In recent years, there has been an increasing demand for pediatric dental treatment under general anesthesia and sedation. General anesthesia and sedation techniques have been a boon to some pediatric or adolescent patients who need dental treatment but are particularly uncooperative, fearful, anxious or unable to communicate, as well as to patients who need to perform complex or prolonged oral operations. The use of this technique makes it easy for the dentist to operate, but requires the cooperation of both the dentist and the anesthesiologist. In addition, the technology has clear regulations and strict clinical implementation procedures for personnel qualification requirements, equipment requirements, qualification requirements for conducting units, and clinical work requirements.
This standard specifies the management of dental treatment techniques for children under general anesthesia and sedation.
This standard applies to the dental treatment of patients under general anesthesia or sedation in all levels and types of medical institutions and related professional medical personnel (mainly dentists) nationwide.
Terminology and definitions
The following terms and definitions are applicable to this document.
1.General anesthesia (general anesthesia)
Refers to a state in which anesthetic drugs are inhaled through the respiratory tract, injected intravenously or intramuscularly into the patient’s body to produce temporary reversible depression of the central nervous system, clinically manifested by loss of consciousness, loss of generalized pain sensation, amnesia, inhibition of reflexes and skeletal muscle relaxation.
2.deep sedation
The patient’s consciousness is deeply suppressed under the action of the drug and is not easily awakened, but responds to continuous or heavy pain stimulation. The patient’s ability to breathe on his own is significantly reduced, and may require manual maintenance of airway patency, if necessary, the establishment of an artificial airway, circulatory function can usually be maintained within the normal range.
3.Moderate sedation (conscious sedation)
The patient’s consciousness is diminished under drug induction, and he/she responds to commanded speech and/or to light touch. Usually, it can maintain voluntary respiratory function and circulatory function within the normal range.
4. minimal sedation
The patient’s consciousness is mildly diminished and he/she responds correctly to physical stimuli or verbal commands. Although the patient’s cognitive ability and coordination are somewhat diminished, respiratory and circulatory functions are not significantly affected.
5.Titration method ( titration)
A technique to achieve a predetermined depth of sedation through fine regulation of the amount of sedative drug entering the patient’s body.
6.Daytime outpatient (daily clinic patient)
Patients who are not hospitalized and are treated in the outpatient clinic and are under 18 years of age.
Personnel qualification requirements
1.Sedation is generally performed by anesthesiologists and/or nurse anesthetists, and general anesthesia and deep sedation must be performed by anesthesiologists. Non-anesthesia physicians performing sedation must have certain qualifications and undergo relevant training.
2, to carry out mild and moderate sedation of children’s dental treatment techniques of dentistry, should have the professional and technical title of attending physician and above, or engaged in the practice of this specialty for more than five years; or dentistry physician to carry out this technique with the assistance of anesthesiologists.
3, qualified stomatologists need to be identified within the training institution, to receive training in sedation expertise and clinical operations training, and after passing the examination before carrying out light and moderate sedation techniques independently. Specific training content includes at least: theoretical knowledge of sedation, knowledge of emergency resuscitation, advanced life support, airway management, clinical monitoring and operational capabilities. The competence of the trained personnel should be assessed at the end of the training.
Equipment requirements
1, to carry out light and moderate sedation need to have at least the following equipment, these devices must have the appropriate accessories for children
(1) Monitor: should have the ability to perform ECG, heart rate/pulse rate, non-invasive blood pressure, pulse rate, and oxygen saturation monitoring.
(2) Negative pressure suction device and suction equipment equipment.
(3) Oxygen and positive-pressure oxygen supply device: independent oxygen supply source, and can be connected to oxygen supply device and simple artificial respirator.
(4) simple artificial respirator.
(5) At least the following emergency drugs should be available: central nervous system stimulants, anti-shock vasoactive drugs, cardiac drugs, anti-arrhythmics, hypotensive drugs, vasodilators, diuretics, dehydration drugs, bronchodilators, M choline receptor blockers, hormones, hydrophobic acid-base balance drugs, anti-allergy drugs, intravenous fluids, etc.
(6) Apparatus and disposable supplies for establishing intravenous access.
(7) Emergency lighting facilities.
(8) Direct laryngoscope, tracheal intubation related instruments.
(9) Defibrillator.
(10) Adequate space for emergency treatment.
2, when carrying out deep sedation and general anesthesia, in addition to the above-mentioned equipment, the following equipment is also required.
(1) Pediatric anesthesia machine.
(2) Intravenous infusion devices (liquid infusion pumps), including target-controlled input devices.
(3) Drugs: general anesthesia drugs and cardiopulmonary resuscitation routine drugs.
3.Housing hardware facilities
(1) carry out general anesthesia and deep sedation of each treatment space must not be less than 20 square meters.
(2) carry out general anesthesia and deep sedation need to have an independent anesthesia recovery room, and equipped with emergency drugs and equipment.
Qualification requirements for carrying out units
1, light sedation and moderate sedation can be carried out in dental hospitals, general hospital dentistry, dental clinics.
