A device with everything necessary for carrying out anesthesia in children.
There is such a wonderful phobia in people who faced Soviet punitive dentistry in childhood - stomatophobia. Then it was believed that local anesthesia was invented for the faint of heart, and it is normal to endure the smell of burnt dentin and terrible pain for an hour. Despite the fact that now no sane dentist will heal without anesthesia, sad people still walk among us, traumatized by these memories. Sometimes such patients overpower themselves and come to an appointment with a panoramic dental X-ray. More precisely, with a dozen dilapidated roots and many infected purulent foci in the bone structure of the jaw.
If people have already got used to the idea that children should be treated under local anesthesia, then general anesthesia is still scary. Many people still remember the difficult recovery from anesthesia with nausea and "helicopters" during the use of heavy old drugs. And until now, people have a feeling that any general anesthesia is something extremely dangerous and even more unacceptable for use in children, except for emergency indications. In fact, everything has changed a lot.
In short, let's talk about anesthesia in children. And also - about modern options with nitrous oxide, propofol and sevoflurane. They are very good, but remember that independent experiments with them may end up meeting with Kurt Cobain.
Depth of anesthesia
Let's generally figure out what anesthesia is. Our brain is a complex set of neurons that constantly exchange impulses with each other. Some substances can inhibit synaptic transmission between separate groups of neurons. Moreover, different substances have different mechanisms of action and their own characteristics. In fact, anesthesia is also one of the types of anesthesia. Only in contrast to the local shutdown of local pain neurons during local anesthesia, we partially “turn off the brain”.
As a result, general anesthesia is not like a complete "shutdown" of the brain. It is rather a kind of very deep sleep, from which you can wake up only when the anesthesiologist allows it. What is being suppressed first? To begin with, this is consciousness. The main purpose of general anesthesia is to reduce the stress level of the patient. We want to make sure that the entire treatment goes unnoticed for him and does not leave any unpleasant memories. In addition, pain sensitivity is suppressed and motor activity is inhibited. That is, with the right anesthesia, the patient does not hurt, and he does not try to get up and leave, posing as a lunatic.
Of course, suppression of the functions of the central nervous system should turn off only consciousness and pain, without affecting the important autonomous centers of regulation of heartbeat, respiration and vascular tone. Only experienced doctors can provide all this correctly. Usually, four degrees of depth of anesthesia are distinguished:
- Superficial anesthesia.
- Light anesthesia.
- Full anesthesia.
- Superdeep anesthesia.
If necessary, the anesthesiologist can vary the degree of CNS depression, for example, to ask the patient to move the jaw correctly. This can be done when using propofol, for example. Or, conversely, increase the depth if the patient begins to worry.
Why are such methods needed at all, if there is a conditional local articaine, which most often can be done? First of all, the problem is panic fear and stomatophobia. A good patient is a calm patient, not one who tries to run away in horror and shudders at every movement of the doctor. This will not benefit the patient himself and will not help the doctor to cure him qualitatively. Additional arguments in favor of anesthesia will be a very pronounced gag reflex and a large amount of intervention. We can't just inject anesthetic into a patient, especially a little one. Local anesthetic also has a limiting dosage for simultaneous administration, and, for example, bilateral conduction anesthesia in the lower jaw can cause difficulty breathing due to the complete shutdown of tongue sensitivity.And the most important thing is that even the most sensitive doctor will never agree with a child on the treatment of 15–20 teeth at the same time. Yes, it also happens when children do not brush their teeth properly, eat rolls and do not go to the dentist.
Therefore, oddly enough, it is general anesthesia that can often be an easier and more comfortable choice for the little patient and the attending physician.
Key drugs for general anesthesia
Before we go into detail on how we use general anesthesia in children, let's go over a few key drugs. These are nitrous oxide, propofol and sevoflurane (better known by the commercial name "Sevoran"). Without them, it is difficult to imagine a modern safe general anesthesia with an easy and quick awakening.
The correct use of modern methods is very important for the child to easily tolerate the anesthesia.
Nitrous oxide
Nitrous oxide has long been known exclusively as "laughing gas".
The history of the medical use of nitrous oxide began in 1799, when a sophomore named Humphrey Davy, who became an eminent scientist, noticed that inhalation of this gas causes euphoria and intoxication. In the process of experiments, he accidentally drew attention to the fact that under the influence of gas, toothache disappears. Don't ask what these experiments were. In 1844, Horace Wells performed the first dental surgery under nitrous oxide anesthesia. Now it is one of the most common gases used to relieve pain sensitivity with small-volume manipulations.
