Features of local anesthesia in pediatric dentistry. What is the danger of general anesthesia for a child Features of anesthesia in children in dentistry

Most surgical operations today are unthinkable without adequate anesthesia. Although general anesthesia has been successfully used in pediatrics for a long time, parents are afraid of the prospect of having it performed on a small baby - they are afraid of possible dangers and complications after surgery, they are worried about the consequences for the child. Parents should be aware of the intricacies of the procedure and contraindications to it.

Some manipulations with a child cannot be performed without general anesthesia

General anesthesia is a special state of the body in which, under the influence of special drugs, the patient falls asleep, total loss consciousness and loss of sensitivity. Children do not tolerate any medical manipulations, therefore, during serious operations, it is necessary to “turn off” the baby’s consciousness so that he does not feel pain and does not remember what is happening - all this can cause severe stress. Anesthesia is also needed by the doctor - diverting attention to the reaction of the child can lead to errors and serious complications.

The child's body has its own physiological and anatomical features - the ratio of height, weight and body surface area changes significantly as they grow older. It is advisable for children under three years of age to administer the first drugs in a familiar environment and in the presence of their parents. It is preferable to carry out induction anesthesia at this age with the help of a special toy mask, diverting attention from unpleasant sensations.

Carrying out mask anesthesia for a child

As he grows older, the baby tolerates manipulations more calmly - a child of 5-6 years old can be involved in induction anesthesia - for example, invite the child to hold the mask with his hands or blow into the anesthesia mask - after exhalation, a deep breath of the drug will follow. It is important to choose the right dosage of the drug, since the child's body reacts sensitively to exceeding the dose - the likelihood of complications in the form of respiratory depression and overdose increases.

Preparation for anesthesia and necessary tests

General anesthesia requires parents to carefully prepare the baby. It is necessary to examine the child in advance and pass the necessary tests. Typically required general analysis blood and urine, examination of the coagulation system, ECG, conclusion of a pediatrician about general condition health. On the eve of the operation, a consultation with an anesthesiologist is required, who will perform general anesthesia. The specialist will examine the child, clarify the absence of contraindications, find out the exact body weight to calculate the required dosage and answer all questions of interest to parents. It is important to make sure that there is no runny nose - nasal congestion is a contraindication to anesthesia. Another important contraindication to anesthesia is fever for unknown reasons.

Before general anesthesia, the child should be examined by doctors

The stomach of the baby during anesthesia should be completely empty. Vomiting general anesthesia dangerous - children have very narrow airways, so the likelihood of complications in the form of aspiration of vomit is very high. Newborns and infants under one year of age receive the last breast 4 hours before surgery. Children under 1 year of age, who are bottle-fed, maintain a hungry pause of 6 hours. Children over 5 years of age take their last meal the night before, and it is contraindicated to drink plain water 4 hours before anesthesia.

How is anesthesia performed in childhood

The anesthesiologist always tries to minimize discomfort from anesthesia for a child. To do this, premedication is carried out before the operation - the baby is offered sedatives that relieve anxiety and fear. Children under the age of three or four are already in the ward receiving drugs that put them in a state of half sleep and complete relaxation. Small children under 5 years of age are very painful to part with their parents, so it is advisable to be with the child before he falls asleep.

Children older than 6 years of age usually tolerate anesthesia well and arrive in the operating room conscious. The doctor brings a transparent mask to the child's face, through which oxygen and a special gas are supplied, causing anesthesia for children. As a rule, the child falls asleep within a minute after the first deep breath.

Introduction to anesthesia occurs in different ways depending on the age of the child.

After falling asleep, the doctor regulates the depth of anesthesia and carefully monitors vital signs - measures blood pressure, monitors the condition skin child, evaluates the work of the heart. In the case when general anesthesia is performed on an infant up to a year old, it is important to prevent excessive cooling or overheating of the baby.

Anesthesia for children under one year old

Most doctors try to delay the moment of introducing general anesthesia to the baby up to a year as far as possible. This is due to the fact that in the first months of life there is an active development of most organs and systems (including the brain), which at this stage are vulnerable to adverse factors.

General anesthesia for a 1 year old child

But in case of urgent need, anesthesia is also done at this age - anesthesia will do less harm than the absence of the necessary treatment. The greatest difficulties in children under one year old are associated with observing a hungry pause. According to statistics, infants under one year of age tolerate anesthesia well.

Consequences and complications of anesthesia for children

General anesthesia is a rather serious procedure that carries a certain risk of complications and consequences, even when taking into account contraindications. It is believed that anesthesia can damage neural connections in the brain, promotes increased intracranial. At risk for the occurrence of unpleasant consequences are children under 2-3 years of age and younger, especially those with diseases of the nervous system. However, it should be noted that such symptoms in most cases developed with the introduction of outdated anesthetics, and modern drugs for anesthesia have minimal side effects. In most cases, unpleasant symptoms disappeared some time after the operation.

Children under 2-3 years of age are the most difficult to tolerate anesthesia

Of the possible complications, the most dangerous is the development of anaphylactic shock, which occurs when you are allergic to the administered drug. Aspiration of gastric contents is a complication that occurs more often in emergency operations when there was no time for appropriate preparation.

It is very important to choose a competent anesthesiologist who will evaluate contraindications, minimize the risks of developing unpleasant consequences, choose the right drug and its dosage, and also quickly take action in case of complications.

The choice of method of anesthesia is carried out depending on the clinical picture (tooth condition), the age of the child and the technical capabilities of its implementation.

Anesthesia methods

Non-injectable:

physical methods (cooling, use of electric current);

anesthetic electrophoresis;

application method.

Injection anesthesia:

infiltration;

conductive. 3. Needle-free jet anesthesia. 4. Local anesthesia with sedative preparation. 5. Local anesthesia combined with surface anesthesia. Local anesthesia is performed after:

psychological preparation;

physiological distraction or

medical preparation. The most popular anesthetics based on articaine (Septanest, Ultracaine, Ubistezin) and mepivacaine (Scandonest). Given its vasodilating effect, it is used in combination with vasoconstrictors (eg epinephrine). However, the use of epinephrine is not indicated in children under 5 years of age, as well as those suffering from cardiovascular diseases and endocrine pathology. Pharmacological preparation of children in order to correct the emotional state of the child before the operation of tooth extraction is widely used. Preoperative medications currently used are more often herbal sedatives (drops of valerian, motherwort) and tranquilizers. Dosages of individual drugs are presented in Table 4.

Prevention of complications of local anesthesia in children

Peculiarities of a child's psycho-emotional state often present additional difficulties when performing local anesthesia in dentistry. Practical recommendations for the prevention of complications of local anesthesia are presented in the work of Yu. G. Kononenko et al., (2002) and other authors.

Table 4

Doses of drugs used in pediatric practice for preoperative preparation

1. Careful history taking from the child's parents. It is better if at the initial appointment and getting to know the child there was a mother, because. many problems with the general somatic, physical and psycho-emotional development of the child may be due to the peculiarities of the birth act and the nature of the conduct of the birth itself, which led to birth trauma to the bones of the skull, cervical spine and spinal cord. Moreover, these changes can be viewed by a neurologist earlier.

