmentbeforethedayoftheprocedure,aswellasaccesstopreoperativepreparationbyregisteredchildren’snursesand/orplayspecialists.Ifsuchstaffarenotemployedwithinthedepartment,arrangementsshouldbemadetoensureappropriateavailabilityonaflexiblebasis.

(GRADED)

Recommendation11

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbecaredforinafamily‐orientatedenvironment.Thisshouldallowtheparent/carertoaccompanythechildduringinductionofgeneralanaesthesia,whereappropriate.Treatmentroomsshouldbechild‐friendly,withsuitableplayandrecreationalequipmentinthewaitingareas.Thereshouldbephysicalseparationfromadultpatients,aswellasadequatespacetoaccommodatetheequipmentrequiredtomeettheneedsofthechildwithphysicaldisabilities.

(GRADED)

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Recommendation12Parents and carers should be informed of the potential adverse effects of generalanaesthesia, including the timescale of these. Advice should be given about return toschool and normal activities, as well as the management of behavioural changes athome.(GRADEC)

Recommendation13

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbemanagedbystaffwhohavereceivedappropriatetraining,andwhoarecompetentinpaediatricanaesthesiaandpaediatricresuscitation.Regularupdatesinresuscitationtechniques,togetherwithpracticeasateaminthemanagementofsimulatedemergencies,areessentialtomaintainskillsandoptimiseeffectiveteamworkinginagenuinecrisis.

(GRADED)

Recommendation14

Whenevergeneralanaesthesiaisadministeredtoachild,clinicalobservationshouldbesupplementedbyminimumstandardsofmonitoring.Thesestandardsshouldbeuniformirrespectiveoftheduration,locationormodeofanaesthesia.

(GRADED)

Recommendation15

Intravenousaccessshouldbeconsideredforeverypatient.Topicallocalanaestheticcream(Ametop®/EMLA®/LMX4®)shouldbeappliedpreoperativelytopotentialsitesforvenepuncture,whereappropriate.

(GPP)

Recommendation16

AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct2004(oritsequivalent),therightsofthechild,safeguardingofchildren/childprotectionandtheprocessofobtainingconsent.Allmembersofstaffwhocareforchildrenshouldbeawareoflocalpoliciesconcerningthemanagementofuncooperativechildren.

(GPP)

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Recommendation17Allclinicalstaffcaringforchildrenshouldhavethenecessarylevelofcompetenceinthesafeguardingofchildren/childprotection.*(MANDATORY)

*Thisshouldbeaminimumof“Level2Competence”,asoutlinedbytheIntercollegiateDocumentonSafeguardingChildrenandYoungPeople(2010).75

9.5PERIOPERATIVEANALGESIA

Recommendation18

Unlesscontraindicated,non‐steroidalanti‐inflammatorydrugs(NSAIDs)and/orparacetamolshouldbeusedtoprovideanalgesiafordentalextractionsundergeneralanaesthesia.Thesedrugsmaybecombinedorgivenseparatelybefore,duringoraftersurgery.Opioidsarenotroutinelyrequiredforuncomplicateddentalextractions.

(GRADEB)

Recommendation19

Infiltrationofalocalanaestheticagentcombinedwithavasoconstrictoragentmayhavearoleinachievinghaemostasis,withpossiblysomebenefitintermsofanalgesiaintheolderchildwhoisabletounderstandthesensationofnumbness.

(GRADEB)

Recommendation20Thestandardsforrecoveryanddischargefollowinggeneralanaesthesiafordentalextractionsinchildrenshouldbethesameasthosefollowinggeneralanaesthesiaforanyotherprocedure.(GPP)Recommendation21Childrenshouldbemanagedinadedicatedandappropriatelyequippedchildren’srecoveryarea,onaone‐to‐onebasis,bydesignatedmembersofstaffwhoreceiveregulartraininginpaediatricresuscitation.Aregisteredchildren’snursemustbeavailabletoprovidecareforpaediatricpatientsandtosuperviseothernursingstaffwhomaybeinvolvedinthecareofchildren.Amemberofstaffwhoistrainedandcompetentinadvancedpaediatriclifesupportshouldbeavailableuntilthechildisdischargedfromthedepartment.(GRADED)

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9.6RECOVERYANDDISCHARGE

Recommendation22

Facilitiesshouldallowparents/carerstobepresentassoonastheirchildemergesfromgeneralanaesthesia.Adequatetimeshouldbeallowedforthesecondstageofrecoveryandappropriatefacilitiesshouldbeprovidedforthechildwhorequiresprolongedrecoveryformedical,nursing,orsocialreasons.

(GPP).

Recommendation23Dischargeortransferofthepatientshouldbebasedonspecifiedcriteria,irrespectiveofthetimetakentoachievethese.(GPP)

Recommendation24

Suitabletransporthomeshouldbearranged.Thechildmustbeaccompaniedbyaresponsibleadult.

(GPP)

Recommendation25

Writtenandverbaladviceaboutpostoperativecareshouldbeprovidedfortheparent/carer.Aresponsibleadultmustbeavailableforcareofthechildathome.Clearinformationshouldalsobeprovidedonappropriatelinesofcommunicationintheeventofanysubsequentqueriesorpostoperativeproblems.

(GPP)

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10.APPLICATIONOFTHESEGUIDELINES

Theseguidelinesareintendedtoapplytochildrenandyoungpeopleaged1–18years.

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11.CONDITIONSREQUIRINGSPECIALCONSIDERATIONINCHILDRENREFERREDFORDENTALEXTRACTIONSUNDER

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

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12.REFERRAL,ASSESSMENTANDPREPARATION

12.1REFERRAL

Dentalproceduresshouldonlybeperformedundergeneralanaesthesiawhenthelatterisjudgedtobeclinicallynecessarytodelivertherequiredtreatment(6).Clearjustificationfortheuseofgeneralanaesthesiashouldbemadeinthereferralletter(7).(EvidenceLevel4)

Recommendation1

Dentalextractionsshouldonlybeperformedundergeneralanaesthesiawhenthisisconsideredtobethemostclinicallyappropriatemethodofmanagement.

