1. INHALATION ANESTHESIA VS
INHALATION ANESTHESIA VS. TOTAL INTRAVENOUS ANESTHESIA FOR AMBULATORY DENTAL SURGERY IN CHILDREN
Kristin D. Neal

2. Committee Members Dr. Alberto Coustasse, DrPH, MD, MBA, MPH
Committee Chair
Graduate of Business, Marshall University
Dr. Cassy Taylor, CRNA, DNP, DMP
CAMC School of Nurse Anesthesia
Steve Lusk, CRNA
CAMC Health System, Memorial Hospital

3. Why I Chose This Topic
Until recently, inhalation anesthesia has dominated the practice of general anesthesia in pediatrics.
Total Intra Venous Anesthesia (TIVA) is now being used more frequently in children.
Growing number of children requiring general anesthesia for dental procedures (over 10,000 charts in 9+ years).

4. Background Dental Caries Also known as tooth decay.
Most common chronic childhood disease in the United States.
Can lead to loss of function, pain, infection, and other preventable diseases without proper treatment.

5. Background General Anesthesia for Pediatric Dental Procedures
American Academy of Pediatric Dentistry has recognized that dental care through nonpharmacologic techniques is not feasible with all children.
Pediatric dental procedures are increasingly performed under general anesthesia due to disabilities, medical conditions, inadequate cooperation, circumstantial anxiety, and other behavioral issues.

6. Background Inhalation anesthesia
Most commonly used technique for pediatric anesthesia.
Effective, reliable, safe, stable, and easy to deliver.
Sevoflurane is the inhalation agent of choice in pediatric patients.

7. Background Advantages of Sevoflurane Disadvantages of Sevoflurane
Smooth and rapid induction due to its nonpungency and rapid increases in alveolar concentrations.
Fast recovery when the anesthetic is discontinued due to the limited solubility which reduces its potency.
Disadvantages of Sevoflurane
Can induce hyperalgesia and increase peripheral and central sensitivity to heat, pressure, or surgical incision.
20% incidence of Post Operative Nausea & Vomiting (PONV).
Must maintain large concentration during induction to prevent movement while attempting intravenous (IV) access.

8. Background
TIVA
Recent appealing option for general anesthesia in pediatric patients.
Propofol is the drug of choice due to its pharmacodynamic and pharmacokinetic properties.
Induction of anesthesia with propofol is achieved within seconds due to increased metabolism of children.

9. Background Advantages of TIVA with Propofol
Effective at reducing incidence of PONV due to its antiemetic properties.
Improved quality of emergence with smooth and peaceful recovery in children.
Disadvantages of TIVA with Propofol
No reliable, noninvasive measure to estimate the depth of anesthesia.
Detecting a disconnect in the IV line or subcutaneous infiltration of TIVA can be difficult as the arms of children are frequently tucked.
Limited availability of syringe pumps and lack of efficiency with dismantling and refilling pumps.

10. Statement of Problem
Optimal recovery from anesthesia is vital in the pediatric population.
Postoperative pain is the single most important problem following general anesthesia for surgical procedures.
Unrelieved pain can increase pain vulnerability later in life.
Pain upon emergence results in increased postoperative interventions and distressed parents.
PONV can lead to lead to dehydration with unplanned hospitalization following surgery.
Prolonged Post Anesthesia Care Unit (PACU) Length of Stay (LOS) from oversedation results in slower discharge of patients, which is not conducive to ambulatory surgery.

11. Potential Benefit
Increased knowledge regarding these methods of pediatric anesthesia can provide anesthetists with information for application of the best practice method and result in an improved quality of recovery in pediatric patients.

12. Literature Review
Konig, et al. (2009) found the use of sevoflurane significantly increased incidence of PONV and number of postoperative nursing interventions compared to propofol.
Children anesthetized with propofol required less pain medication.
Discharge criteria was met 10 minutes earlier in children who received sevoflurane.
Parental satisfaction with child’s recovery was equal in both groups.

13. Literature Review
Pieters, et al. (2010) found less administration of fentanyl in the PACU with propofol anesthesia compared to sevoflurane anesthesia.
Incidence of PONV was 36.8% in the sevoflurane group compared to 5.4% in the propofol group.
Total time spent in PACU was the same for both groups.
Equal parental and PACU nurse satisfaction for both groups.