So, in the prevention of complications of local anesthesia is important:

general somatic status and the presence of concomitant diseases, the definition of which allows the child to be assigned to a certain health group (see table in the appendix);

allergic status,

the nature of the child and his current psycho-emotional mood.

H

Do not perform manipulations without the consent of the child!

When injecting anesthesia: a) each child should be tested for tolerability of the anesthetic solution; b) children under 5 years old do not use an anesthetic solution with a vasoconstrictor; We recommend using a 3% solution of mepivacaine without vasoconstrictors. For example: Scandonest 3% SVC, Ultracain D and others; in) children over 5 years old it is desirable to use an anesthetic solution with a low concentration of a vasoconstrictor (1:200,000). For example: Ultracain DS, etc.

3. In children aged 3-10 years, it is better to use infiltration papillary anesthesia, injections into dense dental gums and intraosseous anesthesia. 4. In children over 10-13 years, the use of infiltration anesthesia in the apical region and conduction (mandibular) anesthesia is recommended.

5. The technique of anesthesia must be carefully worked out, the dose of anesthetic is accurately calculated.

A novice doctor can be advised to draw into the syringe only that dose (0.5-1 ml of anesthetic solution) that needs to be injected. If there is a large dose of anesthetic in the syringe, and the child is restless, turns his head, then it is possible to introduce a larger dose of anesthetic than necessary, and this can cause a number of complications (toxic reaction, etc.).

The end result should be 100% pain relief!

Why is general anesthesia dangerous for a child? Yes, in some cases it is necessary. Often - to save the life of a child.

But there are also negative aspects of the action of anesthesia. That is, it is like a coin that has two sides, like a double-edged sword.

Naturally, before the upcoming operation for the child, parents are trying to find out how dangerous this intervention is, what exactly is the danger of general anesthesia for the child.

Sometimes general anesthesia scares people even more than surgery. In many ways, this anxiety is fueled by numerous conversations around.

Surgeons who prepare the patient for surgery say little about anesthesia. And the main specialist in this matter - the anesthesiologist - advises and explains everything only shortly before the operation.

People are looking for information online. And here she is, to put it mildly, different. Who to believe?

Today we will talk about the types of anesthesia in pediatric medical practice, about indications and contraindications for it, about possible consequences. And, of course, we will dispel the myths in this topic.

Many medical manipulations are very painful, so even an adult cannot bear them without anesthesia. What is there to say about the child?

Yes, exposing a child to even a simple procedure without anesthesia is a huge stress for a small organism. This can cause neurotic disorders (tics, stuttering, sleep disturbances). It is also a lifelong fear of people in white coats.

That is why, in order to avoid discomfort and reduce stress from medical procedures, painkillers are used in surgery.

Actually anesthesia is called general anesthesia. This is an artificially created, controlled state in which there is no consciousness and no reaction to pain. At the same time, the vital functions of the body (respiration, heart function) are preserved.

Modern anesthesiology has advanced significantly over the past 20 years. Thanks to it, today it is possible to use new drugs and their combinations to suppress involuntary reflex reactions of the body and reduce muscle tone when such a need arises.

According to the method of conducting general anesthesia in children, it is inhalation, intravenous and intramuscular.

In pediatric practice, inhalation (hardware-mask) anesthesia is more often used. With hardware-mask anesthesia, the child receives a dose of painkillers in the form of an inhalation mixture.

This type of anesthesia is used during short, simple operations, as well as in some types of research, when a short-term shutdown of the child's consciousness is required.

Painkillers used for mask anesthesia are called inhalation anesthetics (Ftorotan, Isoflurane, Sevoflurane).

Intramuscular anesthesia for children is practically not used today, since with such anesthesia it is difficult for the anesthetist to control the duration and depth of sleep.

It has also been established that such a commonly used drug for intramuscular anesthesia, like Ketamine, is unsafe for the child's body. Therefore, intramuscular anesthesia is leaving pediatric medical practice.

For long and difficult operations, intravenous anesthesia is used or combined with inhalation anesthesia. This allows you to achieve a multicomponent pharmacological effect on the body.

Intravenous anesthesia involves the use of various medications. It uses narcotic analgesics (not drugs!), muscle relaxants that relax skeletal muscles, sleeping pills, various infusion solutions.

During the operation, the patient is given artificial lung ventilation (ALV) with a special apparatus.

Only the anesthesiologist makes the final decision on the need for this or that type of anesthesia for a particular child.

It all depends on the condition of a small patient, on the type and duration of the operation, on the presence of concomitant pathology, on the qualifications of the doctor himself.

To do this, before the operation, the anesthetist must tell the parents as much information as possible about the characteristics of the growth and development of the child.

In particular, the physician should learn from parents and/or medical records:

• How was the pregnancy and childbirth?
• what was the type of feeding: natural (up to what age) or artificial;
• what illnesses the child had;
• whether there were cases of allergies in the child himself or in the next of kin and to what exactly;
• what is the vaccination status of the child and whether any negative reactions of the body during vaccination were previously identified.

Contraindications

There are no absolute contraindications to general anesthesia.

Relative contraindications may include:

The presence of concomitant pathology, which can adversely affect the condition during anesthesia or recovery after it. For example, anomalies of the constitution, accompanied by hypertrophy of the thymus gland.

A disease accompanied by difficulty in nasal breathing. For example, due to the curvature of the nasal septum, the growth of adenoids, chronic rhinitis(for inhalation anesthesia).

Having an allergy to medications. Sometimes before the operation, the child is given allergy tests. As a result of such tests (skin tests or test tube tests), the doctor will have an idea of ​​which drugs the body takes and which gives an allergic reaction.

Based on this, the doctor will decide in favor of using one or another drug for anesthesia.

If the child had an acute respiratory viral infection or another infection with fever the day before, then the operation is postponed until the body is fully restored (the interval between the disease and treatment under anesthesia should be at least 2 weeks).

If the child ate before the operation. Children with a full stomach are not allowed for surgery, as there is a high risk of aspiration (gastric contents entering the lungs).

If the operation cannot be delayed, then the gastric contents can be evacuated using a gastric tube.

Before the operation or the actual hospitalization, parents should conduct a psychological preparation of the child.

Hospitalization itself for a baby, even without surgery, is a difficult test. The child is frightened by separation from parents, alien environment, regime change, people in white coats.

Of course, not in all cases the child needs to talk about the upcoming anesthesia.

If the disease interferes with the child and brings him suffering, then it is necessary to explain to the baby that the operation will save him from the disease. You can explain to the child that with the help of a special children's anesthesia, he will fall asleep and wake up when everything has already been done.

Parents should always communicate that they will be with the child before and after the operation. Therefore, the baby should wake up after anesthesia and see the dearest and closest people to him.

If the child is old enough, you can explain to him what awaits him in the near future (blood test, measurement blood pressure, electrocardiogram, cleansing enema, etc.). So the child will not be scared various procedures because he didn't know about them.

The hardest thing for parents and young children is given to keep a hungry pause. I have already spoken about the risk of aspiration above.

6 hours before anesthesia, the child cannot be fed, and 4 hours before, you can not even drink water.

A breastfed baby can be applied to the breast 4 hours before the upcoming operation.

A child who is receiving formula milk should not be fed 6 hours before anesthesia.

Before the operation, the intestines of a small patient are cleaned with an enema so that during the operation there is no involuntary stool discharge. This is very important for abdominal operations (on the abdominal organs).