(MANDATORY)

Guidelinesonthereferralprocessandacceptancecriteriashouldbeissuedtoallreferrers.Astandardreferralproformashouldbeusedtoobtainessentialinformationforpatienttriage(8‐12).(EvidenceLevel2+)

Inaccordancewithexistingguidelines,thereferrershouldspecifyanyindicationsfortheuseofgeneralanaesthesiatoperformthedentalextractions.Theultimatedecisiononwhethergeneralanaesthesiaisadministeredshould,however,bemadebytheserviceproviderwhenthepatientattendstheassessmentappointment.(6,7,13,14)(EvidenceLevel4)

Recommendation2

Allservicesshoulddevelopalocalreferralproforma,distributedwithappropriateguidancetoallreferrers.Thereferrallettershouldclearlyjustifytheuseofgeneralanaesthesia,thoughtheultimatedecisiononwhethergeneralanaesthesiaisadministeredshouldbemadeattheassessmentappointment.

(GRADED)

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12.2ASSESSMENTANDPREPARATION

Dentalextractionsinchildrenareoftenperformedintheprimarydentalcaresetting,usinglocalanaesthesiaeitherwithorwithoutsedation.Generalanaesthesiamayberequiredifthesetechniquesarenotsuitable,particularlyiftheyhavebeenpreviouslyunsuccessful.Otherfactorstobeconsideredinclude:

Thepotentialinabilityofthechildtocooperate,determinedbyage,development,languageordisability

Theexistenceofanypsychologicaldisorder

Thepresenceofacutedentalinfection

Therequirementforextractionsinmultiplequadrants

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofassessmentandpreparationaschildrenadmittedforanyotherprocedureundergeneralanaesthesia.(GPP)

Priorassessmenthasbeendemonstratedtofacilitatethepatientpathwayonthedayofsurgery(15).(EvidenceLevel4)

Recommendation3

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofassessmentandpreparationaschildrenadmittedforanyotherprocedureundergeneralanaesthesia.

(GRADED)

12.2.1SEPARATEASSESSMENTVISIT

Assessmentshouldideallyoccurataseparatevisitandincorporatedental,medical,andpreliminaryanaestheticassessments(14,16‐18).(EvidenceLevel2+,4)Specialconsiderationmayberequiredinurgentclinicalcasesorwheretherearegeographicaland/orsociallimitations.

Aseparateassessmentappointmentmayallow:

Confirmationoftheneedfortreatment

Modificationstotheproposedtreatmentplan

Opportunityfordetaileddiscussionandconsiderationofalternativetreatmentoptions,togetherwiththeassociatedrisks.Optionsforthedentalextractionsinclude:localanaesthesia,localanaesthesiasupplementedwithconscioussedation,orgeneralanaesthesia(19).

Assessmentofthedegreetowhichtheexplanationsareunderstoodbytheparent/carerandthechild(6,7,14,17).(EvidenceLevel2+,4)

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Reductionintherequirementforgeneralanaesthesiabyusingalternativemethodsofpainandanxietymanagement(16),(EvidenceLevel2+)

Reductionintherequirementforrepeatgeneralanaesthesiathroughappropriate

treatmentplanning(16,20).(EvidenceLevel2+) Identificationofanymedicalproblemsthatmayrequiretheadviceofan

anaesthetist.(21).(EvidenceLevel4)

Supportforthechildandparent/carerduringpreparationforgeneralanaesthesia

Assessmentoftherequirementforsedativepremedication

Discussionof:fastinginstructions,appropriateescortsforthechildonthedayoftheprocedure,painmanagement,dischargeadvice,suitabletransporthomeandreturntonormalactivities

Recommendation4

Optionsforthedentalextractionsincludingwhethertheyareperformedunderlocalanaesthesia,localanaesthesiasupplementedwithconscioussedation,orgeneralanaesthesia,shouldbeexplainedtotheparent/carerandchild(whereappropriate),allowingadequatetimeforeachoptiontobeconsidered.Theassociatedbenefitsandrisksofeachtechniqueshouldalsobediscussed.

(MANDATORY)

12.2.2CONSENT

Inchildren,theprocessofobtainingconsentfordentalextractionsundergeneralanaesthesiashouldbethesameasobtainingconsentforanyotherdiagnosticortherapeuticprocedure.

InformedconsentmustbeobtainedinwritingfromaparentorguardianwithparentalresponsibilityinaccordancewiththeChildrenAct2004(oritsequivalent),aswellasotherprofessionalguidelinesonobtainingconsent.(22‐26)Childrenwhoarecompetentshouldbeinvitedtotakepartintheconsentprocess.Inordertoprovideinformedconsenttoexaminationortreatment,childrenandtheirparents/carersshouldreceiveverbalandwritteninformationaboutthefollowing(25,27,28):

Detailsoftheproposedtreatmentplan,includingbenefitsandrisks Availabilityofalternativetreatmentoptions Theprocessofgeneralanaesthesia,includingpotentialsideeffectsand

complications Preoperativefasting,appropriateescortsforthechildonthedayoftheprocedure,

suitabletransporthome,postoperativecareandanalgesia(7,29)(EvidenceLevel4)

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The decision to perform the procedure should involve the provision of information,acquisitionofinformedconsentandmaintenanceofconfidentiality(30).Informationfortheparent/carershouldbeprovidedinanappropriateandeasilyunderstoodformat.Similarly, informationforthechildshouldbeprovidedinasuitable formatandwherepossible,thechild’sunderstandingshouldalsobeestablished(27,28).Whentreatmentisnotconsideredtobeanemergency,obtainingconsentshouldbeseenasaprocessandnottheisolatedeventofsecuringasignatureimmediatelypriortotheprocedurebeingperformed.Theconsentprocessshouldinvolveadiscussionoftreatmentoptionswiththeprovisionofsufficient informationtotheparent/carerandthechild. Appropriatetimeshouldthenbeprovidedtoallowaninformeddecisiontobereached.Informationabout the potential side effects and complications of general anaesthesia should bediscussedearlyinthisprocess.(EvidenceLevel4)

If general anaesthesia is required for the dental extractions, the process of consentshould begin before the patient meets the anaesthetist. It is neither practical nordesirable forall the information tobeprovided tochildrenandparents/carersat thepreoperativemeetingwiththeanaesthetist.Otherthaninexceptionalcircumstances,itisnot acceptable toprovide childrenorparents / carerswithnew information at thetimeofgeneralanaesthesia(26).EvidenceLevel4)

Preoperative preparation for children and parents / carers should employ a range ofmedia and pre‐treatment programmes, with contributions from all members of themultidisciplinaryteam(30).(EvidenceLevel4)

Recommendation5

Unlessthereisanurgentclinicalneedfortreatment,assessmentshouldideallybeundertakenataseparateappointment.Thisshouldincludetheformationofatreatmentplan,preparationfortheprocedureandassociatedgeneralanaesthesia,assessmentoftheneedforsedativepremedication,informationsharing,dischargeplanningandanexplanationoffastinginstructionstogetherwithanappropriateregimenforanalgesia.Sufficienttimeshouldbeprovidedtoallowtheparent/carerandchildtoarriveataconsideredopinionandtogiveinformedconsent.

