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提要：小儿麻醉前准备的目的在于尽量缓解患儿与家庭成员的恐慌与焦虑,详细了解患儿外科疾病和其他并存疾病,对麻醉中可能出现的问题做出评估,拟定相应的防范措施,降低围术期疾病的发生率,改善患儿预后。麻醉前对患儿身体情况的准确评估与详尽的准备,是保证麻醉安全与手术顺利进行的基础。本文从麻醉前访视、术前禁食、麻醉前用药、特殊疾病患儿、麻醉用具等方面对小儿麻醉前准备与用药进行阐述。     

Rectal ketamine and midazolam for premedication in pediatric dentistry

Rectally administered midazolam (0.30 mg/kg) and ketamine (5 mg/kg) were compared for preanesthetic medication in children undergoing dental extractions. Sixty patients between the ages 2 and 9 years were randomly allocated to three groups in this double-blind study. In one group of patients who received ketamine rectally, intravenous midazolam (0.05 mg/kg) also was administered immediately after induction of anesthesia. The results from this trial show that 30 minutes after rectal administration of the two drugs, good anxiolysis, sedation, and cooperation were obtained in most patients. Although midazolam appeared to be marginally more efficacious than ketamine in the majority of assessments made and seemed to have less adverse effects, no statistically significant differences could be shown. Ketamine showed a slight decrease and midazolam a slight increase in average blood pressures after premedication. These blood pressure differences were, however, considered to be of little clinical importance.     

Recall rates and caries experience of patients undergoing general anesthesia for dental treatment

PURPOSE: The purpose of this study was to evaluate the recall rate and caries experience of children seen under general anesthesia (GA) at The University of Iowa Hospitals and Clinics. METHODS: After a retrospective chart review, information from 217ASA (American Society of Anesthesiologists) 1 patients undergoing GA between 1998 and 2002 was gleaned regarding: (1) date of GA; (2) age at time of GA; (3) follow-up (recall) visits; (4) referral status; (5) new caries experience; and (6) treatment of new/recurrent lesions. A 19-question survey was also mailed to parents/legal guardians for satisfaction. RESULTS: Survey data were not reported in this study due to the poor (25%) return rate after several attempts: 41% of the patients were referrals; 54% returned for a 2 week postoperative visit, but only 13% returned for a 6-month recall, with subsequent recoils being even lower; 72% were insured by Medicaid; and 25% had recurrent or new lesions at follow-up appointments. CONCLUSION: Recall rates after general anesthesia for dental treatment at a university hospital are very low, and new or recurrent caries experience is high.     

Nasal versus oral midazolam sedation for pediatric dental patients

PURPOSE: The purpose of this study was to evaluate and compare intranasal (IN) and oral (PO) midazolam for effect on behavior, time of onset, maximum working time, efficacy, and safety for patients requiring dental care. METHODS: Forty anxious subjects (20 IN, 20 PO, Frankl Scale 3 and 4, ages 2-6 years, ASA I and II) were sedated randomly with either IN (0.3 mg/kg) or PO (0.7 mg/kg) midazolam. The dental procedure under sedation was videotaped and rated by a blinded and calibrated evaluator using Houpt's behavior rating scale. RESULTS: There was no statistical difference for overall behavior (F3,27 = 0.407; P = .749). The planned contrasts showed significant interactions between time and route (IN vs PO) between 25 and 30 minutes after starting sedation. The time of onset (P = .000) and the working time (P = .007) were significantly different between IN and PO midazolam. There were no statistically significant differences in vital signs (O2 sat, HR, RR, BP) between PO and IN (P = .595). IN subjects showed more movement and less sleep toward the end of the dental procedures, and faster onset time but shorter working time than PO. Vital signs were stable throughout the procedures with no significant differences. CONCLUSIONS: Mean onset time was approximately 3 times faster with IN administration compared to PO administration. Mean working time was approximately 10 minutes longer with PO administration than it was with IN administration. Overall behavior under PO and IN was similar. However, more movement and less sleep were shown in subjects under IN than those under PO toward the end of the dental session. All vital signs were stable throughout the procedures and showed no significant differences between PO and IN administration.     