In children's clinics, doctors have many devices in their arsenal to divert the attention of children from upcoming procedures. These are breathing bags (masks) with images of various animals, and flavored face masks, for example, with the smell of strawberries.

There are also special children's ECG devices, in which the electrodes are decorated with the image of the muzzles of different animals.

All this helps to distract and interest the child, conduct a survey in the form of a game, and even give the child the right to choose, for example, a mask for himself.

The consequences of anesthesia for the child's body

In fact, much depends on the professionalism of the anesthesiologist. After all, it is he who selects the method of introduction into anesthesia, the necessary drug and its dosage.

In pediatric practice, preference is given to proven drugs with good tolerance, that is, with minimal side effects, and which are quickly excreted from the child's body.

There is always a risk of intolerance to drugs or their components, especially in children prone to allergies.

It is possible to predict this situation only if the close relatives of the child had a similar reaction. Therefore, this information is always clarified before the operation.

Below I will give the consequences of anesthesia, which can occur not only due to intolerance to medications.

• Anaphylactic shock (immediate type allergic reaction).
• Malignant hyperemia (temperature rise above 40 degrees).
• Cardiovascular or respiratory failure.
• Aspiration (reflux of stomach contents into the respiratory tract).
• Mechanical trauma during venous catheterization or Bladder, intubation of the trachea, the introduction of a probe into the stomach.

The probability of such consequences exists, although it is extremely small (1-2%).

Recently, information has appeared that anesthesia can damage the neurons of the child's brain and affect the pace of development of the baby.

In particular, it is assumed that anesthesia disrupts the processes of memorizing new information. It is difficult for a child to concentrate and learn new material.

This pattern was suggested after the use of injectable drugs such as Ketamine for intramuscular anesthesia, which is practically not used in pediatric practice today. But the validity of such conclusions is still not fully proven.

Moreover, if there are such changes, they are not lifelong. Usually, cognitive abilities are restored within a few days after anesthesia.

Children after anesthesia recover much faster than adults, since metabolic processes are faster and the adaptive capabilities of a young organism are higher than in adulthood.

And here much depends not only on the professionalism of the anesthesiologist, but also on individual features child's body.

Children are at greater risk early age ie up to two years. Children at this age are actively maturing nervous system, and new neural connections are formed in the brain.

Therefore, operations under anesthesia, if possible, are postponed for a period after 2 years.

Myths about anesthesia

“What if the child does not wake up after the operation?”

World statistics say that this is extremely rare (1 out of 100,000 operations). Moreover, more often such an outcome of the operation is associated not with a reaction to anesthesia, but with the risks of the surgical intervention itself.

It is in order to minimize such risks that the patient undergoes a thorough examination during elective operations. If any disorders or diseases are detected, the operation is postponed until the complete recovery of the small patient.

“What if the child feels everything?”

Firstly, no one calculates the dosage of anesthetics for anesthesia "by eye". Everything is calculated based on the individual parameters of a small patient (weight, height).

Secondly, during the operation, the child's condition is constantly monitored.

The pulse, respiratory rate, blood pressure and body temperature of the patient, the level of oxygen / carbon dioxide in the blood (saturation) are tracked.

In modern clinics with good operating equipment, even the depth of anesthesia, the degree of relaxation of the patient's skeletal muscles, can be monitored. This allows you to accurately track the minimum deviations in the child's condition during the operation.

“Mask anesthesia is an outdated technique. A safer form of anesthesia intravenous "

Most operations (more than 50%) in pediatric practice are performed using inhalation (hardware-mask) anesthesia.

This type of anesthesia eliminates the need for potent medicines and their complex combinations, in contrast to intravenous anesthesia.

At the same time, inhalation anesthesia gives the anesthesiologist more room for maneuver and allows better management and control of the depth of anesthesia.

In any case, regardless of the reasons for which the operation with anesthesia is indicated for the child, anesthesia is a necessity.

This is a savior, an assistant who will allow you to get rid of the disease in a painless way.

Indeed, even with minimal intervention under local anesthesia, when the child sees everything, but does not feel, the psyche of not every child can withstand this “spectacle”.

Anesthesia allows the treatment of non-contact and low-contact children. Provides comfortable conditions for the patient and the doctor, reduces the time of treatment and improves its quality.

Moreover, not in all cases we have the opportunity to wait, even if the child is small.

In this case, doctors try to explain to parents that, leaving the child’s illness without surgical treatment, it is possible to provoke big consequences than the likelihood of developing temporary consequences of general anesthesia.

What is the danger of general anesthesia for a child, you were told by a practicing pediatrician and twice mother Elena Borisova-Tsarenok.

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Terminologically, anesthesia during surgical interventions is divided into general, conduction and local.

The main requirement for anesthesia in both adults and children is its adequacy. Under the adequacy of anesthesia understand:

• compliance of its effectiveness with the nature, severity and duration of the surgical injury;
• taking into account the requirements for it in accordance with the patient's age, comorbidities, severity of the initial condition, features of the neurovegetative status, etc.

In this regard, the concept of the so-called ideal anesthetic has been put forward, which determines the main directions and trends in the development of pharmacology.

Anesthesiologists working in pediatrics take into account the characteristics of the child's body that affect the pharmacodynamics and pharmacokinetics of the components of anesthesia. Of these, the most important are:

• decrease in the binding ability of proteins;
• increased volume of distribution;
• reduction in the proportion of fat and muscle mass.

Means of inhalation anesthesia

In most inhalation anesthetics, the role of metabolic transformation is small (20% for halothane), so there is a certain relationship between the value of the inhaled concentration and the concentration in the tissues (directly proportional to anesthesia with nitrous oxide).

The depth of anesthesia mainly depends on the tension of the anesthetic in the brain, which is directly related to its tension in the blood. The latter depends on the volume of alveolar ventilation and the magnitude of cardiac output (for example, a decrease in alveolar ventilation and an increase in cardiac output increase the duration of the induction period). Of particular importance is the solubility of the anesthetic in the blood. Diethyl ether, methoxyflurane, chloroform, and trichlorethylene, which are currently little used, have high solubility; low - modern anesthetics (isoflurane, sevoflurane, etc.).

The anesthetic can be delivered through a mask or endotracheal tube. Inhalation anesthetics can be used in the form of non-reversible (exhalation into the atmosphere) and reversible (exhalation partly into the anesthesia machine, partly into the atmosphere) circuits. The reverse circuit has a system for absorbing exhaled carbon dioxide.

In pediatric anesthesiology, a non-reversible circuit is more often used, which has a number of disadvantages, in particular, heat loss to patients, pollution of the operating room atmosphere, and high consumption of anesthetic gases. AT last years In connection with the advent of a new generation of anesthesia and respiratory equipment and monitoring, the reverse circuit method using the low flow anaesthesia system is increasingly being used. The total gas flow in this case is less than 1 l/min.

General anesthesia with inhalation anesthetics in children is used much more often than in adult patients. This is primarily due to the widespread use of mask anesthesia in children. The most popular anesthetic in Russia is halothane (halothane), which is usually used in combination with nitrous oxide.