Nitrous oxide has virtually no toxic effects when used correctly. It is metabolized: 99.996% of the gas is excreted unchanged during exhalation. Because of this, its effects are very short and most often stop within a minute after stopping the feed. Its safety profile is so good that it is used for pain relief in children and pregnant women during childbirth. In the second case, it is used in the so-called “anesthesia on demand” mode, when a woman in labor takes several breaths of a mixture of nitrous oxide and oxygen from a mask of a special apparatus before the beginning of a contraction. In this case, the contraction is almost painless. Not as effective as with epidural anesthesia, but clears up much faster.
The main effects are achieved due to the antagonistic effect on NMDA receptors. Many synthetic opiates, such as tramadol, act in a similar way. But unlike opiates, nitrous oxide is not addictive and does not suppress the respiratory center, which leads to its high safety profile. Also, according to a not entirely clear mechanism, endorphins are released, which triggers our internal mechanism for limiting pain sensations - the antinociceptive system. At the same time, the analgesic effect is quite strong and is approximately equivalent in strength to 15 mg of morphine . But nitrous oxide alone is not enough to do anything with the teeth, so it is used in combination with local anesthesia.
Mild euphoria and increased mood are achieved by stimulating the release of dopamine, judging by the data of experiments on rats.
It also has an anxiolytic effect: it suppresses anxiety. In small doses, nitrous oxide increases the sensitivity of the GABAA receptors. The benzodiazepine anti-anxiety drugs work in much the same way. As a result, the patient's anxiety decreases, he relaxes and shows slight drowsiness. There is also a slight anticonvulsant effect.
An overdose as such is also almost impossible. The main key point to be monitored is the patient's saturation to prevent oxygen starvation. Well, if there is no anesthesiologist nearby and the action takes place in a nightclub - so that the patient does not have time to knock over and hit during his attack of Viking madness on protruding objects and guards.
Brief summary: Treating teeth with nitrous oxide is fun and safe, as long as it does not involve very deep interventions. Then the pain still breaks through.
Propofol
Ampoule with propofol emulsion.
Propofol is another significant drug in the practice of an anesthesiologist. The drug has a milky white color due to the fact that it is not a solution, but an emulsion. The active substance itself is insoluble in normal saline solution, therefore it is introduced in the form of a stabilized emulsion with a phospholipid base.
The drug works interesting. You have probably seen how in the films something is injected into the patient, and he instantly turns off. Propofol has exactly the same effect. Our brains are largely composed of fats, in which propofol is highly soluble. Therefore, the time from its introduction to loss of consciousness is only a few seconds. It takes literally a few heart beats to deliver the required dose of the drug to the central nervous system.
Interestingly, propofol has only a sedative effect, suppressing the activity of the central nervous system. At the same time, it does not suppress pain and tactile sensitivity. Therefore, it must be combined with local anesthetics. And he also has a very funny feature: it causes retrograde amnesia, that is, the last thing the patient remembers upon awakening is the events shortly before the drug was administered. Moreover, similar to sodium thiopental, propofol allows you to control patients to perform the simplest commands: stick out your tongue, close your mouth, open your mouth. That is, some contact remains, which is a big plus in some situations. Actually, it is precisely for this combination of amnesia and controllability that the same sodium thiopental was described in all spy novels as "truth serum." In fact, a real interrogation would be difficult to conduct,as the patient is likely to simply hum something incoherent.
Just propofol - you feel everything, it hurts, you follow simple commands and you can even mumble incoherently: "Fuck off, I'm married", but then you forget everything. Propofol + topical remedy removes the pain from this situation, but you twitch and interfere with the doctor, your heart rate can accelerate dangerously with an incision. Propofol + the same sevoran remove the pain and allow you to control the situation completely, but even turn off the level of consciousness that allowed humming.
Sevoflurane
A pleasantly sweetish smelling gas with a common commercial name "Sevoran" is one of the most convenient and safe options for inhalation anesthesia, displacing halothane and isoflurane in modern anesthesiology. It has become widespread due to its excellent safety profile and easy administration and recovery from anesthesia. With its appearance, the typical "helicopters" with vomiting for long hours after the operation, typical of the previous generations of drugs, are a thing of the past.
Due to moderate relaxation of the respiratory muscles and general sedation, it suppresses the trigger zones of the cough and gag reflexes. This means that the doctor can work calmly without fear that the patient will suddenly start to vomit or cough during the process of delicate manipulations (for which gastroenterologists love him separately with FGDS). At the same time, the anesthesiologist continuously monitors the patient's blood pressure and oxygen saturation. It is important to avoid even the smallest lack of oxygen supply even in the smallest patients.
The laryngeal mask is inserted like this.
