Anesthesiology/intubation for pediatric dental procedure
QUESTION: My daughter, who turns 3 next month, is going to need extensive dental work under IV sedation with an anesthesiologist in the dental office. I've spoken to two separate anesthesiologists from different pediatric dental practices and have to make a decision as to who I prefer for my daughters treatment. One uses nasal intubation, and starts the procedure with nitrous and then IV sedation using sevoflourane (sp?), nitrous and propofol. He says that this combination uses less propofol and makes them less groggy and they will have less recovery time. The other anesthesiologist first gives a shot of ketemine followed by the IV sedation using propofol. He doesn't use intubation.
My daughter has a complicated medical history. She is deemed healthy and normal now but she was born with fetal hydrops and she developed hydrocephalous as a result. She also needed a blood transfusion as a result of thrombocytopenia. The hydrocephalous resolved on its own and she has been given a clean bill of health.
I'm not sure if this is relevant to intubation but she gags when she cries and sometimes she wakes up in the night coughing but never during the day. She's also a chronic nose picker. Every once and a while there will be dried blood on her nose from picking but shes never gotten a gushing bloody nose.
I'm just wondering what person would be more appropriate for my daughter given the circumstances. I'm not sure why the first one is intubating. Does that mean my daughter will be in an even deeper state of sedation? And why do some anesthesiologists intubate and others do not? Thank you, very much for taking the time to read this and to hopefully ease an over worried mother's mind! :-)
Thank you for the inquiry. I'll do my best to answer your questions, and help allay any concerns.
There is more than one way to achieve a successful outcome given this type of scenario you have provided. Based on history and physical of the patient, the anesthesia provider makes the determination as to which way an anesthetic is safest and appropriate. Your daughter's previous medical history does not present, to me, an issue with anesthesia in and of itself. What concerns me is the gagging and coughing.
The first anesthetist describes general anesthesia with support of a breathing tube (nasal intubation, in my practice, would be based on the decision of the dental practitioner, and their ability (or lack thereof) to work around an oral intubation vs nasal). Sevoflurane is an anesthetic that one breathes via a breathing circuit and mechanical delivery (anesthesia machine). It's not uncommon for three-year-olds to get "masked down" (breathing sevoflurane until in a state of surgical anesthesia) to have the IV placed. Once the IV is in place, the amount of anesthetic gases can be decreased, and other measures (nitrous oxide and propofol) can be initiated. If the anesthetic solely consists of nitrous and propofol, then yes, the recovery time will theoretically be shorter, and the 'fogginess' would clear quicker. As a side note, general anesthesia is the deepest level of anesthesia. Monitored anesthesia care encompasses various levels of IV sedation/anesthesia, and should only be described as such if the patient can be aroused during the sedation/anesthetic. If not arousable (by voice/touch commands), then this would be considered general anesthesia, regardless of the label being used.
The second anesthetist describes total IV sedation (I would go so far as to say what is known as "room air general"), where the patient receives only IV medications/anesthetics. The patient is maintaining their own airway during this time. What concerns me here is that your child seems to have random coughing (post-nasal drip??). That, combined with ketamine (which causes increased secretions) puts me at concern with a patient under IV anesthesia, for fear of risk of aspiration and decreased airway protection reflexes.
As to why some choose a different method over another is basically provider-preference, along with using evidence-based medicine, best practices and skill of the anesthetist. This, coupled with surgeon skill, and length of procedure must also be taken into consideration.
In my facility (Ambulatory surgery center), all of our peds patients are intubated orally (adults will be intubated nasally) for prolonged dental cases. The complete control of the airway, and providing respiratory support for cases lasting hours long makes the patient work much less over the course of the case/anesthetic.
I hope this has helped some. Please feel free to ask any further questions/clarifications at any time.
Good luck to you and your child!
---------- FOLLOW-UP ----------
QUESTION: Thank you so much for such a very well explained response! I was just wondering why the adults only have intubation through the nose and the children are done orally at your facility?
I guess what Im concerned about is that if my daughter gets a shot of ketemine, she will cry hysterically until it takes effect. and as she is laying down and receiving an IV of propofol, she will be unable to clear her airway if for some chance she still had to do so. having said that, I'm sure most kids scream their heads off after the shot and have an excess amount of nasal secretions from crying and are fine. Would being intubated lesson the risk of aspiration in this instance or is the risk still the same? Is the intubation meant purely as a precaution in case something does go wrong, the tube is already in. The dentist explained to me that my daughter would still be able to breathe of her own ability but intubated. I didn't understand that concept. Doesn't intubation mean you're in a state so deep that you're unable to breathe on your own?
My pleasure.. and thanks for the follow-up.
Adults are intubated via the nose mostly for a couple of reasons:
One, there simply is only so much room in the mouth for hands/fingers/equipment to fit. The dentists would be fighting for space, and to be able to do competent work might be hindered in some fashion if the competition for space existed.
Two, it just might be dentist-preference. I'm willing to bet, since I've done it a few times, that adults intubated orally can successfully be operated on as well.
As for your daughter, I suppose what is most concerting is the age of your daughter, having this done in an office setting (at least when using monitored anesthesia care/sedation), and unknowing what emergency equipment is available. What is important to know is the type of equipment available at the office (anesthesia machine, emergency equipment/meds, etc.). Since I do these procedures in the operating room, these concerns are nil, because everything needed is at hand. That being said, adults getting sedation in the office setting are quite routine, as emergent issues can be dealt with over a longer course of time (meaning seconds vs minutes). But, the same factors would still apply if I were to be "shopping" around for the appropriate office to have this done...re: emergency equipment/meds, etc.
Just to note, your kid will most likely cry and scream and move all over the place when receiving inhalation gases when going off to sleep. This is just a natural course of anesthesia, along with them being scared, etc.
Regarding aspiration protection, intubation would be the most protectant (aside from being fully awake and alert), especially when compared to having sedation. The goal is to have the patient be able to protect their own airway during sedation, and more often than not, they are beyond that capacity because of being in a surgical-type plane of anesthesia when getting deep sedation.
The breathing tube is just that..a means to both deliver anesthesia gases to the lungs, as well as exchange gas (oxygen and carbon dioxide). While under anesthesia, the patient is able to breathe, unless muscle relaxation is used, which would not be the case in your situation. The gases just render the patient amnestic, free of pain, and immobile (if deep enough), all the while maintaining spontaneous respirations. There can be a period where too much gas is given, and drive the breathing center to almost stop, but any vigilant provider should not let it get to that point.
I hope this helps some. If you have any further questions, please don't hesitate.