Dental Anaesthesia

Quick Answer

Dental anaesthesia presents unique challenges due to the shared airway between anaesthetist and surgeon. Key principles: Nasopharyngeal airway placement to maintain airway patency, throat pack insertion to prevent aspiration of blood and debris, and meticulous haemostasis. Airway management options: Nasopharyngeal airway + spontaneous ventilation most common; LMA or ETT for more complex cases; nasal intubation for mandibular/maxillary procedures. Throat pack management: Essential for preventing aspiration; must be documented, visible, and removed before extubation; use large gauge ribbon gauze or commercial packs; tie to jaw or tongue stitch. Haemorrhage risk: Rich vascular supply of head and neck; major vessels include maxillary artery branches, facial artery; controlled hypotension (MAP 60-70 mmHg) may be used. Special populations: Children often require treatment (dental caries most common reason for GA in children in Australia); learning disabilities and autism spectrum common; faciomaxillary trauma requires careful airway assessment. Recovery: Extubate awake, sitting position, suction oropharynx thoroughly, visual confirmation of pack removal. [1-25]

The Shared Airway Challenge

Concept and Implications

Definition:

• The anaesthetist and surgeon must access the same anatomical space
• Oral cavity shared between airway management and surgical field
• Continuous coordination required throughout procedure
• Limited visibility and access for anaesthetist once procedure underway

Challenges:

• Airway obstruction: Surgeon's hands and instruments in airway
• Monitoring difficulty: Face and airway obscured by surgical drapes
• Limited access: Cannot easily perform laryngoscopy or adjust airway
• Aspiration risk: Blood, saliva, irrigation fluid, tooth fragments
• Communication: Surgeon concentration on procedure may delay response
• Emergency airway management: Difficult if airway lost during surgery

Solutions:

• Nasopharyngeal airway (NPA): Maintains airway patency beyond surgical field
• Throat pack: Isolates airway from surgical site
• Head positioning: Aligns airway while providing surgical access
• Throat suction: Continuous or intermittent aspiration of secretions
• Careful monitoring: Vigilance for signs of obstruction

Airway Management Options

Option 1: Nasopharyngeal Airway + Spontaneous Ventilation

• Indication: Most routine dental extractions and minor oral surgery
• Technique: Well-lubricated NPA (size 6-8 for adults) inserted nasally
• Advantages: Preserves spontaneous ventilation, unobstructed surgical field, rapid emergence
• Disadvantages: Variable airway security, CO₂ monitoring essential, obstruction possible
• Monitoring: Continuous SpO₂, capnography (sidestream if available), airway observation

Option 2: Laryngeal Mask Airway (LMA)

• Indication: Longer procedures, higher aspiration risk, need for controlled ventilation
• Technique: Standard LMA insertion; Proseal or Supreme for better seal
• Advantages: Secure airway, enables positive pressure ventilation, gastric access (some types)
• Disadvantages: May obscure surgical field, risk of displacement during jaw manipulation
• Consideration: Throat pack placement around LMA

Option 3: Endotracheal Tube (ETT)

• Indication: Complex procedures, major maxillofacial surgery, high aspiration risk, prone/supine positioning
• Technique: Oral or nasal intubation; nasal preferred for mandibular access
• Advantages: Definitive airway protection, controlled ventilation, secure
• Disadvantages: May limit surgical access; nasal intubation requires expertise
• Secure fixation: Essential; risk of dislodgement during jaw manipulation

Option 4: Tracheostomy

• Indication: Complex maxillofacial reconstruction, significant airway compromise, prolonged ventilation expected
• Timing: May be performed as part of surgical procedure
• Advantages: Completely bypasses shared airway, secure long-term access
• Disadvantages: Invasive; complications; delayed speech

Nasopharyngeal Airway Management

Indications and Contraindications

Indications:

• Routine dental extractions
• Minor oral surgery
• Patients with obstructive sleep apnoea (maintains patency)
• Short procedures (<30-60 minutes)
• Patients with difficult mask ventilation
• Bridge between induction and definitive airway

Contraindications:

• Absolute: Basilar skull fracture (risk of intracranial placement)
• Relative: Coagulopathy (epistaxis risk), severe nasal obstruction, recent nasal surgery
• Procedure-related: Major maxillofacial surgery, prone positioning, high aspiration risk

Insertion Technique

Sizing:

• Adults: Size 6-8 (internal diameter mm)
• Measurement: Tip of nose to tragus of ear
• Better to use slightly smaller than too large
• Multiple sizes available

Preparation:

• Lubrication: Essential with water-soluble lubricant
• Nasal preparation: Topical vasoconstrictor (phenylephrine, oxymetazoline) reduces bleeding
• Patency check: Ensure nares patent bilaterally

Insertion:

• Insert perpendicular to face (parallel to hard palate)
• Advance gently along floor of nasal cavity
• Do not force; if resistance, try other nostril or smaller size
• Advance until flange at nasal opening
• May induce sneeze reflex initially

Position Confirmation:

• Air movement through airway
• Capnography waveform
• No oropharyngeal bleeding
• SpO₂ maintained
• Absence of gastric insufflation sounds

Maintenance and Monitoring

During Procedure:

• Continuous observation: Look for airway obstruction signs
• Capnography: Essential for respiratory monitoring
  • Normal waveform: Indicates adequate ventilation
  • Obstruction: Reduced or absent waveform
  • Rising EtCO₂: Hypoventilation or obstruction
• SpO₂: Continuous monitoring
• Auscultation: Chest and airway sounds

Adjuncts:

• Bite block: Prevents patient biting NPA or surgeon's fingers
• Throat pack: Essential adjunct for isolation
• Head positioning: "Sniffing" position or slight extension
• Chin support: May help maintain airway patency

Troubleshooting:

• Partial obstruction: Reposition head, adjust NPA depth, suction oropharynx
• Complete obstruction: Remove and reinsert, consider LMA/ETT
• Excessive secretions: Suction, consider anticholinergic (glycopyrrolate)
• Laryngospasm: Positive pressure ventilation, deepen anaesthesia, possible NPA removal

Throat Pack Management

Purpose and Types

Purpose:

• Isolation: Separates surgical site from lower airway
• Protection: Prevents aspiration of blood, tooth fragments, irrigation fluid
• Haemostasis: Aids in controlling minor bleeding
• Visibility: Improves surgical field by absorbing blood

Types:

1. Ribbon Gauze:

• Material: Large gauge (2-4 inch) cotton ribbon gauze
• Preparation: Fold into layered pack
• Placement: Posterior oropharynx, either side of uvula
• Securing: Tie to molar tooth, jaw wire, or tongue suture
• Visibility: Must be visible throughout procedure
• Advantages: Inexpensive, readily available, conformable
• Disadvantages: May fragment, difficult to ensure complete removal

2. Commercial Throat Packs:

• Material: Synthetic or cotton with radio-opaque marker
• Design: Tapered, often with attached tape/tie
• Features: May include x-ray detectable strip
• Advantages: Purpose-designed, radio-opaque, consistent quality
• Disadvantages: Cost, availability

3. Gauze Roll:

• Material: Large roll of gauze
• Placement: Rolled and placed in posterior oropharynx
• Securing: Long tape tied to molar/jaw
• Advantages: Simple, inexpensive
• Disadvantages: Large, may interfere with visibility

Placement Technique

Insertion:

1. Deepen anaesthesia: Prevent gagging/laryngospasm
2. Visualization: Direct visualization with headlight or laryngoscope
3. Suction: Clear oropharynx of secretions
4. Placement: Insert gently into posterior oropharynx
   • Location: Behind soft palate, either side of uvula
   • Depth: Extends from soft palate to posterior pharyngeal wall
   • Avoid: Laryngeal inlet, oesophageal opening
5. Confirmation: Visualize pack placement
6. Securing: Tie securely to tooth or jaw

Positioning:

• Must isolate oral cavity from hypopharynx/larynx
• Should not obstruct laryngeal inlet
• Must remain visible throughout procedure
• Secure attachment to prevent displacement

Removal and Documentation

Removal Protocol:

1. Before pack removal:

   • Ensure procedure complete
   • Surgeon confirms no bleeding
   • Suction oropharynx

2. Removal technique:

   • Gentle traction on securing tie
   • Slow, steady removal
   • Visualize complete pack removal
   • Inspect pack for integrity (ensure no fragments retained)
   • Count and document

3. After removal:

   • Direct laryngoscopy to ensure complete removal
   • Suction oropharynx and hypopharynx thoroughly
   • Inspect for retained fragments
   • Document removal in notes

Documentation:

• Insertion: Time, type, location, securing method
• During: Any pack displacement or replacement
• Removal: Time, complete/incomplete, any difficulties
• Count: Number of packs placed and removed (if multiple)
• Sign-off: Anaesthetist confirms removal

Critical Safety Check:

• Throat pack removal is a "Never Event" if retained
• Never extubate with throat pack in place
• Never bypass visual confirmation of removal
• Always document removal
• Consider two-person verification (surgeon and anaesthetist)

Haemorrhage Management

Vascular Anatomy and Bleeding Risk

Arterial Supply:

• Maxillary artery: Main arterial supply to deep facial structures

  • Middle meningeal artery (skull base)
  • Inferior alveolar artery (mandible, teeth)
  • Posterior superior alveolar artery (maxillary teeth)
  • Greater palatine artery (hard palate)
  • Sphenopalatine artery (nasal cavity)

• Facial artery: Superficial facial structures

  • Superior and inferior labial arteries (lips)
  • Angular artery (medial canthus)
  • Tonsillar branch

• Superficial temporal artery: Scalp and temple

• Lingual artery: Tongue and floor of mouth

Venous Drainage:

• Pterygoid plexus: Extensive venous network; difficult to control bleeding
• Facial vein: Communicates with cavernous sinus (infection risk)
• Retromandibular vein: Deep to mandible

Haemorrhage Prevention

Preoperative:

• Medication review: Anticoagulants, antiplatelet agents
• Coagulation studies: If indicated (warfarin, liver disease)
• Local anaesthesia: Vasoconstrictor (adrenaline 1:100,000-200,000) reduces bleeding
• Positioning: Head-up (reverse Trendelenburg) reduces venous bleeding

Intraoperative:

• Controlled hypotension: MAP 60-70 mmHg (controversial, not routine)
• Throat pack: Aids haemostasis
• Topical agents: Tranexamic acid, thrombin, oxidized cellulose
• Electrocautery: For significant bleeding
• Bone wax: For bone bleeding

Technique:

• Gentle tissue handling
• Identification and ligation of vessels
• Pressure packing when needed
• Skeletal stabilization reduces bleeding

Major Haemorrhage Management

Recognition:

• Blood in oropharynx despite throat pack
• Rising blood loss estimate
• Haemodynamic instability (tachycardia, hypotension)
• Surgical field obscured by blood
• Difficult ventilation (aspiration of blood)

Immediate Management:

1. Call for help: Alert surgical team, additional anaesthetist, blood bank
2. Secure airway:
   • Remove throat pack (if severely bleeding)
   • Suction aggressively
   • Consider ETT if aspiration risk or airway compromise
3. Large-bore IV access: 14-16 gauge; additional lines if needed
4. Fluid resuscitation: Crystalloid bolus; blood products if significant loss
5. Blood products: O-negative if life-threatening; type-specific ASAP
6. Haemostasis: Surgeon control bleeding; pressure; cautery; ligation
7. Medications: Tranexamic acid (1g IV); consider DDAVP if platelet dysfunction

Massive Transfusion Protocol:

• Activated if blood loss >1.5-2L in adults
• Ratio: RBC:FFP:Platelets 1:1:1
• Consider tranexamic acid, calcium supplementation
• Arterial line for monitoring
• Rewarming (hypothermia impairs coagulation)

Surgical Control:

• External carotid artery ligation (rare)
• Angiographic embolization (selected cases)
• Packing and delayed definitive control

Special Clinical Scenarios

Paediatric Dental Anaesthesia

Epidemiology:

• Dental caries: Most common reason for GA in children in Australia
• 40-50% of Australian children aged 5-10 have dental caries
• Indigenous children: 2-3 times higher rates
• Early childhood caries associated with prolonged bottle feeding, diet

Considerations:

• Airway: Smaller, more collapsible; larger tongue relative to oropharynx
• Equipment: Age-appropriate NPA (size 4-6 for children), smaller instruments
• Throat pack: Smaller size; more delicate placement
• Ventilation: Higher oxygen consumption; rapid desaturation
• Temperature: Higher risk of hypothermia; warming essential
• Fasting: Same guidelines as adults (clear liquids 2 hours, solids 6 hours)
• Postoperative: High risk of emergence delirium; parents present helpful

Parental Presence:

• Induction: Parental presence common in paediatric dentistry GA
• Parent escorted out once child anaesthetized
• Reunited in recovery
• Evidence of benefit for child anxiety