(GRADED)

12.2.3DENTALASSESSMENT

Dentalassessmentshouldideallybeperformedbyaspecialistinpaediatricdentistry(17,31), or a dentist who can demonstrate the necessary competencies to carry outcomprehensivetreatmentplanningforchildrenwhorequiregeneralanaesthesia.Wheretheassessingdentistisnotaspecialist,supportfromaspecialistorconsultantshouldbereadily available, if required, through established clinical networks. Access to otherspecialties,suchasorthodontics,oralsurgeryandmaxillofacialsurgeryshouldalsobeavailableforallchildren.

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The assessing dentist should be trained and experienced in the behaviouralmanagement of children and the use of conscious sedation techniques, particularlyinhalationsedation(32).(Evidencelevel4)

Theassessingdentistshouldalsobeconversantwithallclinicalguidelinesrelevant totheassessment,diagnosis,treatmentplanningandmanagementofchildrenwhorequiredentalextractionsundergeneralanaesthesia.(33,34)(EvidenceLevel4)

Familiaritywith themanagementofanxiouschildren isalso important indeterminingthe requirement for sedative premedication. The opinion of a suitably trained andexperienced anaesthetist should be available prior to the treatment appointment, ifrequired, with dental and relevant medical case records also made available. (21)(EvidenceLevel4)

Comprehensive assessment, including radiography should facilitate the treatmentplanningprocessandmayreducetherequirementforrepeatgeneralanaesthesia(14,35).(EvidenceLevel4)

Recommendation6

Theassessingdentistshouldideallybeaspecialistinpaediatricdentistry,oradentistwhocandemonstratethenecessarycompetenciestocarryoutcomprehensivetreatmentplanningforchildrenwhorequiregeneralanaesthesia.Thedentistshouldbetrainedandexperiencedinthebehaviouralmanagementofchildren,includingconscioussedation(particularlyinhalationalsedation).Thedentistshouldalsobeconversantwithallclinicalguidelinesrelevanttotheassessment,diagnosis,treatmentplanningandmanagementofchildrenrequiringdentalextractionsundergeneralanaesthesia.Relevantradiologicalinvestigationsshouldbeavailableattheassessmentappointment.

(GRADED)

12.2.4ANAESTHETICASSESSMENT

Althoughquestionnairesmaybeusedfortheinitialscreeningprocesspriortogeneralanaesthesia, there should always be access to the opinion of a suitably trained andexperiencedanaesthetist.Theanaesthetistisultimatelyresponsiblefortheanaestheticassessment 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 relevantmedical case records should be made available at the time of the anaestheticassessment.(EvidenceLevel4)

Accepted guidance(21, 36) emphasises the importance of preoperative assessment toensurethat:‐

Patientsarefitforgeneralanaesthesia

Resultsofanyrelevantinvestigationsareavailableatthetimeoftreatment

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Childrenandparents/carersaregivenanopportunitytoexpressanyconcernstheymayhaveaboutgeneralanaesthesiaandtheproposedtreatmentplan.

All patients requiring general anaesthesia must be seen by an anaesthetistpreoperatively(21).Theanaesthetistisresponsiblefordecidingwhetherornotapatientisfitforgeneralanaesthesia,howeveritiscommonforotherprofessionalgroupstobeinvolvedintheassessmentprocess.(EvidenceLevel4)It is inappropriate for a particular type of premedication, technique of anaesthesia ormethodofpainmanagementtobeagreedwithoutconsultationwithananaesthetist.(21)(EvidenceLevel4)

Writtenmaterialmay improve the information acquiredbyparents / carers andmayenhance satisfaction. The timing of delivery of this information is also important.(37)(EvidenceLevel2+)

Parents / carers and children should be advised that theywill meet the anaesthetistpriortotreatment,withtheopportunityforfurtherdiscussionandexplanation.

Recommendation7

Attheassessmentappointment,writteninformationshouldbeprovidedinsuitableformatsforthechildandtheparent/carer.Thisshouldincludedetailsabout:

Preoperativepreparation,includingpreoperativefasting

Theproposedtreatmentplan,includingbenefitsandrisks

Theavailabilityofalternativetreatmentoptions

Theprocessofgeneralanaesthesia,includingpotentialsideeffectsandcomplications

Appropriateescortsforthechildonthedayoftheprocedure

Postoperativearrangements,includingsuitabletransporthome

Postoperativecareandanalgesia.

(GRADED)

Recommendation8

Theopinionofasuitablytrainedandexperiencedanaesthetistshouldbeavailable,ifrequired,priortothetreatmentappointment.Dentalandrelevantmedicalcaserecordsshouldalsobeavailable.

(GRADED)

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13.APPROPRIATESITEANDFACILITIES(ASDEFINEDBYTHEDEPARTMENTOFHEALTH)

General anaesthesia for dental extractions should only be administered within a‘hospitalsetting’. Theterm ‘hospitalsetting’wasdefinedintheDepartmentofHealthdocument ‘A Conscious Decision’ (2001) as … “any institution for the reception andtreatment of persons suffering illness or any injury or disability requiringmedical ordentaltreatment,whichhascriticalcarefacilitiesonthesamesiteandincludesclinicsandoutpatientdepartments in connectionwithany such institution” (7). The terms ‘hospitalsetting’and‘criticalcarefacilities’werefurtherclarifiedbytheDepartmentofHealthinMay2001.(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 atleast equivalent to that of a hospital within the NHS, including clinics and day carefacilitiesassociatedwiththoseinstitutions,where:

Surgeryorprocedureswhichinvolvetheuseofgeneralanaesthesia,withorwithoutlocalanaesthesia,areregularlyundertaken,

Trained personnel are immediately available to assist the anaesthetist with theresuscitation of a collapsed patient so that the patient’s airway, breathing andcirculationarefullysupportedwithoutdelay,

Facilities and staff are able to support and maintain a collapsed patient pendingrecoveryorsupervisedtransfertoahighdependencyunit(HDU)orintensivecareunit(ICU)thatmay,insomeinstances,beonaseparatehospitalsite.