Children require a higher concentration of inhalation anesthetic (about 30%) than adults, which seems to be due to the rapid increase in alveolar anesthetic concentration due to the high ratio between alveolar ventilation and functional residual capacity. A high cardiac index and its relatively high proportion in cerebral blood flow also matter. This leads to the fact that in children, the introduction into anesthesia and the exit from it, all other things being equal, occur faster than in adults. At the same time, a very rapid development of a cardiodepressive effect is also possible, especially in newborns.

Halothane (halothane, narcotan, fluotan)- the most common inhalation anesthetic in Russia today. In children, it causes a gradual loss of consciousness (within 1-2 minutes); the drug does not irritate the mucous membranes respiratory tract. With its further exposure and an increase in the inhaled concentration to 2.4-4 vol.%, 3-4 minutes after the start of inhalation, complete loss of consciousness occurs. Halothane has relatively low analgesic properties, so it is usually combined with nitrous oxide or narcotic analgesics.

Halothane has a bronchodilator effect, and therefore is indicated for anesthesia in children with bronchial asthma. The negative properties of halothane include increased sensitivity to catecholamines (their administration during anesthesia with halothane is contraindicated). It has a cardiodepressive effect (inhibits the inotropic ability of the myocardium, especially in high concentrations), reduces peripheral vascular resistance and blood pressure. Halothane markedly increases cerebral blood flow, and therefore its use is not recommended for children with increased intracranial pressure. It is also not indicated for liver pathology.

Enflurane (etrane) has a slightly lower blood/gas solubility than halothane, so induction and recovery from anesthesia is somewhat faster. Unlike halothane, enflurane has analgesic properties. The depressive effect on respiration and cardiac muscle is pronounced, but the sensitivity to catecholamines is much lower than that of halothane. Causes tachycardia, increased cerebral blood flow and intracranial pressure, toxic effects on the liver and kidneys. There is evidence of the epileptiform activity of enflurane.

Isoflurane (foran) even less soluble than enflurane. The extremely low metabolism (about 0.2%) makes anesthesia more manageable and induction and recovery faster than halothane. Has an analgesic effect. Unlike halothane and enflurane, isoflurane does not significantly affect the myocardium at moderate concentrations. Isoflurane reduces blood pressure due to vasodilation, due to which it slightly increases the heart rate, does not sensitize the myocardium to catecholamines. Less than halothane and enflurane, affects brain perfusion and intracranial pressure. The disadvantages of isoflurane include an increase in the induction of airway secretion, cough, and fairly frequent (more than 20%) cases of laryngospasm in children.

Sevoflurane and Desflurane- inhalation anesthetics latest generation not yet widely used in Russia.

Nitrous oxide- a colorless gas heavier than air, with a characteristic odor and a sweetish taste, not explosive, although it supports combustion. Supplied in liquid form in cylinders (1 kg of liquid nitrous oxide forms 500 liters of gas). Does not metabolize in the body. It has good analgesic properties, but a very weak anesthetic, therefore it is used as a component of inhalation or intravenous anesthesia. It is used in concentrations of not more than 3:1 with respect to oxygen (higher concentrations are fraught with the development of hypoxemia). Cardiac and respiratory depression, effects on cerebral blood flow are minimal. Prolonged use of nitrous oxide can lead to the development of myelodepression and agranulocytosis.

Components of intravenous anesthesia

These funds are used both in combination with inhalation and without them - the latter method is called total intravenous anesthesia (TVA). It is with this method of anesthesia that it is possible to completely avoid the negative impact on the body of the operating room staff.

Hypnotics provide turning off the patient's consciousness. They tend to be highly lipid soluble, passing rapidly through the blood-brain barrier.

Barbiturates, ketamine, benzodiazepines and propofol are widely used in pediatric anesthesiology. All of these drugs have different effects on respiration, intracranial pressure and hemodynamics.

Barbiturates

Sodium thiopental in children is used mainly for induction intravenously at a dose of 5-6 mg/kg, under the age of 1 year 5-8 mg/kg, in newborns 3-4 mg/kg. Loss of consciousness occurs in 20-30 seconds and lasts 3-5 minutes. Doses of 0.5-2 mg/kg are required to maintain the effect. In children, a 1% solution is used, and in older ones, 2%. Like most other hypnotics, sodium thiopental has no analgesic properties, although it does lower the pain threshold.

In children, thiopental metabolizes 2 times faster than in adults. The half-life of the drug is 10-12 hours, which mainly depends on the function of the liver, since very little is excreted in the urine. a large number of. It has a moderate ability to bind to proteins, especially albumins (free fraction is 15-25%). The drug is toxic when administered subcutaneously or intra-arterially, has a histamine effect, causes respiratory depression, up to apnea. It has a weak vasodilating effect and causes myocardial depression, activates the parasympathetic (vagal) system. Negative hemodynamic effects are especially pronounced with hypovolemia. Thiopental increases reflexes from the pharynx, can cause coughing, hiccups, laryngo- and bronchospasm. Some patients have tolerance to thiopental, and in children it is less common than in adults. Premedication with promedol in children makes it possible to reduce the induction dose by approximately 1/3.

Hexenal differs little from thiopental in its properties. The drug is easily soluble in water, and such a solution can be stored for no more than an hour. In children, it is administered intravenously as a 1% solution (in adults 2-5%) in doses similar to thiopental. The half-life of hexenal is about 5 hours, the effect on respiration and hemodynamics is similar to thiopental, although the vagal effect is less pronounced. Cases of laryngo- and bronchospasm are less often recorded, so it is more often used for induction.

The dose of thiopental and hexenal for induction in older children (as in adults) is 4-5 mg / kg when administered intravenously. Unlike thiopental, hexenal can be administered intramuscularly (IM) and rectally. With the / m administration, the dose of hexenal is 8-10 mg / kg (in this case, the induction of narcotic sleep occurs after 10-15 minutes). With rectal administration, hexenal is used at a dosage of 20-30 mg / kg. Sleep comes in 15-20 minutes and lasts at least 40-60 minutes (with subsequent prolonged depression of consciousness requiring control). Nowadays, this method is rarely resorted to and only in cases where it is not possible to use more modern methods.

Ketamine is a derivative of phencyclidine. With its introduction, laryngeal, pharyngeal and cough reflexes are preserved. In children, it is widely used for both induction and maintenance of anesthesia. It is very convenient for induction in the form of intramuscular injections: the dose for children under 1 year old is 10-13 mg / kg, up to 6 years old - 8-10 mg / kg, older ones - 6-8 mg / kg. After the / m administration, the effect occurs after 4-5 minutes and lasts 16-20 minutes. Doses for intravenous administration are 2 mg/kg; the effect develops within 30-40 seconds and lasts about 5 minutes. To maintain anesthesia, it is used mainly as a continuous infusion at a rate of 0.5-3 mg / kg per hour.

The introduction of ketamine is accompanied by an increase in blood pressure and heart rate by 20-30%, which is determined by its adrenergic activity. The latter provides a bronchodilating effect. Only 2% solution of ketamine is excreted in the urine unchanged, the rest (overwhelming) part is metabolized. Ketamine has a high lipid solubility (5-10 times higher than that of thiopental), which ensures its rapid penetration into the central nervous system. As a result of rapid redistribution from the brain to other tissues, ketamine provides a fairly rapid awakening.

With rapid administration, it can cause respiratory depression, spontaneous movements, increased muscle tone, intracranial and intraocular pressure.

