paeds dental

(May-2008 Q11) You are the anaesthetist at a childrens' hospital. A 3yo schedules for dental restoration and extractions is found to have a systolic murmur during your preoperative assessment on the day of surgery. They have been on a waiting list for 6 months and have had a dental abscess that settled with antibiotics. Describe how you would evaluate the significance of this murmur and how this decision would affect your decision to proceed or not with surgery.

Evaluate

I would evaluate the significance of the murmur with history, physical examination and investigations.

I will speak to the parents regarding the child's antenatal and developmental history, specifically asking for any diagnosis of pre-existing syndromes or abnormalities that could include congenital heart disease.

I will ask about any recent change in health especially failure to thrive, developmental delay, symptoms of heart failure such as decreased effort tolerance, dyspnea , wheezing, cyanosis. Recent fever that could accompany SBE, medication history and course of abx for dental abscess

medical records of previous examination/admissions

Examination: Thorough cardiovascular examination, development/ general inspection

clubbing/ cyanosis,

nature of the murmur: if it is fixed, not related to movement/respiration-unlikely to be a flow murmur

pulse oximetry

investigations: if my history/examination is suggestive of IE, given that the child had a dental abscess and may have infective endocarditis/valve disease secondary to IE, refer to a paediatric cardiologist, to 12 lead ECG, CXR, 2DEcho

FBC: anaemia, TW, CRP

Decision

-multidisciplinary: consult cardiologist, dentist (children's hospital, proximity of paeds cardiologist available)

-discuss with parents

-if child is well thrived, not symptomatic, -unlikely IE minor surgery-proceed

-relative urgency of surgery: postponed 6 months, ago, may be a constant focus of infection and source of bacterial seeding, already had complications (abscess requiring abx), stress of cancellation on staff and family,

-give antibiotic prophylaxis of IV ampicillin 50mg/kg before procedure (if pathological murmur; not indicated for innocent murmur)

-admit post op for observation and investigations

if suspected IE: sympathetic discussion with family, consult cardiologist, alter list to allow time for investigations

exam report:

Hx, examination, integration of info to form decision

3 year old: commonest age for innocent murmur

-acknowledge; high risk of bacterial seeding with procedure

-reference to 2decho, IE prophylaxis (NICE and AHA guidelines)

LMA in dental surgery

(Sep-2004 Q10) Justify the use of a laryngeal mask airway in a 25 yo, 80kg man having general anaesthesia for removal of 4 molar teeth.


Anaesthetic indications:
Use of a LMA in this case is less invasive than endotracheal intubation. As this surgery is most likely in the setting of ambulatory surgery, this reduces the need of muscle relaxation, reduces morbidity from sorethroat, especially if the patient is obese and is potentially difficult to intubate. The option of a flexible LMA also allows the tube to be manipulated away from the side of surgery.

Provided that the adequacy of spontaneous ventilation can be achieved to maintain adequate depth of anaesthesia.

The surgeon also has to be agreeable to the use of a supragottic device and is vigilant about suctioning of wash and secretions.

supraglottic devices, if used with adequate depth of anaesthesia, causes a lower risk of laryngospasm.

increased turnover time
easier to insert,

contraindications to LMA: patient with reflux.
disadvantages: less secure airway-may dislodge or kink, shared airway and limited access, secretions, leak with higher airway pressures (esp if obese)