Thisdoesnotnecessarilymean thatgeneral anaesthesia fordental extractions shouldonly be provided in what might be considered the main operating suite of thoseinstitutions. Usually, the clinics and day care facilities described above would besituatedwithinthegroundsofthehospitalandeitherwithin,orcloseto,themainbodyofthehospital.AgreedprotocolsandappropriatecommunicationlinksmustbeinplacetosummonextrahelpandalsoforthetimelytransferofpatientstodedicatedareassuchasHDUsorICUs,shouldtheneedoccur.

Usually, it is self‐evidentwhether or not a particular site for the provision of generalanaesthesia for dental extractions is part of the hospital setting. In cases of doubt,decisionsonwhetheraproposedsiteisacceptableshouldbemadebytheresponsiblecommissioningandhealthcareproviderorganisationsonasite‐by‐sitebasistakingintoaccount:

Thebuilding,equipmentandfacilitiesavailable,

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Thearrangementsmadefortheimmediateprovisionofcriticalcare(seebelow)attheproposedsite.Thisshouldincludeeasyaccessforemergencyservicesandforapatientonastretcher,

ThearrangementsinplaceforthetimelytransferofthepatienttoHDUsorICUs,shouldthisbenecessary.

13.2‘CRITICALCAREFACILITIES’(38)

A‘criticalcarefacility’inthiscontextisanareaorroomwhichhasthespace,equipmentand appropriately trained personnel to enable critical care and resuscitation to beefficientlyandeffectivelyundertaken,shouldtheneedarise.Thespacerequiredcouldbe the existing operating area, if this is of sufficient size. Of paramount importancehowever, is theimmediate,efficientandeffectivemanagementofthecollapse. ‘Criticalcarefacilities’inthecontextofthisguidancearenotnecessarilydedicatedareassuchasHDUsorICUs.

If there is a sudden and serious collapse of a patient during general anaesthesia fordental extractions, the overriding need is to provide swift and expert medical care.Additional skilled personnelmust be immediately available, togetherwith emergencydrugsandequipmentincludingdefibrillationfacilities.

Allpersonnelinvolvedwiththeadministrationofgeneralanaesthesiamusthaveup‐to‐dateskills inadvanced life support.Theadditional skilledsupport requiredshouldbeprovidedbypersonnelwhoaretrainedspecificallyasateamtomanagelife‐threateningsituations.Thelevelofcareprovidedshouldbebasedontheneedsofthepatientandatleast equivalent to “Level 2 Critical Care”, as defined for adults by theDepartment ofHealth.(39)

Agreed protocols and appropriate communication links must be in place, both tosummon additional assistance in an emergency situation, as well as for the timelytransferofpaediatricpatientstodedicatedareassuchasHDUsorICUs,shouldtheneedoccur.

Recommendation9

Childrenrequiringgeneralanaesthesiafordentalextractionsshouldbemanagedinachild‐centred,family‐friendlyhospitalsetting.Thisshouldprovidethespace,facilities,equipmentandappropriatelytrainedpersonnelrequiredtoenableresuscitationandcriticalcaretobeimmediately,efficientlyandeffectivelyundertaken,shouldtheneedarise.Agreedprotocolsandappropriatecommunicationlinksmustbeinplace,bothtosummonadditionalassistanceinanemergencysituationandforthetimelytransferofpaediatricpatientstodedicatedareassuchashighdependencyunits(HDUs)orintensivecareunits(ICUs),ifnecessary.

(MANDATORY)

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14.PERIOPERATIVECARE

14.1GENERALPRINCIPLESOFCARE

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandard of care as children admitted for any other procedure under generalanaesthesia.Thisincludesthecompletionofanappropriatepreoperativechecklist(40‐46).(EvidenceLevel4)

Anopportunityshouldbeprovidedforthechildrentovisit thedepartmentbeforetheday of the procedure. There should also be access to preoperative preparation byregistered children’s nurses and / or play specialists (40, 41, 43‐46). If such staff are notemployeddirectlywithinthedepartment,flexibleoptionsshouldbeconsideredinordertoensureappropriateavailabilityonasessionalbasis.(EvidenceLevel4)

Recommendation10

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldreceivethesamestandardofcareaschildrenadmittedforanyotherprocedureundergeneralanaesthesia.Thisshouldincludeanopportunitytovisitthedepartmentbeforethedayoftheprocedure,aswellasaccesstopreoperativepreparationbyregisteredchildren’snursesand/orplayspecialists.Ifsuchstaffarenotemployedwithinthedepartment,arrangementsshouldbemadetoensureappropriateavailabilityonaflexiblebasis.

(GRADED)

Children requiring general anaesthesia for dental extractions should bemanaged in asafe,family‐orientatedandchild‐friendlyenvironment,separatefromadultpatients(47,48). This should allow parents / carers to accompany their child during induction ofgeneralanaesthesia,whereappropriate.Suitableequipment,toysandgamesshouldbeprovided,togetherwithaplayareatoreduceanxietyandimproverecovery(49,50).Theemotionalandphysicalrequirementsofchildrenshouldbereflectedinthedesignoftheoperatingtheatredepartment,theappearanceoftheanaestheticandrecoveryareas,aswell as the working practices of the staff involved (48, 50, 51). There should also beadequatespacetoaccommodatetheequipmentrequiredtomeettheneedsofthechildwithphysicaldisabilities(41,47,51,52). Aregisteredchildren’snursemustbeavailabletosupervise other nursing staff who may be involved in the care of children. Playspecialistsshouldalsobeavailable.(50).(EvidenceLevel4)

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Recommendation11

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbecaredforinafamily‐orientatedenvironment.Thisshouldallowtheparent/carertoaccompanythechildduringinductionofgeneralanaesthesia,whereappropriate.Treatmentroomsshouldbechild‐friendly,withsuitableplayandrecreationalequipmentinthewaitingareas.Thereshouldbephysicalseparationfromadultpatients,aswellasadequatespacetoaccommodatetheequipmentrequiredtomeettheneedsofthechildwithphysicaldisabilities.