In adults and older children, administration of the drug (usually intravenous) without prior protection benzodiazepine (BD) derivatives (diazepam, midazolam) can cause unpleasant dreams and hallucinations. To stop side effects, not only BD is used, but also piracetam. In 1/3 of children in the postoperative period, vomiting occurs.

Unlike adults, children tolerate ketamine much better, and therefore the indications for its use in pediatric anesthesiology are quite wide.

In self-anaesthesia, ketamine is widely used for painful manipulations, central vein catheterization and dressings, small surgical interventions. As a component of anesthesia, it is indicated during induction and for maintenance as part of combined anesthesia.

Contraindications

Sodium oxybutyrate in children is used to induce and maintain anesthesia. For induction, it is prescribed intravenously at a dose of about 100 mg / kg (the effect develops after 10-15 minutes), orally in a 5% glucose solution at a dose of 150 mg / kg or intramuscularly (120-130 mg / kg) - in In these cases, the effect appears after 30 minutes and lasts about 1.5-2 hours. For induction, oxybutyrate is usually used in combination with other drugs, in particular with benzodiazepines, promedol or barbiturates, and with inhalation anesthetics to maintain anesthesia. There is practically no cardiodepressive effect.

Sodium oxybutyrate is easily included in the metabolism, and after decay is excreted from the body in the form of carbon dioxide. Small amounts (3-5%) are excreted in the urine. After intravenous administration, the maximum concentration in the blood is reached after 15 minutes, when taken through the mouth, this period is extended to almost 1.5 hours.

May cause spontaneous movements, a significant increase in peripheral vascular resistance and some increase in blood pressure. Sometimes there is respiratory depression, vomiting (especially when taken orally), motor and speech excitation at the end of the action, with prolonged administration - hypokalemia.

Benzodiazepines (DB) widely used in anesthesiology. Their action is mediated by an increase in the inhibitory effect of gamma-aminobutyric acid on neuronal transmission. Biotransformation occurs in the liver.

Diazepam is the most widely used in anesthetic practice. It has a calming, sedative, hypnotic, anticonvulsant and muscle-relaxing effect, enhances the effect of narcotic, analgesic, neuroleptic drugs. In children, unlike adults, it does not cause mental depression. It is used in pediatric anesthesiology for premedication (usually IM at a dose of 0.2-0.4 mg/kg), as well as intravenously as a component of anesthesia for induction (0.2-0.3 mg/kg) and maintenance of anesthesia in the form boluses or continuous infusion.

When taken orally, it is well absorbed from the intestine (peak plasma concentration is reached after 60 minutes). About 98% binds to plasma proteins. It is one of the slowly excreted drugs from the body (half-life is from 21 to 37 hours), and therefore it is considered a poorly controlled drug.

When administered parenterally in adult patients with hypovolemia, diazepam can cause mild arterial hypotension. In children, a decrease in blood pressure is observed much less frequently - when combined with thiopental, fentanyl or propofol. Violations respiratory function may be associated with muscular hypotonia of central origin, especially when combined with opioids. With intravenous administration, pain along the vein can be observed, which are removed by preliminary administration of lidocaine.

Midazolam is much more manageable than diazepam, and therefore is increasingly used in anesthesiology. In addition to hypnotic, sedative, anticonvulsant and relaxing effects, it causes anterograde amnesia.

It is used for premedication in children: 1) by mouth (in our country, an ampoule form is used, although special sweet syrups are produced) at a dose of 0.75 mg / kg for children from 1 to 6 years old and 0.4 mg / kg from 6 to 12 years old, its effect is manifested after 10-15 minutes; 2) intramuscularly at a dose of 0.2-0.3 mg/kg; 3) per rectum in an ampoule of the rectum at a dose of 0.5-0.7 mg/kg (the effect occurs in 7-8 minutes); 4) intranasally in drops for children under 5 years of age at a dose of 0.2 mg / kg (in this case, the effect occurs within 5 minutes, approaching intravenous). After premedication with midazolam, the child can be easily separated from the parents. Widely used as a component of anesthesia for induction (IV 0.15-0.3 mg/kg) and maintenance of anesthesia as a continuous infusion in a titration regimen at a rate of 0.1 to 0.6 mg/kg per hour and its termination 15 minutes before the end of the operation.

The half-life of midazolam (1.5-4 hours) is 20 times shorter than that of diazepam. When taken orally, about 50% of midazolam undergoes hepatic metabolism. With intranasal administration, due to the lack of primary hepatic metabolism, the effect approaches intravenous, and therefore the dose must be reduced.

Midazolam has little effect on hemodynamics, respiratory depression is possible with the rapid administration of the drug. Allergic reactions are extremely rare. In recent years, in foreign literature, one can find indications of hiccups after the use of midazolam.

Midazolam combines well with various drugs (droperidol, opioids, ketamine). Its specific antagonist flumazenil (anexat) is given to adults at a loading dose of 0.2 mg/kg followed by 0.1 mg every minute until awakening.

Propofol (Diprivan)- 2,6-diisopropylphenol, a short-acting hypnotic with very rapid action. Produced in the form of a 1% solution in a 10% soybean oil emulsion (intralipid). It has been used in children since 1985. Propofol causes a rapid (within 30-40 seconds) loss of consciousness (in adults at a dose of 2 mg / kg, the duration is about 4 minutes), followed by a rapid recovery. When inducing anesthesia in children, its dosage is much higher than in adults: the recommended dose for adults is 2-2.5 mg / kg, for young children - 4-5 mg / kg.

To maintain anesthesia, a continuous infusion is recommended at an initial rate in children of about 15 mg/kg per hour. Further, there are various infusion modes. A distinctive feature of propofol is a very fast recovery after the end of its administration with rapid activation motor functions compared to barbiturates. Combines well with opiates, ketamine, midazolam and other drugs.

Propofol suppresses laryngeal-pharyngeal reflexes, which makes it possible to successfully use the introduction of a laryngeal mask, reduces intracranial pressure and cerebrospinal fluid pressure, has an antiemetic effect, and practically does not have a histamine effect.

Side effects of propofol include pain at the injection site, which can be prevented by the simultaneous administration of lignocaine (1 mg per 1 ml of propofol). Propofol causes respiratory depression in most children. With its introduction, dose-dependent arterial hypotension is observed due to a decrease in vascular resistance, an increase in vagal tone and bradycardia. Excitation, spontaneous motor reactions can be observed.

In schemes of total intravenous and balanced anesthesia, droperidol, a neuroleptic of the butyrophenone series, is widely used. Droperidol has a pronounced sedative effect. It combines well with analgesics, ketamine and benzodiazepine derivatives. It has a pronounced antiemetic effect, has an a-adrenolytic effect (this may be beneficial for preventing spasm in the microcirculation system during surgical interventions), prevents the effect of catecholamines (anti-stress and anti-shock effects), has a local analgesic and antiarrhythmic effect.

Used in children for premedication intramuscularly 30-40 minutes before surgery at a dose of 1-5 mg/kg; for induction, it is used intravenously at a dose of 0.2-0.5 mg / kg, usually together with fentanyl (the so-called neuroleptanalgesia, NLA); The effect appears after 2-3 minutes. If necessary, it is administered repeatedly to maintain anesthesia in doses of 0.05-0.07 mg/kg.

