What are the anaesthetic considerations for pediatric patients undergoing dental surgery, including preoperative, intraoperative, and postoperative care?

Anaesthetic Considerations for Pediatric Dental Surgery

Preoperative Assessment and Preparation

Preoperative assessment for pediatric dental patients should focus on psychological preparation, fasting optimization, and identification of specific risk factors rather than routine medical screening in healthy children. 1

Key Preoperative Elements

• Psychological preparation is critical to minimize anxiety and prevent day-of-surgery refusal; utilize play specialists and age-appropriate information resources to prepare both child and parents 1

• Implement shortened fasting protocols: adopt a 1-hour rule for clear fluids and encourage children to drink until shortly before surgery to reduce prolonged fasting complications 1

• Identify high-risk populations requiring special consideration:

  • Children with Down syndrome (risk of severe bradycardia during induction with sevoflurane) 2
  • Patients with neuromuscular disease (risk of perioperative hyperkalemia with volatile agents) 2
  • Children with obstructive sleep apnea 1
  • Patients with autism spectrum disorders (avoid preoperative sedation when possible to prevent behavioral escalation) 3

• For females aged 12 and older, ascertain pregnancy status on day of surgery with appropriate documentation 1

• Establish parental responsibility and obtain informed consent for both the procedure and anesthesia, discussing common complications and side-effects appropriate to the child's age 1

• Assess home environment: ensure parents have access to transport, telephone, can understand instructions, and recognize complications requiring hospital return 1

Intraoperative Management

Airway Management Options

Sevoflurane inhalation anesthesia with laryngeal mask airway (LMA) provides faster recovery and fewer complications than nasal endotracheal intubation for routine pediatric dental surgery. 4

• LMA insertion is significantly faster than nasal intubation and associated with shorter recovery time, less sore throat, and reduced postoperative nausea and vomiting 4

• For nasal endotracheal intubation when required: use rocuronium and remifentanil during 8% sevoflurane induction 4

• Nitrous oxide/oxygen (50:50) can be used for minimal sedation in ASA class I or II patients who maintain verbal communication; if combined with other sedatives or used >50%, implement moderate/deep sedation guidelines 1

Induction Considerations

• In Down syndrome patients: incrementally increase inspired sevoflurane concentration, closely monitor heart rate, and have anticholinergic and epinephrine immediately available due to risk of severe bradycardia and cardiac arrest 2

• Avoid rapid intravenous injection in neonates (less than 2 minutes with midazolam), particularly when combined with fentanyl, due to severe hypotension risk 5

• Discuss induction options with parents (gaseous vs. intravenous) during preoperative visit, explaining what to expect in the anaesthetic room 1

Analgesia Strategy

Implement multimodal analgesia with local anesthetic infiltration, NSAIDs, and paracetamol as the foundation, reserving opioids for breakthrough pain only. 1

Basic Level Intraoperative Analgesia:

• Local wound infiltration with long-acting local anesthetic by the surgeon 1
• Intravenous or rectal NSAID and/or paracetamol 1
• Intravenous fentanyl in divided doses for breakthrough pain 1

Advanced Level Intraoperative Analgesia:

• Intravenous NSAID (ketorolac 0.5-1 mg/kg) or paracetamol 3
• Intravenous metamizole where available 1, 3
• Regional anesthesia techniques with ultrasound guidance when appropriate:
  • Inferior alveolar nerve blocks for mandibular procedures 6
  • Maxillary nerve blocks for upper dental procedures 6
  • Consider adjuvants (clonidine) with long-acting local anesthetics 1

Adjunctive Medications

• Dexamethasone or methylprednisolone to reduce postoperative swelling 1
• Intraoperative alpha-2 agonists (clonidine) as co-analgesic 1
• Intraoperative ketamine as co-analgesic drug 1

Critical Intraoperative Pitfalls

• Avoid prolonged anesthesia exposure (>3 hours) in children under 3 years when possible, as anesthetic agents blocking NMDA receptors and/or potentiating GABA activity may cause neuronal apoptosis and long-term cognitive deficits 2, 5

• Monitor for emergence delirium, particularly in young children after short procedures; modify anesthetic techniques to minimize risk 1

• Implement PONV prophylaxis for high-risk procedures, considering necessity and dosing of opioids and choosing appropriate anti-emetics effective in children 1

Postoperative Management

Immediate Recovery (PACU)

Intravenous fentanyl or other suitable opioid should be available to treat breakthrough pain in the PACU. 1

• Monitor for common complications: pain (14.0-95.0% of cases), nausea/vomiting, and sore throat within first 24 hours 7

• Ensure adequate pain control before discharge, as complaints occur in 43.0-98.9% of cases within first 24 hours 7

Ward/Home Management

Parents must receive clear verbal and written instructions on pain assessment and management, with emphasis on appropriate weight-based dosing regimens. 1

Multimodal Oral Analgesia Regimen:

• Oral or rectal NSAID during entire postoperative period 1
• Oral or rectal paracetamol during entire postoperative period 1
• Combination of NSAID and paracetamol reduces opioid requirements and is essential when IV rescue is unavailable 1

Rescue Analgesia:

• Oral tramadol or other suitable agent as rescue 1
• Intravenous metamizole (where available) as first-line rescue analgesic 1, 3
• Avoid codeine per FDA guidelines due to respiratory risks in children 3

Discharge Criteria and Instructions

• Ensure safe ambulation before discharge, particularly in pediatric patients 5

• Advise no hazardous activities (operating machinery, driving for adolescents) until effects of sedation have subsided or one full day after anesthesia, whichever is longer 5

• Provide telephone support access for parents to manage concerns about pain, bleeding (particularly post-extraction), or other complications 1

• Emphasize importance of adequate analgesia for procedures causing significant pain (extractions, surgical procedures) which may persist up to 2 weeks postoperatively 1

Special Postoperative Considerations

• For neonates exposed to midazolam: monitor for sedation (respiratory depression, lethargy, hypotonia) and withdrawal symptoms (hyperreflexia, irritability, tremors, feeding difficulties) 5

• Extended monitoring with pulse oximetry if opioids are required, particularly in younger children and those with risk factors 1, 3

• Major complications are rare in pediatric dental procedures under general anesthesia, but minor complications are virtually universal 7