Common Procedures:

• Multiple extractions
• Stainless steel crowns
• Pulpotomies
• Restorations
• Full dental rehabilitation

Learning Disabilities and Autism Spectrum

Challenges:

• Cooperation: May not tolerate local anaesthesia or outpatient treatment
• Communication: Variable ability to consent and cooperate
• Behaviour: Challenging behaviours; stereotypies
• Medical comorbidities: Epilepsy, cardiac abnormalities (Down syndrome), respiratory issues
• Medications: Multiple psychotropic medications; interactions

Management:

• Preoperative assessment: Multidisciplinary involvement
• Carer involvement: Essential for history, consent, support
• Anxiety management: Premedication (midazolam) if indicated
• Specialized centres: Dedicated facilities for special needs patients
• Recovery: May require extra support; familiar carers present

Consent:

• Capacity assessment
• Best interests decision if lacking capacity
• Family/carer involvement
• MDT decision-making

Faciomaxillary Trauma

Airway Priority:

• Airway may be compromised by trauma itself
• Blood, oedema, foreign bodies, anatomical disruption
• C-spine precautions if high-energy mechanism
• Difficult airway: High likelihood; prepare for difficult intubation

Assessment:

• Mechanism: High-energy (MVA, assault, fall) vs low-energy
• Injuries: Lefort fractures, mandibular fractures, zygomatic injuries
• Other trauma: Head, C-spine, chest, abdomen
• Aspiration risk: Blood, gastric contents, teeth

Airway Management:

• RSI with in-line stabilization: If C-spine risk
• Nasal intubation: If midface stable; contraindicated if base of skull fracture
• Tracheostomy: If airway severely compromised or prolonged ventilation expected
• Awake fibreoptic: If difficult airway predicted
• Surgical airway: Cricothyroidotomy if cannot intubate/cannot ventilate

Anaesthetic Considerations:

• Full stomach: Assume; RSI technique
• Cervical spine: Immobilization; imaging before movement
• Head injury: ICP management; neuroprotection
• Haemorrhage: Significant blood loss possible
• Shared airway: Standard techniques with added complexity

Temperomandibular Joint (TMJ) Procedures

Indications for GA:

• TMJ arthroscopy
• Open joint surgery
• Condylar fracture fixation
• Joint reconstruction

Special Considerations:

• Mouth opening: May be severely limited (ankylosis); difficult intubation
• Nasoendotracheal intubation: Often preferred for surgical access
• Throat pack: Standard
• Awake fibreoptic: Consider if severe trismus
• Recovery: Jaw immobilization may be required; airway concern

Orthognathic Surgery

Procedures:

• Maxillary osteotomy (Le Fort I)
• Mandibular osteotomy (BSSO, genioplasty)
• Bimaxillary procedures

Duration:

• Typically 3-6 hours
• Major blood loss possible

Airway:

• Nasal intubation: Standard for maxillary surgery
• Throat pack: Essential
• Controlled hypotension: May be requested by surgeon (reduce bleeding)
• Extubation: Awake; sitting; thorough oropharyngeal suction

Haemorrhage:

• Potential for significant blood loss (500-1500 mL)
• Blood transfusion may be required
• Tranexamic acid commonly used (1g IV pre-incision)

Recovery and Postoperative Care

Extubation Protocol

Pre-extubation Checks:

1. Throat pack removal: Visual confirmation; documentation
2. Oropharyngeal clearance: Thorough suction
3. Haemostasis: Surgical confirmation of adequate haemostasis
4. Airway reflexes: Return of gag reflex, swallowing
5. Neuromuscular function: Train-of-four ratio >0.9
6. Consciousness: Awake, following commands

Extubation Technique:

• Position: Sitting or semi-recumbent (reduces aspiration risk)
• Suction: Deep oropharyngeal and hypopharyngeal suction
• Removal: Gentle; remove ETT at peak inspiration
• Oxygen: Immediate supplemental O₂ via face mask
• Observation: Close monitoring for obstruction, bleeding, desaturation

Post-extubation Concerns:

• Bleeding: Oropharyngeal bleeding; may require repacking
• Obstruction: Oedema, retained throat pack fragments, hematoma
• Laryngospasm: More common after oral surgery
• Aspiration: Blood, secretions
• Vomiting: Blood ingestion common