Most often, it is used in a mixture with nitrous oxide and oxygen to induce anesthesia. When the patient falls asleep, the face mask is changed to a laryngeal mask. Further, the patient's breathing is controlled by mechanical ventilation. At the same time, the introduction of a laryngeal mask for inhalation anesthesia in children differs from that in adults. Children have a different structure of the larynx and different angles of introduction. For example, we always take into account the characteristics of children with a relatively short neck or malocclusion. A good doctor who works with children will do this as gently as possible - so that the child will not have any unpleasant sensations in the larynx after waking up.
Which anesthesia option is better
So, we went over the main properties of drugs for general anesthesia. Now let's look at which options are better in each case. Children are not the same, they are all different. Some child will be calm about inserting a catheter at a very young age, and some will refuse a painless mask at the age of eight or nine. Therefore, we always carefully communicate both with the baby himself and with his parents. This is necessary in order to establish a trusting contact between the doctor and the little patient. Without this, it simply will not work normally. At the same time, the most detailed information on the characteristics of the child's health is collected so that the anesthesiologist can choose the most comfortable and safe option for general anesthesia.
Interestingly, children very quickly begin to trust doctors if they see that everything has gone painlessly and the tooth no longer bothers. As a rule, further treatment is much easier. We had a case when a girl fell from a swing in a kindergarten, bumped and lost an artificial crown, which she had to put almost three together. As a result, she herself returned to the clinic with her parents, brought the crown in her palm and asked to return it to its place.
Local anesthesia only
Suitable for : brave children of all ages who trust a doctor.
This option is a little past the main topic of our post, but I also want to mention it. If the child initially comes with a bunch of damaged teeth, and even for some reason intimidated by relatives, then such a scenario may not be possible. And it is necessary to treat. This is where the whole arsenal of means for general anesthesia will help us.
Local anesthesia and nitrous oxide
The child should have free nasal breathing. Nitrous oxide has a ton of effects we want. It relaxes, eliminates anxiety, slightly improves mood. During treatment, the patient will be awake. At the same time, it will not be possible to anesthetize it in its pure form, it will still be painful to prepare teeth. Therefore, we usually let the child breathe through a special mask that covers only the nose. Many people like it very much, plus we often tell stories about test pilots who also have special masks with breathing gas.
When the child relaxes, you can already do application anesthesia with a gel and then inject the main anesthetic. Unfortunately, under nitrous oxide, it will not be possible to do a large amount of intervention immediately. Children get tired of lying with their mouths open, the mask begins to irritate. Therefore, this method is better suited for small one-stage interventions - one or two teeth. At the same time, we cannot increase the concentration above 50% for a child, we need to look for other, stronger, but safe drugs.
Local anesthesia and sevoflurane
Sevoflurane can be given to school-age children without any problems, but there are several nuances. With older children, it is easier to negotiate awake local anesthesia or intravenous propofol. There are several advantages to a complete shutdown of consciousness, which does not happen with the same nitrous oxide.
Firstly, the child does not experience wild stress and does not earn stomatophobia for the rest of his life. There is nothing worse than a stern nurse kneeling on you and holding a mouth speculum while the doctor frantically tries to do something in the mouth.
Secondly, it allows for high-quality treatment when the doctor is sure that the patient will not twitch, will not start waving his tongue, or try to escape in the middle of an important stage.
The anesthesiologist can vary the depth of anesthesia by changing the composition of the gas mixture. This makes it possible to accurately monitor the patient's vital signs and provide the desired level of relaxation and immobility. If you need to treat caries, then there is no point in additionally injecting an anesthetic. The degree of CNS suppression is sufficient to make the patient comfortable. If it is planned to treat pulpitis or periodontitis, to remove teeth, then we additionally inject a local anesthetic. Otherwise, painful impulses will still reach the “sleeping” brain and cause an adrenaline rush and involuntary movements. With a complete shutdown of consciousness, we can carry out any amount of intervention. And we are talking not only about some painful things like the treatment of six carious teeth in one go, but also, for example,on taking accurate impressions for the subsequent manufacture of orthopedic and orthodontic structures. Try convincing a sobbing four-year-old to sit still while the silicone in his mouth hardens in the impression spoon.
Local anesthesia and propofol
A child under three years old is prohibited from using this. We have already discussed the features of propofol above. It has no analgesic effect, but only suppresses consciousness. That is why it needs to be supplemented with local anesthesia, as if the patient were awake. But its main plus when working with the same teenagers is that they can perform simple commands. This makes the doctor's job easier. You can lower the depth of anesthesia and ask to bite the template, model the structure according to the bite, or something similar. For the dentist, it is important not only to depict fillings at the site of carious defects, but to carefully model the occlusal ratios of the jaws so that after treatment the biomechanics of chewing is ideal.
FAQ
Can I eat before anesthesia?
