Week of procedure:

Ideally after you and your dentist have decided on proceeding with anesthesia you will get a COVID-19 test for your child.  We would like to know the status of your child for the safety of staff and the patient.  Although we will practice COVID-19 safe procedures regardless of known status, we can better advise you if the test is done.  If your child has developed any recent respiratory tract symptoms, fever, or exposure to individuals with these symptoms we may decide it is best to delay the procedure.  The pediatric dentist office will do a thorough review of symptoms and history prior to scheduling in order to screen for safety.

Day before procedure:

On the day before the procedure our anesthesiology team will contact you.  Preferably one contact number will have been designated.  We will confirm your child’s medical history as well as any allergies.  We will verbally take you through the procedure step by step.  NPO orders (not drinking or eating after midnight prior to the procedure) will be confirmed.  All questions regarding monitoring, medications, safety, and post anesthesia expectations will be discussed in our phone call with you.

Day of procedure:

The procedure space will have been thoroughly cleaned and wiped down before initiating any anesthesia. Oxygen and other gas flows will have been checked. Our monitors will have been positioned and initialized.  Necessary medications for the anesthesia will have been prepared.  An IV and breathing circuit will have be readied.  Safety and resuscitative medications are checked.  We are now ready for your child.

Step 1. A premedication known as versed (midazolam) will be administered.  Versed is a benzodiazepine similar to Valium but it works much more quickly and doesn’t last nearly as long.  It will be administered nasally for those children that are not good at taking oral medications (usually most children under 5).  It will be given orally (mixed with a small amount of flavored Tylenol or Motrin ) for those children that will cooperate with drinking the medicine.  Either way the effect is usually evident within 10 minutes or so of intake.  The children probably feel about like having a couple of glasses of champagne for the first time very quickly. Most children will be goofy and giggly. The medicine will make the initial separation much easier.

Step 2. Next, we will transport your child back to our procedure area.  Once there we will make them comfortable and have them start breathing some nitrous oxide (laughing gas) through a flavored mask.  We will start to get monitors on at this time.  The addition of laughing gas to the versed is all in preparation for an IV.

Step 3. At this point we will place an IV.  The IV is of a small gauge, usually 22g or 24g.  If your child were wide awake this size IV feels like a hard pinch but with the versed and nitrous oxide working they will barely notice it.  It will not be a traumatic event. As we secure the IV we will complete our monitoring placement.

Step 4. Shortly after the IV is in place we will have them under general anesthesia with our main anesthetic Propofol.  Propofol is used because the level of anesthesia can be varied quickly from deep to much lighter depending on the level of stimulus.  These variations can be made without significantly altering the wake up time at procedure end.  Propofol also has a mild side effect profile and has been noted not to cause nausea post procedure. This results in almost immediate return to eating and drinking.

Step 5. As we have started general anesthesia we will secure the safety of the airway and respiratory status by placing an appropriately sized endotracheal tube (breathing tube).  This will insure that the patient always has an unimpeded source of oxygen and can breath out the CO2 they produce.  It helps to protect the airways/lungs from dental debris accidentally contaminating or even blocking the ability of your child to get oxygen.  We are monitoring the O2/CO2 throughout.

Step 6Other parameters that we are monitoring on a constant basis are the blood pressure, the ECG, the body temperature, and most importantly the Oxygen saturation.  Oxygen blood saturation is continuously monitored with the use of Pulse Oximetry.  This is the standard level of monitoring used in operating rooms. 

Step 7At the conclusion of the dental procedure we will thoroughly suction any remaining debris from the mouth and stomach.  When your child has established a reliable breathing pattern we will remove the breathing tube.  We will then observe your child’s breathing for approximately 10 minutes with the breathing tube out to make sure they are adequately maintaining their airways without assistance.  At this point we will bring your child to you.

Step 8Your child will recover in your arms.  In general, as children awake, there will be a period of what we refer to as “emergence”.  “Emergence” is often an emotional state where the children are trying to reorient themselves to the situation, their mouths feel different (often numb), they are often unhappy that they are not at home. As they  progress through this phase they will become more focused on letting their parents know that they want to go home and they become more verbal.  You may also notice that their breathing and cries have a dry almost hoarse quality to them when we initially bring them to you.  This is because we give a drying agent at the start of the case to help with the integrity of the dental restorations. There is also a small gauze that is placed at the back of the mouth by the dentist prior to the start of the procedure to catch stray debris. This may also contribute to the dryness.  This hoarse sound usually resolves with a little water. 

Step 9Home!  On average this will occur 20-25 minutes after we have brought your child to you post procedure.  Before you leave we will discuss how to approach eating and pain control. We recommend a quiet day at home with a return to normal activities the following day.