General Anesthesia for Three-year-old?

We have a 3 1/2 year old son who needs deep cavity work done on his two front teeth. Our pediatric dentist is recommending general anesthesia in the form of Ketamine and Versed. Can you comment on the reputation of this form of anesthesia?

Also, we would like to be in the room with our son or at least be able to monitor him through the window outside the room. Is our request to be in the room or monitor our child unusual or unacceptable in dental etiquette, because the anesthesiologist says that we can't? (We haven't pushed him on this issue, yet.)

Question:

Ketamine produces a type of anesthesia known as dissociative anesthesia. The patient appears to be awake, has his eyes open, and can move his muscles, but he is disassociated from, or unaware of, the environment. Ketamine is generally used for short procedures and is commonly used in for dental procedures in pediatric patients. It is used as an induction agent for general anesthesia, and the onset of action is rapid (usually less than 1 minute). The duration of clinical effect is about 10 minutes. The usual induction dose is about 1-2 milligrams per kilogram of weight. More can be added during the procedure if necessary. However, the higher the dosage of ketamine administered, the longer the recovery period may be.

One main advantage of ketamine is that it does not depress the respiratory system as other general anesthetic agents do. It is also nonirritating to the blood vessels and tissues.

Disadvantages of ketamine include possible increases in heart rate, blood pressure, and eye pressure. The worst disadvantage may be the ability of ketamine to produce a confused state, which can be associated with unpleasant dreams and hallucinations. This reaction is much more common in adults than in children. Some studies have shown that this reaction occurs in about 24% of patients over 16 years, while less than 8% of patients under 16 years old had this reaction (Sussman, D.R. "A comparative evaluation of Ketamine anesthesia in children and adults" Anesthesiology 40:459, 1974). The incidence of this reaction can be minimized by allowing recovery in a quiet, darkened area.

Midazolam (or Versed) is a benzodiazepine compound. The rapid onset of action (about 55 to 143 seconds) for induction of general anesthesia and short half- life of this drug make it ideal for outpatient or ambulatory sedation procedures. One advantage of midazolam is that it produces anterograde amnesia (i.e. the patient generally does not remember anything about the procedure or recovery). In typical doses, it has minimal effect on cardiovascular and respiratory systems. However, careful monitoring needs to be done because diazepam and midazolam are two of the benzodiazepines which can depress the respiratory system by direct depression of the central respiratory drive. Dosages (about 0.15 mg/kg) should be administered slowly, over at least 2 minutes, to carefully evaluate the sedative effect. The most common complaint after administration of Versed is dizziness.

Both ketamine and midozolam are commonly used for this type of procedure. General anesthesia always is accompanied by certain risks, but these risks are greatly reduced by knowledge of the drugs and careful monitoring of the patient.

Your desire to be with your son during the operation is normal. However, it is extremely uncommon for parents to accompany their child into the room while the child is under anesthesia. The anesthesiologist and the dentist need to fully concentrate on the patient. Space may also be limited in the treatment room. This is a surgical procedure in a sterile environment. No one but the patient and caregivers are usually allowed in the operating room. Viewing the procedure through a window may also be limited to medical personnel. The policy for this may vary, however. It is worth asking the doctors, but chances are that you will not be able to view your son during the operation. Jon, this may seem like a harsh rule, but it really will help the doctors focus on your son's well-being. I am sure your son will receive excellent care. Feel free to express your concerns to the doctors before the procedure. They should be able to provide more details to help ease your concerns. I hope this information is helpful.

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