14. Literature Review
Chandler, et al. (2013) found a higher pain score in the sevoflurane group compared to TIVA group.
Longer duration of PACU stay was observed in the TIVA group.
Researchers thought an improved postoperative experience with less pain was of more value than decreased PACU LOS.

15. Literature Review
Hasani, Gecaj-Gashi, Llullaku, & Jashari (2013) found children anesthetized with propofol reported less postoperative pain and did not require analgesics for the first 120 min following surgery.
Children anesthetized with sevoflurane had significantly higher pain scores and required analgesics immediately after surgery.
Recovery time was shorter in the sevoflurane group.
Incidence of PONV was increased in the sevoflurane group.

16. Literature Review
Bryan, et al. (2009) found equal induction times with the use of sevoflurane and propofol.
Shorter PACU LOS in the sevoflurane group.
Results verified both anesthetic techniques were equally safe in pediatric patients.

17. Research Purpose
To compare inhalation anesthesia with sevoflurane versus TIVA with propofol infusion as it relates to improved quality of recovery measured by postoperative pain, PONV, and PACU LOS in pediatric patients undergoing ambulatory dental surgery.

18. Methodology Research Hypothesis
Pediatric patients anesthetized via TIVA with propofol for ambulatory dental surgery would have decreased postoperative pain compared to those anesthetized by inhalation with sevoflurane.
Children in the propofol group would have less frequencey of PONV than the sevoflurane group.
Children in the propofol group would reach discharge criteria faster, resulting in a decreased PACU LOS.

19. Methodology Research Design: Research Setting: Retrospective
Quantitative
Randomized
Case-control
Research Setting:
CAMC Women and Children’s Hospital
CAMC Memorial Hospital Surgicare
CAMC Teays Valley Hospital

20. Methodology Sample Population:
200 patients randomly selected from 10,640 charts from January 1, 2006 through June 1, 2015.
100 patients had documentation as general anesthesia by inhalation with sevoflurane on the intraoperative record.
100 patients had documentation as general anesthesia via TIVA with propofol on the intraoperative record.
Patients were limited to those receiving outpatient dental procedures requiring general anesthesia for use of similar anesthetic technique.

21. Methodology Sample Population: Inclusion criteria: Exclusion criteria:
Male or female.
Ages 2-12 years old.
Scheduled for ambulatory dental surgery requiring general anesthesia.
American Society of Anesthesiology (ASA) physical status I and II.
Exclusion criteria:
<2 years of age and >12 years of age.
ASA class III, IV, V, VI.
Medical contraindication to the use of any drugs used in the study.
History of malignant hyperthermia.
Incomplete medical record information.

22. Methodology Independent Variables: Dependent Variables:
Administration of sevoflurane
Administration of propofol infusion
Dependent Variables:
Postoperative pain score
Frequency of PONV
Length of surgery
Control Variables:
Gender
Age
Body Mass Index (BMI)
ASA status

23. Data Collection
Retrospective review of existing medical records in the Electronic Medical Record.
Data collection tools were developed.
Data were collected and analyzed using the Statistical Package for Social Sciences (SPSS) Version 21.
A p-value <.05 was considered statistically significant for this research.

24. Comparison of Patient Demographics and Clinical Data
Variable
Total Sample
(N=200)
Sevoflurane Group (N=100)
Propofol Group (N=100)
Statistical Value
p-value
Age (years)
4.75
4.87
4.63 NS
BMI (kg/m2)
17.13
17.18
17.08
Length of Surgery (minutes)
58.04
54.65
61.42
Postop Pain Score
.68
1.11
.24
PACU LOS (mintues)
38.65
37.98
39.32
Gender %
Female
45%
47%
42%
Male
55%
53%
58%
NS=Not Significant (p>.05)

25. Results
There were 114 patients with an ASA physical classification of I and 86 patients with an ASA physical classification of II.
A Chi-square test revealed no statistically significant association between ASA physical classification and Group S or Group P (p>.05)

26. Results Group S had 47 female patients and 53 male patients.
Group P had 42 female patients and 58 male patients.
A Chi-square test revealed no statistically significant association between gender and Group S or Group P (p>.05).