No you can not. And parents need not just tell the child about this, but make sure that he does not gorge on cookies from his secret reserves. The child is hungry, he will try to eat at least something. Anesthesia on a full stomach threatens with vomiting during treatment or upon awakening. If it is "in the process of treatment," then the substance can block the airways, which is not needed by anyone.
How easily is anesthesia tolerated?
If all the protocols are followed, the process is monitored by an experienced anesthesiologist, then everything goes without problems and special side effects. To do this, we follow all protocols and everything that is necessary for complete security. For example, here is a study that suggests that with proper anesthesia with propofol and isoflurane, all side effects after waking up last less than a day.
But sometimes our hair just stands on end when mom comes to our clinic after not the most correct anesthesia in another place. Usually we catch such parents with a load of food for a week and a moral expectation of three days of continuous vomiting and dizziness upon waking up. Here you immediately realize that in another place the general anesthesia did not go quite right.
Will he wake up for sure?
Yes. It's not a matter of probability, it's a matter of protocol compliance. It is necessary to check the equipment, have a doctor of the required qualifications, and understand the characteristics of a particular patient. Then there will be no surprises. The process is closely monitored by an anesthesiologist-resuscitator, who is ready to intervene at any time and adjust the parameters of anesthesia. He knows how to smoothly enter and remove from anesthesia, owns all the nuances of resuscitation measures in children.
I was told about doctors who are against anesthesia
Yes, it happens. But I think that they are not entirely right and they simply do not have a good anesthesiologist. The safety of general anesthesia for the health and mental abilities of the baby has been confirmed by numerous studies. For example, they took 19,296 children and studied their development after a lot of anesthesia underwent up to the age of 20. The results prove that everything is fine, and the children are no different from their peers. At the same time, many sources still come to the conclusion that repeated anesthesia under the age of two is undesirable.
In general, sometimes misunderstanding and fear of general anesthesia take strange forms among some doctors. In my memory, there was one wild case when a doctor tried to protect children from a terrible anesthesia, replacing it with a temporary strangulation with a towel. Binds, holds and heals half-smothered. Such a kind doctor. Moreover, in fact, she uses the variant of rausch anesthesia. But it was only relevant several hundred years ago, when even etheric anesthesia was not invented, and the only option to carry out a conditional amputation was a precisely calculated blow with a wooden mallet on the crown. But it was difficult to control the "depth" of such anesthesia and guarantee a successful awakening.
What about the eyes during treatment?
The eyes dry only with deep anesthesia, in our case they are sufficiently moistened with a tear. The eyelids are fixed to the patient with a special plaster. So the eyes remain closed, and the mucous membrane does not dry out. Well, the risk is excluded that something can get into them.
Will hair fall out after surgery?
I know it sounds strange, but this is what parents ask. Here's the thing: if you lose a lot of blood during surgery, then hair loss can be a side effect. But when a mistake is made in surgery, it is most often attributed to uncontrollable factors in the spirit of: "This is such a remedy for anesthesia," and not to the fact that someone could not perform the manipulation on time or did not make the right decision. And the anesthesiologist has nothing to do with it.
Will it affect the child's memory, will it damage the brain?
Will not affect in any way - neither good nor bad. The anesthesiologist carefully monitors the oxygen saturation level so that the young brain receives sufficient oxygen. The device does not supply pure gas, but mixed with oxygen. All sensors are built into the ventilator. If necessary, the doctor can, for example, adjust the composition of the gas mixture. All drugs have an excellent safety profile and a lot of research confirming their safety when used in pediatric patients. We also know how to work quickly. If we used to work on very large interventions for six hours, then up to four, up to three, now the average duration is no more than 2.5 hours: this, in particular, is why we need technology and a professional team.
Will he have bad dreams?
Will not. The child will not remember the process of the anesthesia itself and, most likely, some short period before it. Just try not to scare him again yourself: children are very impressionable. Then we will try to make everything as comfortable as possible for him: fell asleep, woke up, and then we played.
Why is it so important not to scare your child
The most difficult thing in dentistry is not to scare a child. Unfortunately, this is often done for us by some strange grandparents who scare the child with doctors. Please, never tell children things like: “If you eat candy, you ruin your teeth. And then the doctor will be a terrible drill to drill your teeth. " Sooner or later, the little patient will have to face the dentist. And we would like him to trust us, and not run away screaming at the sight of a white robe. Otherwise, everything can end up with persistent stomatophobia, a mouth full of dentures and a bunch of problems for life.
PS In previous posts about palatal dilators and the scientific approach to dentistry, you asked about the clinic. If you want to have your teeth treated with us , then say "I'm from Habr", there will be a small 5% discount.