2, deep sedation and general anesthesia should be carried out in the dental specialty hospital with anesthesia diagnosis and treatment subjects or in the dental department of the general hospital with anesthesia department at the second level or above.
Clinical work requirements
Indications
1, the indications for light sedation and moderate sedation
(1)Patients who need and are willing to receive dental treatment but cannot cooperate due to fear of dental treatment.
(2)Patients who can communicate effectively with the doctor.
(3) Patients who require dental treatment and sedation techniques to protect the patient’s developing physical and psychological health.
(4) Day clinic patients must be ASA class I or II patients.
2. Indications for deep sedation and general anesthesia
(1) Dental patients who need dental treatment but are disabled due to lack of mental or emotional maturity, and/or cerebral palsy, mental retardation, etc.
(2) Child or adolescent patients who require dental treatment but are particularly uncooperative, fearful, anxious or unable to communicate.
(3) Patients who require complex or prolonged oral operations.
(4) The use of general anesthesia and deep sedation is beneficial in reducing medical risks and/or protecting the patient’s mental and psychological well-being.
(5) Day clinic patients must be ASA class I or II patients.
Contraindications
(1) No need for oral treatment or minimal need.
(2) No indication for treatment with pharmacological sedation.
(3) Patients with ASA class III or higher.
(4) The patient’s general condition is not suitable for pharmacological sedation or general anesthesia.
Medical assessment before treatment
1. Medical history taking
A detailed medical history must be taken before using pharmacologic sedation or general anesthesia techniques (a formatted questionnaire is recommended, see Appendix B), including at least.
(1) Any abnormalities in the major organs and systems of the body.
(2) Any previous adverse experiences with anesthesia or analgesia.
(3) History of food allergies, drug allergies, and current medication use.
(4) Time and type of last drug intake.
(5) History of smoking, alcohol consumption, and other hobbies.
(6) Any recent history of respiratory tract infections.
2.Pre-treatment examination
(1) Mild sedation and moderate sedation: check and record blood pressure, pulse, respiratory rate, oxygen saturation and body weight. Assess the patency of the upper airway, and take all kinds of corresponding auxiliary examination means if necessary.
(2) Deep sedation and general anesthesia: In addition to the items in (1), the following tests should be included (1) Blood tests: routine blood tests, coagulation, liver and kidney functions, infectious diseases (hepatitis, syphilis, AIDS, etc.). ②Urinary routine examination. ③ Necessary medical imaging examinations, such as chest X-ray. ④Other examinations as required by the patient’s general condition.
3.Patient health status assessment
In the detailed classification of patients’ general health status by the American Society of Anesthesiologists (ASA) (Appendix A), only patients classified as Class I and II are suitable for the use of pharmacological sedation or general anesthesia techniques during dental outpatient treatment. The applicability of these techniques to patients with systemic diseases (including those undergoing psychological or psychiatric treatment and those with substance abuse problems) needs to be decided after evaluation with the specialist conducting the relevant treatment, and the patient should be admitted to the hospital for the relevant treatment if necessary.
4. Sign the informed consent form
It is the responsibility of the physician to inform the patient and/or guardian of the indications, contraindications and potential risks of using pharmacological sedation or general anesthesia techniques, and ultimately the patient’s legal guardian should decide together with the physician whether to use the technique and sign an informed consent form.
Preparation before treatment
1. Fasting and drinking
In order to avoid intraoperative vomiting and aspiration, elective patients should fast from easily digestible solid food or non-human milk for at least 6h; and from fried food, fat-rich or meat food for at least 8h; if the intake of the above food is too much, the gastric emptying time can be prolonged and the fasting time should be extended appropriately. Newborns, infants and young children should be fasted from breast milk for at least 4h, and easily digestible solid foods, non-human milk or infant formula for at least 6h. Patients of all ages should be allowed to drink water, including drinking water, fruit juice (without pulp), soda drinks, clear tea, and pure coffee, but not alcoholic beverages, 2h before surgery.
2. Composition of the treatment team
(1) Light sedation and moderate sedation: The treatment team should have at least two medical personnel, one of whom is a dentist with the necessary qualifications to carry out the relevant work, and the other is an assistant, who must have the ability to independently observe the data of the monitoring equipment. In the treatment of female patients, at least one of the two medical personnel is a woman.
(2) Deep sedation and general anesthesia: When carrying out general anesthesia, the treatment team should have at least three medical personnel, one of whom is an oral surgeon with the necessary qualifications to carry out the relevant work, one is an anesthesiologist, and one is an assistant. The assistant must have the ability to independently observe the data of monitoring equipment, and the stomatologist and the assistant must master the latest CPR skills.
The treatment team should have at least three health care providers for deep sedation, including a dentist qualified to perform the work, an anesthesiologist who performs or directs the deep sedation, and an assistant. The assistant must have the ability to independently observe the data of the monitoring equipment, and the stomatologist and the assistant must have the latest CPR skills.