儿童口腔门诊全身麻醉操作指南

近年来,在全身麻醉状态下完成门诊儿童口腔诊疗,已逐渐发展成为一种较成熟的行为管理模式。由于门诊儿童口腔诊治时间短、流动性大、周转快,对麻醉及诊疗期的管理提出更高要求。中华口腔医学会镇静镇痛专业委员会组织专家,制定儿童口腔门诊全身麻醉操作指南,从口腔门诊实施全身麻醉的范围、临床基本条件、口腔诊疗种类、诊治前评估与准备、麻醉实施与监测、恢复和苏醒期管理、常见并发症及处理要点等方面给出具有可操作性的实施规范,对促进我国儿童门诊全身麻醉下口腔诊疗安全性和舒适化的快速发展具有重要意义。     

右美托咪定复合七氟烷在儿童口腔全麻治疗中的效果评价

目的: 观察右美托咪定复合七氟烷用于儿童口腔全麻治疗的疗效及其影响因素。方法: 将120例拟行口腔全麻治疗（>90 min）的患儿随机分为右美托咪定复合七氟烷组（D组）和七氟烷组(S组),每组60例。D组经面罩吸入4%~6%七氟烷,静脉推注芬太尼1 μg/kg,咪唑安定0.1 mg,丙泊酚2 mg/kg,罗库溴铵0.3 mg/kg。待患儿睫毛反射消失后,进行气管插管,以2%~3%七氟烷吸入维持。手术开始时,泵注丙泊酚,速度为9~12 mg/(kg·h);同时先以1 μg/kg速度泵注右美托咪定15 min后,减为0.5 μg/（kg·h）维持直至手术结束。S组未泵注右美托咪定。监测患儿入室（T1）、睫毛反射消失（T2）、泵注右美托咪定10 min（T3）、手术开始（T4）、手术结束（T5）时的心率（HR）、平均动脉压（MAP）及Ramsay镇静评分,记录手术完成时间、手术后患儿苏醒时间、拔管时间、麻醉后恢复室（PACU）内小儿苏醒期躁动评分（PAED）。采用 SPSS 20.0软件包对数据进行统计学分析。结果: 2组手术完成时间比较差异无统计学意义;术中T3-T5时D组MAP、HR显著低于S组（P<0.05）, Ramsay镇静评分显著高于S组（P<0.05）;D组苏醒时间、拔管时间显著高于S组;在PACU内,D组小儿苏醒期PAED评分显著低于S组。结论: 右美托咪定复合七氟烷用于儿童口腔全麻手术,患儿循环指标稳定,对呼吸影响小。虽然苏醒时间有所延长,但可提高苏醒质量。     

Parental anxiety levels during pediatric induction with and without administration of premedication for general anesthesia

This study measured parental anxiety before, during, and after elective dental procedures under general anesthesia using the Spielberger State-Trait Anxiety questionnaire. State anxiety started relatively high before the procedures, peaked immediately after induction using general anesthesia, and dropped during recovery to below the initial score. Parents, whose children were premedicated and fathers in general, had significantly higher anxiety immediately after induction. This study supports interventions to lower anxiety of the parents as well as that of children.     