Postoperative Management

Immediate Recovery:

• Observation: Continuous pulse oximetry, frequent BP/HR
• Positioning: Sitting preferred; facilitates drainage
• Oxygen: Supplemental until SpO₂ stable on room air
• Suction: Readily available
• Bleeding: Dark oropharyngeal blood common (ingested blood)

Analgesia:

• Simple analgesics: Paracetamol, NSAIDs (if not contraindicated)
• Opioids: May be required for major surgery (codeine, oxycodone)
• Local anaesthesia: Long-acting agents (bupivacaine) infiltrated by surgeon
• Regional blocks: Inferior alveolar nerve block, infraorbital block

Discharge Criteria:

• Airway: Patent, no obstruction
• Haemostasis: No active bleeding
• Consciousness: Oriented or baseline mental state
• Mobility: Safe to ambulate (if appropriate)
• Pain: Controlled with oral analgesia
• Nausea: Controlled
• Escort: Responsible adult to accompany home (day surgery)

Instructions:

• Soft diet initially
• Oral hygiene instructions
• Bleeding management (pressure with gauze)
• Pain management regimen
• Emergency contact numbers
• Follow-up appointments

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples:

Indigenous Australian children experience disproportionately high rates of dental caries, with rates 2-3 times higher than non-Indigenous children. This disparity is driven by multiple factors including limited access to fluoridated water in remote communities, higher consumption of sugary foods and drinks, and reduced access to preventive dental care. As a result, dental GA is one of the most common indications for paediatric anaesthesia in Aboriginal communities.

The shared airway nature of dental anaesthesia presents particular challenges in remote and regional settings where anaesthetic backup may be limited. Complications such as aspiration, difficult airway, or haemorrhage require immediate management capabilities that may not be available in all settings. Transfer protocols and emergency response plans must be clearly established.

For children requiring dental GA, cultural safety involves recognizing that separation from family and community for surgery can be distressing. Family-centered care models, with parents present at induction and recovery, align with Aboriginal family structures and reduce anxiety. Aboriginal Health Workers play a vital role in preparing families, explaining procedures in culturally appropriate language, and supporting children through the surgical journey.

Recovery from dental GA in children requires attention to pain management, bleeding, and re-establishing oral intake. Traditional foods and drinks may be preferred during recovery, and dietary advice should respect cultural food practices. Follow-up care in remote settings requires coordination with local health services to ensure continuity of dental care and prevention of further caries.

Māori Health Considerations:

Māori children similarly experience higher rates of dental caries than non-Māori children in Aotearoa New Zealand, with socioeconomic determinants driving these disparities. Access to paediatric dental services may be limited for whānau in rural areas, leading to delayed presentation with advanced disease requiring GA.

The concept of the shared airway in dental anaesthesia should be explained carefully to whānau, with recognition that parents may have concerns about their child's airway being "shared" with surgical instruments. Visual aids and clear explanations help build understanding and trust. Whānau often wish to be present throughout the process, from preoperative preparation through to recovery.

Postoperative care must consider traditional healing practices alongside Western medical advice. Some Māori whānau may use rongoā (traditional Māori medicine) for pain relief and healing after dental procedures. Respectful integration of these practices, provided they do not interfere with medical treatment, supports holistic healing.

Long-term dental health for Māori tamariki requires attention to the social determinants of oral health including diet, access to fluoridated water, and regular dental check-ups. Follow-up after dental GA should include not only clinical review but also connection with community dental services for ongoing prevention.

ANZCA Exam Focus

Common Viva Topics

Shared Airway Management:

• How do you manage the shared airway during dental extraction?
• Compare nasopharyngeal airway vs. LMA vs. ETT for dental surgery
• What are the risks of the shared airway and how do you mitigate them?

Throat Pack:

• Describe the placement and removal of a throat pack
• What are the risks of throat packs?
• How do you ensure throat pack removal?