(GRADED)

14.2PROCEDUREONARRIVALATTHEWARD/ADMISSIONAREA

Planned arrival times should allow adequate time for preparation of the child,whilstconsidering that strategies to reduce anxiety should include the shortest safe fastingtimesandminimalwaitingtimes(30)(EvidenceLevel4).

It is essential to confirm that fasting instructions have been followed. Baselinemeasurements and observations should be recorded (e.g. weight, temperature andpulse)forcomparisonwiththoseobtainedpostoperatively.

Afinaldentalandanaestheticassessmentshouldbemadeandtopicallocalanaestheticcream (EMLA®/Ametop®/LMX4®)applied, if appropriate. If the requirement forsedative premedication becomes apparent at this stage, having previously beenunrecognised, it may be appropriate to reschedule the procedure to allow a plannedstrategyforanxietymanagement.

Parents / carers should be given appropriate support to reassure and comfort theirchildduringinductionandrecovery.

14.3MINIMUMSTANDARDSFORSENIORITYANDCOMPETENCEOFANAESTHETISTANDANAESTHETICASSISTANT

Irrespective of the setting, children undergoing general anaesthesia for dentalextractions should receive the same standard of care as those undergoing generalanaesthesia for any other procedure. They should be anaesthetised by a consultantanaesthetist on the specialist register, who in addition to undertaking regular andrelevant paediatric practice sufficient to maintain core competencies, possessesdedicated training and skills in paediatric dental general anaesthesia, and undertakesappropriatecontinuingprofessionaldevelopment(CPD).(13,51,53,54)Childrenmayalsobeanaesthetised by a Staff Grade or Associate Specialist (SAS) anaesthetist, or SpecialtyDoctor (SD), provided that he or she satisfies the same criteria and that there is anominated supervising consultant anaesthetist with appropriate experience (51) .Trainees anaesthetising children should always be appropriately supervised by aconsultantwithrelevantexperience(51).(EvidenceLevel4)

The anaesthetist should be assisted by staff (anaesthetic nurses or operatingdepartment practitioners/assistants) with specific training in paediatrics and skillsrelevanttopaediatricdentalgeneralanaesthesia(13,51).(EvidenceLevel4)

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The anaesthetist should be assisted by staff (anaesthetic nurses or operatingdepartment practitioners/assistants) with specific training in paediatrics and skillsrelevanttopaediatricdentalgeneralanaesthesia(13,51).(EvidenceLevel4)

In the immediatepost‐anaestheticrecoveryperiod,managementof thepatientshouldbeinaccordancewithexistingguidelines.(36,51,55,56)(EvidenceLevel4)Thechildshouldbemanagedintherecoverywardorpost‐anaesthesiacareunit,onaone‐to‐onebasis,byadesignatedtrainedmemberoftherecoveryteamwhohasappropriatetraininginpaediatricresuscitation(55).Aregisteredchildren’snursemustbeavailabletosuperviseother nursing staff whomay be involved in the care of children. Amember of stafftrainedandcompetentinadvancedpaediatriclifesupportshouldbepresentwhenevergeneralanaesthesiaisadministeredtoachild.(51)(EvidenceLevel4)

14.4ANAESTHETICCONSIDERATIONS

Parents / carers should be advised that general anaesthesia may have short‐termadverse effects such as headache, sore throat, sickness, dizziness and mild allergicreaction(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’scognition and behaviour. These usually resolve within 48 hours, however they maypersist forup to2weeks,witheffectson the child’sperformanceat schoolaswell ascare of the child at home.(58, 59) (Evidence Level 3) There is some evidence thatintravenous anaesthesia produces fewer such effects and also reduces postoperativevomiting.(60,61)(EvidenceLevel2+)

Recommendation12Parentsandcarersshouldbeinformedofthepotentialadverseeffectsofgeneralanaesthesia,includingthetimescaleofthese.Adviceshouldbegivenaboutreturntoschoolandnormalactivities,aswellasthemanagementofbehaviouralchangesathome.(GRADEC)

14.5TRAININGINPAEDIATRICRESUSCITATION

Childrenundergoinggeneralanaesthesiashouldbemanagedbystaffwhohavereceivedappropriate training andwho are competent in paediatric anaesthesia and paediatricresuscitation(51).Regularupdatesinresuscitationtechniques,togetherwithpracticeasateaminthemanagementofsimulatedemergencies,areessentialtomaintainskillsandoptimiseeffectiveteamworkinginagenuinecrisis(13).TrainingshouldfollowguidanceoutlinedbytheResuscitationCouncil(UK)(62).(EvidenceLevel4)

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Specifically, anaesthetists administering general anaesthesia for dental extractions inchildren should be trained according to the most recent guidelines in advanced lifesupportforchildrenandshouldmaintainthenecessaryskills(13,36,51,62‐65).Allmembersof the anaesthesia team should have experience in managing clinical emergencies,includingpaediatriclifesupport. Recoverystaffshouldalsoreceiveregulartraininginpaediatric resuscitation. A member of staff trained and competent in advancedpaediatric life support should be present for all sessions during which generalanaesthesiaisadministeredtochildren(36,51).(EvidenceLevel4)

Recommendation13

Childrenundergoinggeneralanaesthesiafordentalextractionsshouldbemanagedbystaffwhohavereceivedappropriatetraining,andwhoarecompetentinpaediatricanaesthesiaandpaediatricresuscitation.Regularupdatesinresuscitationtechniques,togetherwithpracticeasateaminthemanagementofsimulatedemergencies,areessentialtomaintainskillsandoptimiseeffectiveteamworkinginagenuinecrisis.

(GRADED)

14.6MINIMUMSTANDARDSFORPERIOPERATIVEMONITORING

Nationally accepted guidelines on minimum standards of monitoring for generalanaesthesiahavebeenpublishedbytheAssociationofAnaesthetistsofGreatBritainandIreland (AAGBI) (66). Clinical observationmust be supplemented by core standards ofmonitoring whenever a child is anaesthetised, in order to monitor the patient’sphysiological state anddepth of anaesthesia, aswell as the functioning of anaestheticequipment. Theseminimumstandardsshouldbeuniformirrespectiveoftheduration,location,ormodeofanaesthesia.