A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation

PURPOSE: The purpose of this pilot study is to report a cost comparison of general anesthesia (GA) versus oral conscious sedation (CS) for the treatment of pediatric dental patients. METHODS: The study sample included 22 children whose parents/guardian selected GA care for their child. Selection criteria limited inclusion to healthy children (ASA I) ages 24-60 m.o. The subjects acted as their own comparison group to an estimation CS model. Models were developed to assess societal costs for treatment under GA and CS. Treatment rendered was equalized using the dental Relative Based Value Units Scale (RBVU). RESULTS: Ordinary Least Squares Regression analysis techniques showed the association of RBVU to the total societal costs of GA and CS to be significant (P < 0.01) with an adjusted R2 of .64 and .78 respectively. When regression lines were plotted, the intersection represented RBVU level at which societal costs of GA and CS were the same. CONCLUSION: Under the conditions of this pilot study, it is concluded that CS costs exceed GA costs at a RBVU level of 66.4, which would equate to more than three CS appointments.     

Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia

The promulgation and adoption of intraoperative monitoring standards in medicine for anesthesia has resulted in early detection of untoward events during sedation and anesthesia, lowering of malpractice premiums, and an improvement in the quality of care. The American Dental Society of Anesthesiology has devised specific, detailed monitoring standards with universal applicability in the dental setting.     

A review of repeat general anesthesia for pediatric dental surgery in Alberta, Canada

PURPOSE: The purpose of this study was to review data from the province of Alberta, Canada for First Nations children who required more than 1 general anesthesia (GA) procedure for dental surgery from 1996 to 2005. METHODS: This study was limited to First Nations and Inuit children younger than 18 years old in Alberta who received 2 or more GA procedures to facilitate dental treatment Data spanning 1996 to 2005 were provided from the Alberta Regional Office of First Nations & Inuit Health Branch, Health Canada. RESULTS: The entire database contained claims for 339 children who received repeat GA procedures for rehabilitative dental core. Seventy-six percent received 2 procedures, while the remainder underwent 3 or more surgeries. Twenty-four percent of First Nations children in this cohort were subjected to >2 GA procedures. Retreatment of previously restored teeth was a common observation. The majority of children were treated by general practitioners instead of pediatric dentists. Seventy-four percent who had 2 or more surgeries were treated by general dentists at the time of the first GA procedure. The mean age of children at the time of the first GA procedure was not associated with whether children received 2 or more GA procedures for dental care (P=.07). CONCLUSIONS: These data suggest that there may be on over-reliance on GA to treat dental caries for First Notions children in Alberta.     

应用牙科全麻技术治疗30例儿童牙病患者的疗效分析

目的:分析应用牙科全麻技术(DGA)治疗的30例儿童牙病患者的年龄、性别等分布特征以及处置项目情况与随访结果.方法:中国医科大学口腔医学院儿童牙科2006-2007年应用DGA治疗的病例30例,一次性治疗口内所有患牙,处置项目包括龋齿充填术、间接盖髓术、活髓切断术、根管治疗术、拔牙术以及对所有牙的龈上洁治术、光滑面涂布氟保护漆、余留健康前磨牙和乳、恒磨牙窝沟封闭.对患者的自然情况、处置项目以及随访结果进行整理分析,应用SPSS10.0软件包进行χ2检验,比较不同年龄组DGA治疗病例的男女性别比例分布以及各种处置项目所占的比例在乳、恒牙之间的差别.结果:患者年龄19个月～14岁,均为不合作儿童,其中智力发育障碍者占10%,智力健康者占90%;在各年龄组中,男性患者均多于女性;在各处置项目中,龋齿充填术占18.67%,间接盖髓术占23.26%,活髓切断术占0.77%,根管治疗术占29.16%,拔牙术占2.05%,窝沟封闭术占26.09%;乳牙根管治疗术的比例高于窝沟封闭术,而恒牙则相反,统计学上有高度显著性差异(χ2=11.630,P=0.001).复查时,除2例智力发育障碍儿童外,均可配合检查治疗:经过6～12个月的复查,无一例有新龋发生,3例患儿出现充填物脱落,其中前牙3颗,根管治疗后的后牙2颗.结论:龋齿充填术和根管治疗术是儿童DGA治疗的主要项目,采取龋病的综合防治策略,能有效降低儿童的新发龋坏;DGA是对不合作儿童进行治疗的安全有效的行为管理技术.     