27. Logistic Regression Analysis between PONV and Sevoflurane Group and Propofol Group in Pediatric Patients Undergoing Ambulatory Dental Surgery Under General Anesthesia
Score df
Sig.
Gender
1.253 1 NS
Age
1.460
BMI
.004
Length of Surgery
.431
Drug Used
1.005
ASA
1.332
NS=Not Significant (p>.05)
No statistical difference in the association between type of anesthesia, gender, age, BMI, ASA, and length of surgery with the frequency of PONV within the groups (p>.05).

28. Linear Regression Analysis between Postoperative Pain Scores and Sevoflurane Group and Propofol Group in Pediatric Patients Undergoing Ambulatory Dental Surgery Under General Anesthesia
Unstandardized Coefficients
Standardized Coefficients B
Std. Error
Beta t
Sig.
Constant
2.901
.852
3.405 NS
Gender
.047
.266
.013
.179
Age
-.083
.062
-.100
-1.339
BMI
-.057
.037
-.109
-1.501
ASA
.267
.276
.070
.966
Length of Surgery
.077
.005
.099
1.394
Drug Used
-.968
.262
-.265
-3.695
*.001
a. Dependent Variable: Postop Pain Score, *Indicates Statistical Significance (p<.05), NS=Not Significant (p>.05)
Statistical significance in the drug used (p<.05).

29. Linear Regression Analysis between PACU LOS and Sevoflurane Group and Propofol Group in Pediatric Patients Undergoing Ambulatory Dental Surgery Under General Anesthesia
Unstandardized Coefficients
Standardized Coefficients B
Std. Error
Beta t
Sig.
Constant
57.440
7.114
8.075 NS
Gender
.517
2.217
.017
.233
Age
-.550
.515
-.081
-1.068
BMI
-.964
.317
-.225
-3.044
*.003
ASA
-3.745
2.306
-.120
-1.624
Length of Surgery
.002
.043
.004
.056
Drug Used
1.367
2.187
.044
.625
a. Dependent Variable: Postop Pain Score, *Indicates Statistical Significance (p<.05), NS=Not Significant (p>.05)
The BMI did indicate a statistical significant for PACU LOS and drug used where as BMI increased, PACU LOS decreased (p<.05).

30. Discussion
A decreased association between average postoperative pain score with the administration of propofol.
No association between frequency of PONV and type of anesthesia administered.
Only 1 out of 200 patients received an antiemetic drug in the PACU.
Finding suggests anesthesia providers are aware of importance of PONV prevention and administer an antiemetic before complications arise.

31. Discussion
No statistically significant decreased association between PACU LOS with propofol, but rather similar average PACU LOS between the two groups.
BMI did indicate statistical significant association between PACU LOS and drug used where as BMI increased, PACU LOS decreased.
This finding could be explained by the tendency of anesthesia providers to under treat overweight/obese patients.
Pediatric patients with an increased BMI are more likely to have oxygen desaturation, difficult mask ventilation, PACU upper airway obstruction, and hospital admission following outpatient surgery.

32. Limitations Retrospective case-control design. Documentation errors.
Information from three hospitals all owned and governed by same corporation.
Limited to outpatient dental procedures.
Patients who received analgesics or antiemetics intraoperatively were not excluded.
Objective pain scale used.

33. Conclusion Implications Decreased pain scores
Use of TIVA via propofol infusion was associated with decreased pain scores.
Improved patient and parental satisfaction.
Less PACU nursing interventions and LOS.

34. Conclusion Implications Decreased frequency of PONV Increased PACU LOS
Less incidence of dehydration and unplanned hospitalization.
Decreased PACU LOS.
Increased PACU LOS
Results in more cost to the patient.
Less turnover time between patients in a fast paced outpatient setting results in more cost to the hospital.

35. Conclusion
With the growing trend of general anesthesia for pediatric patients undergoing ambulatory dental surgery, results from this study suggest favorable outcomes with the use of TIVA via propofol infusion.
Anesthesia providers should be knowledgeable in various techniques of pediatric anesthesia care and tailor the anesthesia plan to each child.
The results of this research can enhance the quality of care being provided and improve overall patient safety and satisfaction as well.

36. Questions?