Thefollowingmonitoringdevicesmustalwaysbeavailabletoensurethesafeconductofgeneralanaesthesia:

Pulseoximeter Non‐invasivebloodpressuremonitor Electrocardiogram Airwaygasmonitor(oxygen,carbondioxideandvolatileagent) Airwaypressuremonitor (whenever intermittentpositivepressureventilation

isemployed)

A nerve stimulator (if a neuromuscular blocking agent has been administered) andmeansofmeasuringthepatient’stemperaturemustalsobeavailable.Inchildren,itmaynotalwaysbepossibletoattachallmonitoringbeforetheinductionof anaesthesia due to lack of, or potential loss of, cooperation. Monitoring shouldhoweverbecommencedassoonaspossible,andthereasonsforanydelayrecordedinthepatient’scase‐records.Adetailedsummaryoftheanaesthetictechniqueemployed

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shouldbeclearly recorded, togetherwith the informationprovidedby themonitoringdevices.

Monitoring should be maintained postoperatively until the child has fully recoveredfrom general anaesthesia (i.e. has reached the end of Stage 1 Recovery),with clinicalobservations being supplemented by the following monitoring devices, whereappropriate:

Pulseoximeter Non‐invasivebloodpressuremonitor

Thefollowingmustalsobeimmediatelyavailable:

Electrocardiogram NerveStimulator(ifaneuromuscularblockingagenthasbeenadministered) Temperaturemeasuringdevice Capnograph

Recommendation14

Whenevergeneralanaesthesiaisadministeredtoachild,clinicalobservationshouldbesupplementedbyminimumstandardsofmonitoring.Thesestandardsshouldbeuniformirrespectiveoftheduration,locationormodeofanaesthesia.

(GRADED)

14.7INTRAVENOUSACCESS

Recent national surveys have demonstrated that it is widely considered to be goodpractice to establish intravenous access during the course of general anaesthesia fordentalextractionsinchildren(67‐69).Intravenousaccessshouldbeconsideredforeverypatient. Topical local anaesthetic cream (Ametop® / EMLA®/ LMX4®) should beapplied preoperatively to potential sites for venepuncture, where appropriate.(EvidenceLevel4)

Recommendation15

Intravenousaccessshouldbeconsideredforeverypatient.Topicallocalanaestheticcream(Ametop®/EMLA®/LMX4®)shouldbeappliedpreoperativelytopotentialsitesforvenepuncture,whereappropriate.

(GPP)

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14.8MANAGEMENTOFTHEUNCOOPERATIVECHILDWHOREQUIRESGENERALANAESTHESIAFORDENTALEXTRACTIONS

AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct2004(oritsequivalent),therightsofthechild,safeguardingofchildren/childprotectionandtheprocessofobtainingconsent(22,25,26,51,53,54,70‐75).Allmembersofstaffwhocareforchildren should be aware of local policies for the management of uncooperativechildren.(70‐72).(EvidenceLevel4)

Recommendation16

AllclinicalstaffshouldbeawareofrelevantlegislationincludingtheChildrenAct2004(oritsequivalent),therightsofthechild,safeguardingofchildren/childprotectionandtheprocessofobtainingconsent.Allmembersofstaffwhocareforchildrenshouldbeawareoflocalpoliciesconcerningthemanagementofuncooperativechildren.

(GPP)

14.9TRAININGINSAFEGUARDINGOFCHILDREN

The safety of the child is paramount. Specific guidance for anaesthetists has beendeveloped jointly by the Association of Paediatric Anaesthetists of Great Britain andIreland, the Royal College of Paediatrics and Child Health, and the Royal College ofAnaesthetists(74). Detailed guidance for the dental team is also available from theDepartment of Health(76). All clinical staffwho have any contactwith children, youngpeople and / or parents / carers should have aminimumof “Level 2” competence insafeguardingchildren/childprotection,inaccordancewiththecompetencyframeworkoutlined in the Intercollegiate Document on Safeguarding Children and Young People(2010)(75).EvidenceLevel4

Recommendation17

Allclinicalstaffcaringforchildrenshouldhavethe necessary level ofcompetenceinthesafeguardingofchildren/childprotection.*

(MANDATORY)

*Thisshouldbeaminimumof“Level2Competence”,asoutlinedbytheIntercollegiateDocumentonSafeguardingChildrenandYoungPeople(2010).75

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15.PERIOPERATIVEANALGESIA

The available evidence on perioperative analgesia in children has recently beensummarisedbytheAssociationofPaediatricAnaesthetistsofGreatBritainandIreland(77). Children undergoing dental extractions should be subject to the same genericprinciples of painmanagement as children undergoing any other surgical procedure.Theseprinciples include theneed forageappropriatepain scoring, considerationof arange of analgesia techniques, togetherwith information and instructions for parentsaboutpostoperativepainmanagement(77).Thereshouldbeappropriatepost‐operativepain assessment and management policies, usually supported by a painteam(30).(EvidenceLevel4)

Dental extractionsareknown tobeassociatedwithpain that canpersist forup to72hoursandanalgesictreatmentisfrequentlyrequired(78,79).(EvidenceLevel2+)Youngerchildrenand thosehavingmultipleextractionsaremore likely toexperiencepainanddistress(80).(EvidenceLevel3)

Children undergoing dental extractions should receive adequate analgesia based onwidely accepted principles of pre‐emptive, multi‐modal analgesia and a modernunderstanding of analgesic pharmacology. Analgesic therapy should preferably startbeforesurgeryandbecontinuedforaslongasrequiredpostoperatively (77).(EvidenceLevel4)

Non‐steroidal anti‐inflammatory drugs (NSAIDs) provide satisfactory analgesia fordental extractions. Diclofenac or ibuprofen, either alone or in combination withparacetamol, each provides more effective analgesia than paracetamol alone (80, 81).(EvidenceLevel2++)

Opioidanalgesicsarenotusuallyrequiredtoprovideanalgesiaforuncomplicateddentalextractions. They demonstrate no analgesia benefit over NSAIDs and may prolongrecoveryandincreasesedation(82‐84).(EvidenceLevel2++)However,opioidanalgesicsmay be considered formultiple or difficult extractions. Theymay also be required asrescueanalgesiawhenNSAIDsandparacetamolarecontraindicatedorhaveprovedtobeinsufficient.