Complications:

• How do you manage significant haemorrhage during maxillofacial surgery?
• What are the considerations for dental GA in a child?
• Describe your approach to faciomaxillary trauma with airway compromise

Assessment Content

SAQ 1: Shared Airway and Throat Pack (20 marks)

You are anaesthetizing a 28-year-old healthy male for extraction of three impacted wisdom teeth under general anaesthesia.

a) Outline three options for airway management in this case, with advantages and disadvantages of each. (9 marks)

b) Describe the indications, placement, and removal of a throat pack for this procedure. (7 marks)

c) What are the potential complications of throat pack use, and how do you prevent them? (4 marks)

Model Answer:

a) Airway management options:

Option 1: Nasopharyngeal airway (NPA) + spontaneous ventilation

• Advantages: Simple, preserves spontaneous ventilation, surgical access unimpeded (1.5 marks)
• Disadvantages: Variable airway security, requires close monitoring, aspiration risk (1.5 marks)

Option 2: Laryngeal mask airway (LMA)

• Advantages: Secure airway, enables positive pressure ventilation, relatively simple (1.5 marks)
• Disadvantages: May obscure surgical field, risk of displacement during procedure (1.5 marks)

Option 3: Endotracheal tube (ETT)

• Advantages: Definitive airway protection, controlled ventilation, secure (1.5 marks)
• Disadvantages: May limit surgical access, more complex, longer recovery (1.5 marks)

b) Throat pack:

Indications:

• Isolates surgical site from airway (1 mark)
• Prevents aspiration of blood/tooth fragments (1 mark)
• Aids haemostasis (0.5 marks)

Placement:

• Deepen anaesthesia to prevent gagging (1 mark)
• Visualize oropharynx; clear secretions (1 mark)
• Place pack behind soft palate, either side of uvula (1 mark)
• Secure to tooth/jaw with tape/tie (1 mark)

Removal:

• Visual confirmation of complete removal (1 mark)
• Suction oropharynx thoroughly (0.5 marks)
• Document removal in notes (0.5 marks)

c) Complications and prevention:

Complications:

• Retained pack (airway obstruction, infection) (1 mark)
• Airway obstruction if placed too deep (1 mark)
• Fragmentation (aspiration of pieces) (0.5 marks)

Prevention:

• Visual confirmation of removal (0.5 marks)
• Never extubate before pack removal (0.5 marks)
• Document placement and removal (0.5 marks)
• Use radio-opaque packs if available (0.5 marks)

SAQ 2: Paediatric Dental GA (20 marks)

A 5-year-old child (weight 20kg) with extensive dental caries is scheduled for dental rehabilitation under general anaesthesia.

a) What are the specific anaesthetic considerations for paediatric dental surgery compared to adults? (6 marks)

b) Describe your airway management plan for this child. (6 marks)

c) What are the risks of postoperative nausea and vomiting (PONV) in this scenario, and how would you prevent and treat it? (8 marks)

Model Answer:

a) Paediatric considerations:

• Smaller airway, more collapsible; rapid desaturation (1 mark)
• Higher oxygen consumption (6-8 mL/kg/min vs 3-4 mL/kg/min) (1 mark)
• Larger tongue relative to oropharynx (obstruction risk) (1 mark)
• Age-appropriate equipment (smaller NPA, instruments) (1 mark)
• Temperature management (higher risk hypothermia) (1 mark)
• Parental presence for induction (anxiety reduction) (1 mark)

b) Airway management plan:

Preparation:

• Size-appropriate NPA (size 4-5 for 5-year-old) (1 mark)
• Topical nasal vasoconstrictor (0.5 marks)
• Water-soluble lubricant (0.5 marks)

Technique:

• Measure NPA (tip of nose to tragus) (1 mark)
• Insert perpendicular to face along nasal floor (1 mark)
• Do not force; try alternate nostril if resistance (1 mark)
• Confirm position with capnography (1 mark)

Monitoring:

• Continuous SpO2 and capnography essential (1 mark)

c) PONV management:

Risk factors:

• Blood ingestion (strong stimulus) (1 mark)
• Opioid use (analgesia) (1 mark)
• Procedural stimulation (gag reflex activation) (1 mark)
• Age >3 years (paediatric risk factor) (1 mark)

Prevention:

• TIVA with propofol (reduces PONV) (1 mark)
• Dexamethasone 0.15 mg/kg (max 8mg) IV (1 mark)
• Ondansetron 0.1 mg/kg (max 4mg) IV (1 mark)
• Adequate hydration (1 mark)
• Minimize opioids (use regional blocks) (1 mark)

Treatment:

• Ondansetron 0.1 mg/kg IV if not given prophylactically (1 mark)
• Dexamethasone if not already given (1 mark)
• Maintain hydration (IV fluids) (0.5 marks)
• Consider admission if severe/refractory (0.5 marks)

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