Side effects- extrapyramidal disorders, severe hypotension in patients with hypovolemia.

Narcotic analgesics include opium alkaloids (opiates) and synthetic compounds with opiate-like properties (opioids). In the body, narcotic analgesics bind to opioid receptors, which are structurally and functionally divided into mu, delta, kappa, and sigma. The most active and effective pain relievers are m-receptor agonists. These include morphine, fentanyl, promedol, new synthetic opioids - alfentanil, sufentanil and remifentanil (not yet registered in Russia). In addition to high antinociceptive activity, these drugs cause a number of side effects, including euphoria, depression of the respiratory center, emesis (nausea, vomiting) and other symptoms of inhibition of the gastrointestinal tract, mental and physical dependence during their long-term use.

According to the action on opiate receptors, modern narcotic analgesics are divided into 4 groups: full agonists (they cause the greatest possible analgesia), partial agonists (weaker activation of receptors), antagonists (bind to receptors, but do not activate them) and agonists / antagonists (activate one group and block another).

Narcotic analgesics are used for premedication, induction and maintenance of anesthesia, and postoperative analgesia. However, if agonists are used for all these purposes, partial agonists are used mainly for postoperative analgesia, and antagonists - as antidotes for agonist overdose.

Morphine- classic narcotic analgesic. Its analgesic strength is taken as one. Approved for use in children of all age groups. Doses for induction in children intravenously 0.05-0.2 mg / kg, for maintenance - 0.05-0.2 mg / kg intravenously every 3-4 hours. It is also used epidurally. Destroyed in the liver; morphine metabolites may accumulate in renal pathology. Among the numerous side effects of morphine, one should highlight respiratory depression, increased intracranial pressure, sphincter spasm, nausea and vomiting, and the possibility of histamine release when administered intravenously. Newborns have hypersensitivity to morphine.

Trimeperidine (promedol)- a synthetic opioid, which is widely used in pediatric anesthesiology and for premedication (0.1 mg/year of life intramuscularly), and as an analgesic component of general anesthesia during operations (0.2-0.4 mg/kg intravenously in 40-50 minutes) , and for the purpose of postoperative analgesia (in doses of 1 mg / year of life, but not more than 10 mg intramuscularly). After intravenous administration, the half-life of promedol is 3-4 hours. Compared with morphine, promedol has less analgesic power and less pronounced side effects.

Fentanyl- a synthetic narcotic analgesic widely used in pediatrics. By analgesic activity exceeds morphine by 100 times. Slightly changes blood pressure, does not cause the release of histamine. Used in children: for premedication - intramuscularly 30-40 minutes before surgery 0.002 mg / kg, for induction - intravenously 0.002-0.01 mg / kg. After intravenous administration (at a rate of 1 ml / min), the effect reaches a maximum after 2-3 minutes. To maintain analgesia during surgery, 0.001-0.004 mg/kg is administered every 20 minutes as a bolus or infusion. It is used in combination with droperidol (neuroleptanalgesia) and benzodiazepines (ataralgesia), and in these cases, the duration of effective analgesia increases (up to 40 minutes).

Due to the high fat solubility, fentanyl accumulates in fat depots, and therefore its half-life from the body can reach 3-4 hours. If rational dosages are exceeded, this may affect the timely restoration of spontaneous breathing after surgery (in case of respiratory depression, opioid receptor antagonists nalorfin or naloxone; in recent years, agonist-antagonists such as nalbuphine, butorphanol tartrate, etc. have been used for this purpose).

In addition to central respiratory depression, side effects of fentanyl include severe muscle and chest stiffness (especially after rapid intravenous administration), bradycardia, increased intracranial pressure, miosis, sphincter spasm, cough with rapid intravenous administration.

Pyritramide (dipidolor) is close in activity to morphine. The dose for induction in children is 0.2-0.3 mg / kg intravenously, for maintenance - 0.1-0.2 mg / kg every 60 minutes. For postoperative analgesia, it is administered at a dose of 0.05-0.2 mg / kg every 4-6 hours. It has a moderate sedative effect. Virtually no effect on hemodynamics. At intramuscular injection the half-life is 4-10 hours. Metabolizes in the liver. Side effects are manifested in the form of nausea and vomiting, spasm of sphincters, increased intracranial pressure. Respiratory depression is possible when using large doses.

Of the opioid receptor agonist-antagonist drugs in Russia, buprenorphine (morphine, temgezik), nalbuphine (nubain), butorphanol (moradol, stadol, beforal) and pentazocine (fortral, lexir) are used. The analgesic potency of these drugs is insufficient for their use as the main analgesic, so they are mainly used for postoperative pain relief. Due to the antagonistic effect on m-receptors, these drugs are used to reverse the side effects of opiates and, above all, to relieve respiratory depression. They allow you to remove side effects, but maintain pain relief.

At the same time, pentazocine in both adults and children can be used at the end of fentanyl anesthesia, when it allows you to quickly stop the symptoms of respiratory depression and retains the analgesic component. In children, it is administered for this intravenously at a dose of 0.5-1.0 mg / kg.

Muscle relaxants

According to the duration of action, muscle relaxants are divided into ultrashort-acting drugs - less than 5-7 minutes, short-acting - less than 20 minutes, medium-lasting - less than 40 minutes and long-acting - more than 40 minutes. Depending on the mechanism of action, MP can be divided into two groups - depolarizing and non-depolarizing.

Depolarizing muscle relaxants have an ultrashort action, mainly suxamethonium preparations (listenone, dithylin and myorelaxin). Neuromuscular blockage caused by these drugs has the following characteristic features.

Intravenous administration causes a complete neuromuscular blockade within 30-40 s, and therefore these drugs remain indispensable for urgent tracheal intubation. The duration of neuromuscular blockade is usually 4-6 minutes, so they are used either only for endotracheal intubation followed by a switch to non-depolarizing drugs, or for short procedures (for example, bronchoscopy under general anesthesia), when their fractional administration can be used to prolong myoplegia.

The side effects of depolarizing MP include the appearance after their introduction of muscle twitching (fibrillation), which, as a rule, lasts no more than 30-40 s. The consequences of this are postanesthetic muscle pain. In adults and children with developed muscles, this happens more often. At the time of muscle fibrillation, potassium enters the bloodstream, which may be unsafe for the heart. To prevent this adverse effect, it is recommended to carry out precurarization - the introduction of small doses of non-depolarizing muscle relaxants (MP).

Depolarizing muscle relaxants increase intraocular pressure, so they should be used with caution in patients with glaucoma and should not be used in patients with penetrating ocular injuries. The introduction of depolarizing MP can cause bradycardia and provoke the onset of malignant hyperthermia syndrome.

Suxamethonium in chemical structure can be considered as a double molecule acetylcholine (AH). It is used in the form of a 1-2% solution at the rate of 1-2 mg/kg intravenously. Alternatively, you can enter the drug under the tongue; in this case, the block develops after 60-75 s.