Recommendation18

Unlesscontraindicated,non‐steroidalanti‐inflammatorydrugs(NSAIDs)and/orparacetamolshouldbeusedtoprovideanalgesiafordentalextractionsundergeneralanaesthesia.Thesedrugsmaybecombinedorgivenseparatelybefore,duringoraftersurgery.Opioidsarenotroutinelyrequiredforuncomplicateddentalextractions.

(GRADEB)

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Evidence suggests that, in children, when dental extractions are performed undergeneralanaesthesia in thepresenceofsystemicanalgesia, theuseof localanaesthesiaforadditionalanalgesiaisofminimalbenefit. (85‐90).Traumatothelip,cheekortonguemay occur following the use of local anaesthesia, particularly in small children. Thesensationofnumbnessmayalso causedistress inyounger children.Nevertheless, thecombination of a local anaesthetic agent with a vasoconstrictor agentmay be useful,primarily to reduce bleeding,with possibly some benefit in terms of analgesia in theolderchildwhoisabletounderstandthesensationofnumbness.(EvidenceLevel2++)

Recommendation19

Infiltrationofalocalanaestheticagentcombinedwithavasoconstrictoragentmayhavearoleinachievinghaemostasis,withpossiblysomebenefitintermsofanalgesiaintheolderchildwhoisabletounderstandthesensationofnumbness.

(GRADEB)

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15.1ANALGESICREGIMENSFORDENTALEXTRACTIONSINCHILDREN

Analgesic drugs may be administered preoperatively, intraoperatively orpostoperatively,via theoral, intravenousorrectalrouteasappropriate.The followingdosage guidelines (Table 1, and accompanying notes) are based on recommendationsfrom the British National Formulary for Children (BNFC) and the publication by theAssociation of Paediatric Anaesthetists of Great Britain and Ireland entitled ‘GoodPracticeinPostoperativeandProceduralPain’(2008).(77,91)(EvidenceLevel4)

Table1.SuggestedAnalgesiaRegimensforDentalExtractionsinChildren

PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE

OPTION1 OralParacetamol20mg/kg,1hrpre‐operatively

‐‐‐‐‐‐‐‐ OralIbuprofen5–10mg/kg,PRN

OPTION2

OralParacetamol20mg/kg,1hrpre‐operatively

Diclofenac 1mg/kgperrectum(PR)afterinduction*

‐‐‐‐‐‐‐‐‐

OPTION3

OralParacetamol20mg/kgandoralIbuprofen5‐10mg/kg,1hrpre‐operatively

‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐

OPTION4 Oral Ibuprofen5‐10mg/kg,1hrpre‐operatively

‐‐‐‐‐‐‐‐ OralParacetamol20mg/kg,PRN

OPTION5 Oral Ibuprofen5‐10mg/kg,1hrpre‐operatively

IV Paracetamol15mg/kg**

‐‐‐‐‐‐‐‐‐

OPTION6 IV Paracetamol15mg/kg**

OralIbuprofen5‐10mg/kg,PRN

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NOTES(toaccompanyTable1):

1. Unlesscontraindicated,allchildrenshouldreceiveapreparationofParacetamoland/orNSAIDperioperatively.

If Paracetamol or NSAIDs have not been administered either preoperatively orintraoperatively, either oral Paracetamol20mg/kgor oral Ibuprofen5 –10mg/kgmaybeadministeredintherecoveryperiod

2. Rectalpreparations*

Diclofenac 1 mg/kg per rectum (PR) may be administered after induction ofanaesthesia and following documented consent (if preoperative NSAIDs have notbeen administered). There is evidence that rectal diclofenac is more rapidlyabsorbed than oral NSAIDs, giving higher plasma levels (92). (NB. RectalParacetamol is not recommended due to high dosage requirements (up to45mg/kg),slowabsorptionandvariableplasmaconcentrations(93,94)).

3. Intravenouspreparations**

IVParacetamol15mg/kgmaybeadministeredasanalternativetotheoralroutefor childrenover1 yearold. This shouldbe infusedover aperiodof15minutes,whichmaylimititsuseforsomeverybriefdentalextractions.

IVDiclofenacmay be considered as an alternative but is not licensed for use inchildren(95).

4. Opioids

Opioidsarenotroutinelyrequiredforuncomplicateddentalextractions,butmaybeadministered intraoperatively for children undergoing multiple or difficultextractions(e.g.Fentanyl0.5–1.0mcg/kgIVorTramadol1–2mg/kgIV)(84,96).Ifanopioidisusedthenanantiemeticagentshouldbeconsidered(pleaserefertotheAPAGBI guidelines for evidence‐based advice on prevention and treatment ofpostoperativenauseaandvomiting).(97)FollowingtheadministrationofParacetamolandanNSAIDeitherpreoperativelyorintraoperatively, 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. LocalanaesthesiaLocal anaesthetic agents may be administered by the dental surgeon. However,thereislimitedevidenceforanybenefitintermsofanalgesiainchildrenundergoinggeneral anaesthesia in the presence of systemic analgesia. Younger children maybecomedistressedbythesensationofnumbness.Thereisalsotheriskoftraumatothetongue,lipsandcheeks.

Return to ToC

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16.RECOVERYANDDISCHARGEHOME

Recoveryfromgeneralanaesthesiacanbedividedintothreestages(98).(EvidenceLevel4)

FirstStageRecovery

Thisstagelastsuntilthepatientisawake,protectivereflexeshavereturnedandpainiscontrolled.

SecondStageRecovery

Thisstagebeginsattheendofstageoneandendswhenthepatientisreadyfordischargefromhospital.

LateRecovery

This phase is very variable and ends when the patient has made a fullphysiologicalandpsychologicalrecoveryfromthesurgicalprocedure.

The anaesthetic technique employed should be designed to maximise the speed andquality of recovery in the first and second stages, and so facilitate discharge fromhospital(98).

