Airway management for dental clearance in a preschool child: A UK survey

Dental extractions are one of the most common reasons for pediatric hospital admission (approximately 82,000 children undergo general anesthesia (GA) for dental procedures in the UK)1 . These cases are undertaken in a range of clinical settings from district general hospitals to specialist referral centres and dental hospitals.


| INTRODUC TI ON
Dental extractions are one of the most common reasons for pediatric hospital admission (approximately 82 000 children undergo general anesthesia [GA] for dental procedures in the UK). 1 These cases are undertaken in a range of clinical settings from district general hospitals to specialist referral centers and dental hospitals.
Shared airway management presents a challenge to the anesthesiologist and surgeon, balancing good surgical access with provision of a reliable safe airway. High case load creates a pressure to avoid inter-case delay. Current guidelines do not address the choice of airway device, technique for maintenance of anesthesia and the timing or the technique for device removal. 2 We aimed to take a snapshot of current UK anesthetic technique and airway choice for pediatric dental extractions under GA. The responses were analyzed using SPSS (Version 25.0). Ethical approval was not required.

The Scenario:
A 4-year-old boy, with no previous GA exposure, arrives for an elective dental clearance. He is 16 kg, fit and well, has no comorbidities, no allergies, and is starved in line with local policy. He is appropriately anxious but engaged with you during your preoperative assessment. There are no behavioral issues.

| RE SULTS
There were 233 respondents, with 54% reporting monthly, or more frequent, management of pediatric dental patients. Most respondents were senior clinicians: 73% Consultant Anesthesiologists (of which 78% had specialist pediatric interest), 6% non-Consultants who had completed training, and 18% senior trainees. 61% of respondents would undertake this case in a specialist pediatric center or dental hospital. Anesthesiologists frequently undertaking pediatric dental anesthesia were more likely to choose an SAD; those not exposed in the last 12 months were more likely to choose an ETT (see Figure 1).

| D ISCUSS I ON
For this hypothetical case, most respondents would use an SAD with removal in PACU in the lateral position; however, approximately one fifth opted to intubate the child. Evidence, including one meta-analysis, has suggested SAD use in pediatric patients reduces the risks of both intra-and postoperative complications including coughing, desaturation, laryngospasm, and breath holding. 3,4 SADs also allow a lighter plane of anesthesia and avoidance of neuromuscular blocking drugs, potentially facilitating a higher turnover of cases. However, SADs may provide less protection to the airway from blood and foreign material.
The use of an anesthetic throat pack is no longer recommended in adult patients undergoing head and neck surgery due to risk of being retained postoperatively. 5 The use of a surgical throat pack should eliminate the risk of inadvertent retention as it is included in the surgical count. We

Survey question
A 4-year-old boy, with no previous GA exposure, arrives for an elective dental clearance. He is 16 kg, fit and well, has no comorbidities, no allergies, and is starved in line with local policy. He is appropriately anxious but engaged with you during your preop assessment. There are no behavioral issues.
Questionnaire 11. Do you feel an educational article with joint input from anesthetists and pediatric oral surgeons would be of interest to your clinical practice? (select one) • Yes