Non-depolarizing muscle relaxants

Non-depolarizing MPs have the following features:

• compared to depolarizing MPs, a slower onset of action (even for short-acting drugs) without muscle fibrillations;
• the effect of depolarizing muscle relaxants stops under the influence of anticholinesterase drugs;
• the duration of elimination in most non-depolarizing MPs depends on the function of the kidneys and liver, although drug accumulation is possible with repeated administration of most MPs even in patients with normal function of these organs;
• most non-depolarizing muscle relaxants have a histamine effect;
• block elongation when using inhalation anesthetics differs depending on the type of drug: the use of halothane causes an elongation of the block by 20%, isoflurane and enflurane by 30%.

Side effects include a pronounced histamine effect that can lead to the development of laryngo- and bronchospasm, lowering blood pressure, and tachycardia. The drug has a pronounced ability to cumulation.

Pancuronium bromide (Pavulon), like pipecuronium bromide (Arduan), are steroid compounds that do not have hormonal activity. They belong to neuromuscular blockers (NMBs) long action; muscle relaxation lasts 40-50 minutes. With repeated administration, the dose is reduced by 3-4 times: with an increase in the dose and frequency of administration, the cumulation of the drug increases. The advantages of drugs include a low probability of a histamine effect, a decrease in intraocular pressure. Side effects are more characteristic of pancuronium: this is a slight increase in blood pressure and heart rate (sometimes marked tachycardia is noted).

Vecuronium bromide (norcuron)- steroid compound, MP medium duration. At a dose of 0.08-0.1 mg/kg, it allows tracheal intubation for 2 minutes and causes a block lasting 20-35 minutes; with repeated administration - up to 60 minutes. It accumulates quite rarely, more often in patients with impaired liver and / or kidney function. It has a low histamine effect, although in rare cases it causes true anaphylactic reactions.

Atracurium bensilate (Trakrium)- a muscle relaxant of medium duration of action from the group of derivatives of the isoquinoline series. Intravenous administration of trakrium in doses of 0.3-0.6 mg/kg allows tracheal intubation to be performed in 1.5-2 minutes. The duration of action is 20-35 minutes. With fractional administration, subsequent doses are reduced by 3-4 times, while repeated bolus doses prolong muscle relaxation by 15-35 minutes. It is advisable to infusion the introduction of atracurium at a rate of 0.4-0.5 mg/kg per hour. The recovery period takes 35 minutes.

Does not adversely affect hemodynamics, does not accumulate. Due to the unique ability to spontaneous biodegradation (Hoffmann elimination), atracurium has a predictable effect. The disadvantages of the drug include the histamine effect of one of its metabolites (laudonosine). Due to the potential for spontaneous biodegradation, atracurium should only be stored in a refrigerator at 2 to 8°C. Do not mix atracurium in the same syringe with thiopental and alkaline solutions.

Mivacurium chloride (mivacrone)- the only non-depolarizing short-acting MP, a derivative of the isoquinoline series. At doses of 0.2-0.25 mg/kg, tracheal intubation is possible after 1.5-2 minutes. The duration of the block is 2-2.5 times longer than that of suxamethonium. May be given as an infusion. In children, the initial infusion rate is 14 mg/kg per minute. Mivacurium has exceptional block recovery parameters (2.5 times shorter than vecuronium and 2 times shorter than atracurium); almost complete (95%) restoration of neuromuscular conduction occurs in children after 15 minutes.

The drug does not accumulate, minimally affects blood circulation. The histamine effect is weakly expressed and manifests itself as a short-term reddening of the skin of the face and chest. In patients with renal and hepatic insufficiency, the initial infusion rate should be reduced without a significant reduction in the total dose. Mivacurium is the relaxant of choice for short procedures (particularly for endoscopic surgery), in one-day hospitals, during operations with an unpredictable duration and, if necessary, a quick recovery of the neuromuscular block.

Cisatracurium (Nimbex)- non-depolarizing NMB, is one of the ten stereoisomers of atracurium. The onset, duration and recovery of the block are similar to the atracurium. After administration at doses of 0.10 and 0.15 mg/kg, tracheal intubation can be carried out for about 2 minutes, the duration of the block is about 45 minutes, and the recovery time is about 30 minutes. To maintain the block, the infusion rate is 1-2 mg/kg per minute. In children, with the introduction of cisatracurium, the onset, duration, and recovery of the block are shorter than in adults.

It should be noted that there were no changes in the circulatory system and (which is especially important) the absence of a histamine effect. Like atracurium, it undergoes Hofmann's organ-independent elimination. Possessing all the positive qualities of atracurium (lack of cumulation, organ-independent elimination, absence of active metabolites), taking into account the absence of a histamine effect, cisatracurium is a safer medium-acting neuromuscular blocker that can be widely used in various areas anesthesiology-reanimatology.

L.A. Durnov, G.V. Goldobenko

Almost every one of us has a story from childhood about going to the dentist, which turned into a subsequent chronic neurosis, which makes itself felt every time a visit to the “dentist” is due. For people whose childhood was at the end of the 20th century, memories of tears and fear in the dentist's office are vivid. Fortunately, times have changed. Today, a visit to the dentist does not necessarily have to turn into a traumatic experience for the child and his parents. Progressive moms and dads have probably heard about such a service as dental treatment under anesthesia.

Who is shown dentistry in a dream and are there any negative sides to this approach? Let's figure it out.

Anesthesia in pediatric dentistry: indications and contraindications

There are stereotypes that anesthesia in pediatric dentistry is a whim of restless parents, and it is not necessary to spend money on the treatment of milk teeth at all (they will soon fall out). Both points of view can be called morally obsolete. More than a decade has passed since anesthesia was considered extremely dangerous. Today, in many countries of the world, dental manipulations in children under the age of three years are legally required to be performed under general anesthesia (there is such an order of the Ministry of Health in the Russian Federation). Milk teeth can and should be treated. First, because any chronic infection in the body (which includes caries) depletes immune system and can affect other organs. Secondly, the premature loss of a milk tooth is fraught with malocclusion, harms chewing food and digestion, inhibits the development of speech and very often interferes with the socialization of the child. Thirdly, nature has planned a period of our life with milk teeth - so it should be so.

Nevertheless, of course, it is not always necessary to treat teeth under anesthesia. Whenever possible, doctors try to avoid unnecessary pharmacological stress on the body, and if your baby calmly tolerates visits to the doctor and does not require serious dental procedures, it is better to limit yourself to the traditional approach.

What are the indications for dental treatment in a dream?

• Traumatic and painful surgical dental intervention or other complex manipulation, in which the use of anesthesia is not only recommended, but also shown without fail.
• Increased anxiety of the child (when non-standard situations cause him to panic, which cannot be dealt with by persuasion).
• Dental phobia (previous negative experience of dental treatment, which leads to a strong fear of visiting the dentist).
• Inability to use local anesthesia(allergy to available anesthetics from this group).
• Dentistry in children 1–3 years old.
• Treatment of several teeth at the same time.
• Pronounced gag reflex.
• Examination and treatment of a "special child" - a baby with hereditary syndromes and neurological diseases complicating interaction with a small patient.

There are a number of contraindications to the use of anesthesia in children in dentistry. Here are the main ones:

• Any sharp infectious diseases(including ARI).
• recent vaccination.
• Chronic diseases of the lower respiratory tract: bronchitis, pneumonia, asthma.
• Deficiency in body weight.
• Heart defects and heart failure in a child.
• Allergy to drugs used for general anesthesia.