16.1EQUIPMENTANDSTAFFINGLEVELSINTHERECOVERYAREA

Recoveryfromgeneralanaesthesiafordentalextractionsinchildrenrequiresthesamestandardsofmonitoringandstaffingasrecoveryfromanyotherprocedureperformedundergeneralanaesthesia(55,66).

Thereshouldbeaseparaterecoveryareaforchildren,allowingparents/carerstobepresent as soon as their child has emerged from general anaesthesia. This should bewithinanage‐appropriatechild‐friendlyenvironment(51,55).(EvidenceLevel4)

The recovery area should have appropriate equipment for management of thepaediatric airway. Resuscitation equipment should also be immediately available.Childrenshouldbemanagedonaone‐to‐onebasis,bydesignatedtrainedmembersoftherecoverystaff,whoreceiveregulartraininginpaediatricresuscitation.Aregisteredchildren’s nurse must be available to provide care for paediatric patients and tosuperviseothernursingstaffwhomaybeinvolvedinthecareofchildren.Amemberofstaff who is trained and competent in advanced paediatric life support should beavailable until the child is discharged from the department(51). No fewer than twomembers of staff should be present when a child who does not fulfil the criteria fordischargeremainswithintherecoveryarea(55).(EvidenceLevel4)

Standards of monitoring during recovery from dental extractions under generalanaesthesia should be the same as those for any other procedure performed under

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general anaesthesia. Clinical observations should be supplemented by use of a pulseoximeter and non‐invasive blood pressure monitor, where appropriate. Anelectrocardiogram and capnograph should also be available, together with a nervestimulatorandadevicetomeasurethepatient’stemperature(66).(EvidenceLevel4)

Recommendation20

The standards for recovery and discharge following general anaesthesia fordental extractions in children should be the same as those following generalanaesthesiaforanyotherprocedure.

(GPP)

Recommendation21

Childrenshouldbemanagedinadedicatedandappropriatelyequippedchildren’srecoveryarea,onaone‐to‐onebasis,bydesignatedmembersofstaffwhoreceiveregulartraininginpaediatricresuscitation.Aregisteredchildren’snursemustbeavailable toprovidecare forpaediatricpatientsand to superviseothernursingstaffwhomaybeinvolvedinthecareofchildren.Amemberofstaffwhoistrainedandcompetent inadvancedpaediatric lifesupportshouldbeavailableuntil thechildisdischargedfromthedepartment.

(GRADED)

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16.2DISCHARGECRITERIA

Dischargefromtherecoveryroom(andultimately,dischargehome)istheresponsibilityoftheattendingclinicians,howevertheadoptionofstrictdischargecriteriaallowsthisdecisiontobedelegatedtotherecoverystaff(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 DischargeScoringSystem(101).The discharge process should create an environment in which parents / carersunderstand their roles and responsibilities for continuing care and therefore feelconfidenttotaketheirchildhome.Whoevertakesresponsibilityforassessingthesuitabilityofachildfordischargeshouldensurethatthefollowingcriteriaarefulfilled:

16.2.1CRITERIAFORDISCHARGE

Consciouslevelshouldbeconsistentwiththechild’spreoperativestate Cardiovascularandrespiratoryparametersshouldbestable Pain,nausea,vomitingandsurgicalbleedingshouldbeminimal Mobilityshouldbeatapreoperativelevel A responsible adultmust be present to accompany the child home (this adult

mustbeabletogivethechildhis/herundividedattentionduringthejourneyhome)

SuitabletransporthomeshouldhavebeenarrangedInadditiontothesecriteriafordischarge,thefollowingshouldalsobeensured:

Contact telephone numbers should be provided for both emergency andcontinuingcare

Verbal andwritten instructions about the child’s recovery at home should begiventotheparent/carer,withconfirmationofthelevelofunderstanding

Follow‐uparrangementsshouldbemadewhereappropriate Support and guidance on the administration ofmedication at home should be

providedasnecessary A letter to the General Dental Practitioner should be posted or given to the

parent/carer,dependingonthepolicyoftheunit Suitablehome environment,with regard to supervision of the child aswell as

accesstofurtherhealthcareservices,ifrequired(102).Althoughdischargehome isnot time‐dependent, adequate timeshouldbeallowed forthesecondstageofrecovery.Appropriate instructionsshouldbegiventotheparent/carerandsuitabletransporthomeshouldbearranged(103,104).Aresponsibleadultmustaccompany the child home and be available for subsequent care at home. Facilities

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shouldbeavailableforthechildwhorequiresprolongedrecoveryformedical,nursingor social reasons. These facilities should allow the parent / carer to accompany theirchild,whereappropriate.

Recommendation22

Facilitiesshouldallowparents/carerstobepresentassoonastheirchildemergesfromgeneralanaesthesia.Adequatetimeshouldbeallowedforthesecondstageofrecoveryandappropriatefacilitiesshouldbeprovidedforthechildwhorequiresprolongedrecoveryformedical,nursing,orsocialreasons.

(GPP)

Recommendation23

Dischargeortransferofthepatientshouldbebasedonspecifiedcriteria,irrespectiveofthetimetakentoachievethese.

(GPP)

Recommendation24

Suitabletransporthomeshouldbearranged.Thechildmustbeaccompaniedbyaresponsibleadult.

(GPP)

Recommendation25

Writtenandverbaladviceaboutpostoperativecareshouldbeprovidedfortheparent/carer.Aresponsibleadultmustbeavailableforcareofthechildathome.Clearinformationshouldalsobeprovidedonappropriatelinesofcommunicationintheeventofanysubsequentqueriesorpostoperativeproblems.

(GPP)

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16.2.2CAREAFTERDISCHARGE

Postoperativeinstructions(14,35)shouldcover:

Analgesia

Postoperativenauseaandvomiting

Residualeffectsofgeneralanaesthesia

Bleeding

Mouth‐care

Detailsofanysuturesin‐situ

Eating

Returntoschoolornormalactivities

Linesofcommunicationintheeventofpostoperativeproblems

Preventionofcaries(35)

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18.APPENDICES (SEEWEBSITEFILEFORAPPENDICES)

Documents

Guidelines For The Management Of Children Referred For ...dentalanaesthesia.org.uk/wp-content/uploads/2016/08/full_guideline… · the British Society of Paediatric Dentistry; the