Commonly used sedative drugs and the mode of administration
1.Commonly used intravenous sedation and general anesthesia drugs. Intravenous sedation and intravenous general anesthesia should be completed by anesthesiologists. Commonly used intravenous sedation drugs are: Midazolam (Midazolam), Diazepam (Diazepam), Dexmedetomidine (Dexmedetomidine), Droperidol (Droperidol) and so on. Commonly used intravenous general anesthetic drugs are: propofol (isoproterenol, Propofol), ketamine (ketamine), etomidate (etomidate), etc.
2, laughing gas – oxygen inhalation sedation and oral benzodiazepines (such as midazolam) of sedation, with mild to moderate sedation, its safety is high, can be operated by trained dentists independently under the premise of strict compliance with the relevant operating guidelines.
Monitoring during treatment
When patients use sedation and general anesthesia in dental treatment, their state of consciousness from wakefulness to loss of consciousness or entering the state of general anesthesia is a continuous change process, and there is no clear demarcation mark between the various stages yet, and their depths are difficult to distinguish precisely and often fluctuate between different stages.
1.Mild sedation and moderate sedation
Monitoring of the patient’s vital signs is very necessary. The basic content of monitoring: the patient’s state of consciousness, respiration, heart rate, blood oxygen saturation and blood pressure.
2.Deep sedation and general anesthesia
Monitoring of the patient’s vital signs is necessary. The content of monitoring includes at least: the patient’s state of consciousness, respiratory rate, ventilation status, ECG, oxygen saturation, heart rate and blood pressure.
Dental treatment
The dental treatment plan is developed and performed by the dentist. The treatment plan should be developed in such a way that the number of sedation treatments is minimized while ensuring the quality of treatment. It is important to follow the norms related to dental treatment during the operation to provide the patient with high quality dental treatment.
Recovery period after treatment
1.The recovery period after dental treatment under sedation or general anesthesia refers to the period from the discontinuation of sedation or anesthesia to the time when the patient’s vital signs are stable or awake, with the possibility of sudden life-threatening complications that require close monitoring and timely treatment.
2. Mild sedation and moderate sedation, the medication is stopped after completing the scheduled dental treatment. The dentist carefully inspects the patient’s oral condition, including whether there is bleeding in the soft tissue, whether there is residue in the oral cavity, and whether the dental treatment has achieved the scheduled effect. Patients are instructed to observe in the designated area accompanied by their family members and are allowed to leave the hospital only after the departure criteria are met. The evacuation criteria for outpatient sedated patients can be assessed according to the Modified Postanesthetic Discharge Scoring (mPADS) (Appendix C), and those with a score of ≥9 can be discharged accompanied by an adult.
3. Deep sedation and general anesthesia are applied, and the medication is discontinued upon completion of the scheduled dental treatment. The dentist carefully inspects the patient’s oral cavity, including whether there is bleeding in the soft tissues, whether there are residues in the oral cavity, and whether the dental treatment has achieved the intended effect. After the surgery, the patient is sent to the anesthesia recovery room for continued observation of the condition to prevent post-anesthesia complications and to ensure patient safety. The patient can be discharged only after reaching the discharge criteria. The criteria for discharge can be based on the overall assessment of the degree of awakening after deep sedation or general anesthesia based on the post-anesthesia recovery score (modified Alderete score, Appendix D), and patients with a score ≥ 9 can leave the hospital accompanied by an adult.
Postoperative medical advice
1. Dental treatment component
The post-operative medical advice is tailored to the specific content of the dental treatment received by the patient. The post-operative response to dental treatment under sedation or general anesthesia is the same as the post-operative response to the same treatment under conventional conditions.
2.Sedation and general anesthesia part
The postoperative medical advice for the sedation and general anesthesia part includes.
(1) Patients should go out less on the day of the end of light sedation or moderate sedation treatment, avoid heavy sports activities, and pay attention to protection during indoor activities.
(2) For patients under deep sedation and general anesthesia, in addition to the above precautions, it is best to avoid outdoor activities on the day of treatment, and someone should accompany the patient throughout the day, and the diet should be gradually transitioned from liquid to regular food.
(3) What emergency measures should be taken in case of discomfort.
Medical records
1.Implement the National Health and Family Planning Commission’s medical record writing standard. The medical record must have accurate and complete records of the whole treatment process, including the patient’s general health, medication history, selection of indications, informed consent, the whole treatment process (including the mode of sedation, dose and duration of drug administration), and postoperative recommendations.
2.For patients under general anesthesia and deep sedation, implement the requirements of anesthesia record sheet writing.
3.Record of dental treatment is carried out with reference to the relevant treatment routines of the dental profession.
Postoperative follow-up
1.Follow-up of sedation and general anesthesia
Although there are no reports that the sedation or general anesthesia drugs used clinically will lead to long-term physiological and psychological changes or adverse reactions in patients, doctors should consciously ask patients whether they have developed any physiological and psychological changes that may be related to sedation and general anesthesia drugs during the review of patients, especially for those patients who have received these treatments several times.
2.Oral follow-up
The review interval and targeted oral hygiene instruction should be decided according to the actual situation of the patient in order to maximize the improvement of oral health and maintain the treatment effect.