Risk factors for nausea and vomiting after day care general anesthesia in mentally challenged patients undergoing dental treatment

Clinically, the incidence of postoperative nausea and vomiting (PONV) may be higher in mentally challenged patients than in normal healthy patients. The aim of this study was to investigate the risk factors for PONV after day care general anesthesia in mentally challenged patients undergoing dental treatment. We analyzed data on 231 day care general anesthesia cases involving mentally challenged patients undergoing dental treatment. Anesthetic records for the past 5 years were investigated retrospectively. Ten items (age, body weight, sex, duration of general anesthesia, use of propofol, use of sevoflurane, use of nitrous oxide, use of neostigmine, treatment accompanied with bleeding, and transfusion volume) were selected as risk factors for PONV. Postoperative nausea and vomiting was evaluated using the postoperative check sheet and linear discriminant analysis was performed to distinguish PONV incidence using the 10 items as independent variables. The reliability of the linear discriminant function was evaluated using a misjudgment rate and information criteria (AIC). Postoperative nausea and vomiting was observed in 13 cases out of 231 cases. The discriminant function with the smallest AIC (-25.0718) consisted of two independent variables: y=-0.077x(1)-0.001x(2)+0.0716(x(1)=use of propofol, x(2)=age). The misjudgment rate was 31.6%. This result suggests that PONV decreases when propofol is used and that the incidence of PONV decreases with age. To investigate other risk factors, an additional analysis was performed using 83 out of the 231 cases in which sevoflurane was used as an anesthetic agent. The results of the subgroup analysis suggest that the incidence of PONV decreases in male patients and higher weight patients, although the patient's body weight may be related to age, as the study cohort included many children. It is suggested that the major risks for PONV in mentally challenged patients after day care general anesthesia are no use of propofol, lower age, female sex and lower weight.     

Comprehensive dental care of pediatric patients treated under general anesthesia in a hospital setting in Saudi Arabia

The aims of this study were to determine the characteristics of patients and type of dental treatment carried out using dental general anesthesia (DGA) during two years in a following three year period. A total of 182 patients received treatment between 1999 and 2001. The mean age was 4.9 years. The main indication for DGA was behavior management problems. Complete oral rehabilitation including complex restorative treatment and extractions was provided under DGA at a single visit. Failure to return for recalls was common; 83% of patients returned for the post-operative recall but only 26% after a three year period. Most of the patients requiring further treatment accepted it in the dental chair. Only one patient received a second DGA during the three years following treatment.     

The effects of general anesthesia legislation on operating room visits by preschool children undergoing dental treatment

PURPOSE: The purpose of this study was to examine the impact of state-level general anesthesia (GA) legislation on operating room visits for the treatment of dental caries on preschool-aged children. METHODS: The North Carolina Ambulatory Surgery Discharge Database was used to observe GA visits for fiscal years (FY) 1997 to 2001. A pretest/post-test design with concurrent comparison groups was used for 2 analyses: (1) all children treated for dental caries were compared to those treated for otitis media; and (2) those whose treatment for dental caries was reimbursed by Medicaid were compared to those whose treatment for dental caries was not reimbursed by Medicaid. RESULTS: In the prelegislation period (FY 1997 and 1998), there were 3,857 GA visits for dental core and 21,038 for otitis media. Postlegislation (FY 2000 and 2001) dental visits increased to 5,511(43%), and otitis media visits increased to 22,279 (6%)-a statistically significant difference (P<.05). Before the legislation, there were 1,370 non-Medicaid dental visits and 2,487 Medicaid dental visits. Non-Medicaid and Medicaid dental visits postlegislation increased to 2,195 (60%) and 3,316 (33%), respectively. This difference was significant (P<.05). CONCLUSIONS: General anesthesia legislation resulted in an increase in access to care for children needing dental care in North Carolina.