All these contraindications are relative. This means that after the treatment of the underlying disease or a certain waiting period, the teeth under anesthesia can still be cured. For some problems with the health of the child, this must be done in a hospital, where "behind" pediatrician Anesthesiologist-resuscitator has dozens of narrow specialists, where it is possible to observe the child for the necessary time. In outpatient practice, only those children whose state of health is not in doubt are accepted for treatment. Therefore, before excluding the possibility of such a solution to the problem, consult with an anesthesiologist-resuscitator of a dental center that inspires confidence in you.

The effect of anesthesia on the child's body

You can often hear that anesthesia in children is "very harmful." Agree, a rather abstract statement, which nevertheless tends to be fixed in the minds of many parents, who sometimes prefer to endure many days of suffering for a baby or forcibly seat him in a dental chair, giving consent to the participation of nurses and doctors in such an execution. Undoubtedly, if a child falls into hysterics at the mere thought of a dentist, refusing anesthesia is much more dangerous than agreeing to its use, if only because in the future this can lead to anxiety disorders(very often), stuttering and even (there have been cases) to enuresis - diseases that will not be easy to deal with even for experienced doctors.

For the first time in world practice, inhalation anesthesia using nitrous oxide was used specifically for dental purposes. American surgeons Wells and Morton in 1945 tested this technology on a volunteer from among the volunteers who gathered for a lecture on revolutionary method anesthesia. True, the first attempt was not very successful: the doctors could not accurately calculate the concentration of "laughing gas" necessary to lull an obese patient to sleep. However, after a year and a half, Morton successfully demonstrated the use of anesthesia, painlessly removing a tooth from a patient with caries.

There are several objective reasons to be wary of general anesthesia in children:

• Allergic reaction for the drug used. In the case of Sevoran, the most popular inhalation anesthetic used in pediatric dentistry, this is extremely rare. However, all clinics that are certified to carry out such procedures should be equipped with a first aid kit with fast-acting antiallergic drugs, which, if necessary, will help prevent any undesirable consequences.
• Aspiration pneumonia or asphyxia due to vomiting during treatment. To avoid such phenomena, parents are given clear instructions on how to prepare the child for anesthesia (six-hour fast and four-hour dry pause). This is the sole responsibility of the parents. If this rule is violated, general anesthesia on an outpatient basis is not performed or immediately terminated when this fact is revealed after it has begun.
• Negative effects of anesthesia on brain cells. This argument is often used by opponents of general anesthesia in children. However, there is no scientific evidence of this phenomenon in the context of the use of minimal doses of drugs in dental practice. At least this applies to the drug "Sevoran".
• Malignant hyperthermia. This is extremely rare genetic disease, which occurs in about 1 out of 80,000 people (according to WHO data for 2015, more than 700,000,000 general anesthesias were performed worldwide using the Sevoran drug). Unfortunately, at present, there is no available test registered in Russia that allows diagnosing this pathology in a child in advance. However, qualified anesthesiologists-resuscitators are well aware of it and are ready to take all possible measures at the first symptoms of a crisis.
• Deterioration of well-being due to exacerbation of existing chronic diseases (heart, lungs, and so on). For each patient planning dental treatment under anesthesia, doctors prescribe tests and examinations aimed at eliminating such complications. The anesthetist monitors the sleeping child's vital signs throughout the process, eliminating the unexpected scenario.
• Medical error or equipment failure. The only way to eliminate this circumstance is to choose a clinic that has all the necessary permits for conducting anesthetic and resuscitation measures. It is important that doctors have extensive experience working with children (especially with children) and that they have everything they need at their disposal.

Thus, taking into account all the risks in each specific case, one can easily determine the personal attitude to the use of anesthesia in pediatric dentistry.

Preparing children for dental treatment under anesthesia

Proper preparation for dental treatment of a child under anesthesia is a prerequisite for successful treatment. It starts at least a few days before the expected date of treatment. In order for doctors to be confident in the safety of anesthesia, parents need to receive test results and diagnostic procedures(ECG, complete blood count and clotting time, as well as a conclusion from other specialists if the child has various kinds of diseases). It is important to communicate in advance with an anesthesiologist-resuscitator, who will assess the scope of the planned intervention and prepare consumables. Finally, everything possible must be done so that the child does not catch a cold on the eve of treatment.

On the day on which dental treatment is scheduled under anesthesia, you can not feed the child six hours before the procedure and drink water four hours before. And yet, it is important to control that he does not eat or drink anything behind your back (check the pockets of the child’s clothes, the glove compartment in the car, etc.). If the appointment is in the afternoon, plan for a walk or an outdoor activity, for example, so he won't be tempted to pop into the kitchen.

Types of anesthesia for dental treatment in children

There are two main types of general anesthesia used in pediatric dentistry:

• Inhalation anesthesia - the most sparing, both from a physiological and psychological point of view, a method of introducing into a drug-induced sleep. The child falls asleep in 15–20 seconds under the influence of a mixture of anesthetic, medical oxygen and air supplied through the mask. The most sparing, most harmless and safe drug for inhalation general anesthesia in pediatric dentistry is currently original drug"Sevoran" (Abbott Laboratories LTD, USA).
• Intravenous anesthesia achieved by injection of the drug "Diprivan" (and its analogues). Usually this method is used in children with a pre-installed intravenous catheter, when there is no need to pierce the skin, which is inevitably accompanied by the excitement of the baby.

The duration of general anesthesia is determined only by a pediatric anesthesiologist-resuscitator based on the health status of a small patient, the volume and complexity of the upcoming treatment - with the informed consent of the parents.

During the procedure

Since the goal of dental treatment under anesthesia is to minimize discomfort for the child, the procedure itself is organized so that the little patient does not feel a “trick” for a minute. As a rule, in the office where manipulations will be carried out, nothing reminds of a hospital. The kid is offered to breathe through the mask under the pretext of playing astronaut or other playful task, after which he imperceptibly falls asleep in his parent's arms. After the examination, when the doctors together with the parents decide on the scope of the intervention, the mothers and fathers leave the office and wait in the cozy lobby for the completion of the treatment. When the teeth are cured, and the anesthesiologist-resuscitator is convinced of the stability of all vital signs, the child will be transferred from the dental office to a soft couch, where he will wake up. Thus, the child does not experience any discomfort and nervousness. Only mothers and fathers are worried. And this is absolutely normal.

In one session of anesthesia, doctors can treat a large number of diseased teeth with high quality, which will save the family time and nerves.

Child after dental treatment under general anesthesia

Waking up from anesthesia is different from just waking up. When the treatment is over, mom and dad are invited to the “awakening room”, where the baby comes to his senses. The child may be offered to drink sweet tea to restore strength, watch their favorite cartoons, and perhaps be presented with small gifts for courage. Under the supervision of doctors, the child is still for some time (no more than an hour). Within 1.5 hours after waking up, a small patient can be fed. The first meal after a long hungry pause should be agreed with the anesthesiologist-resuscitator. The food should not be heavy on the child's stomach. You can also think in advance how tasty (and harmless to teeth) to pamper your baby.

Children's anesthesia in dentistry is a forced measure: ideally, a child should not encounter caries and other diseases of the oral cavity at all. But if the trouble did occur and treatment is inevitable - remember that comfortable and painless treatment teeth is a common practice in modern medicine. Therefore, feel free to choose the approach that minimizes any discomfort for all participants in the process.