(04-19-17) Oral Sedation for Children Flashcards
what are the reasons you should sedate someone?
- longer appt needed
- difficult to cope with procedure pt
- crying
- struggling
what are the reasons you SHOULD NOT sedate a kid?
- can be managed with less risky method (N2O)
- Underlying medical condition
- too much work (GA would be better option)(if two sedations needed then no sedations needed)
- presedation eval shows VERY uncooperative pt
ultimate management of a child depends on what?
practitioner’s training, skills, and competence
refers to the quality and intensity of a relationship an individual has for the caregiver. the “cling” factor
attachement
*is transfereable but varies in intensity
refers to how and individual reacts to a novel environment or stanger
temperment
what does research say about attachment and temperment?
they are related
what is the key to happiness when communicating with the parents?
- lower expectations
- set realistic goals
- be sure parents understand all potential outcomes
- document parents’ understandings
children are not small adults, they differ in regards to what?
- metabolism
- CV response
- airway anatomy
with children, emergencies most often involve what?
respiratory compromise
AIRWAY, AIRWAY, AIRWAY
what are some differneces in a child’s airway as opposed to an adult’s?
- larynx is more superior and anterior with immature cartilage
- tongue is “relatively larger” and sits higher in the mouth
- tonsils and adenoids are more prominent which restricts the airways even more
- proportionately, the head is larger than the body
in a normal healthy child during oral sedation using common sedative agents, which system of the body is the most important to monitor?
respiratory
what must monitoring of the respiratory system include?
- ventilation
- oxygenation
the movement of air into and out of the lungs via the airway
ventilation
*important factors to monitor are patency of airway, depth, and frequency of ventilation
the transport of O2 to metablically active tissues
oxygenation
*important factors to monitor are HR and O2 saturation
how is a child’s breathing different than an adults?
children breathe faster and have smaller tidal volume than adults
what is the Brodsky Scale for airway assessment?
- if the tonsils are greater than half the airway, the likliness of blockage inc dramatically
- DO NOT sedate with chloral hydrate or meperidine (high doses) if tonsils are “kissing”
- always ask the parent if the pt snores and if so how loudly?
what does the Mallapati scale evaluate?
quality of peritonsilar tissue
what are some airway issues of premature infants?
- delayed developement of airway
- reduced levels of surfactant
- inc incidence of early life intubation
*these children will have inc incidence of post-extubation scarring
what can development of an airway impact?
- muscle tone
- reflex arc
- laryngospasms
what are some things what occur with intubation early in life
- palatal grooves (collapse of max arch)
- odontogenic anomalies (enamel hypoplasia, delayed eruption
- hypersensitive gag
- oral aversions and non-nutrititive sucking
- post-intubaiton tracheal stenosis
- hyperoxygenation (branchopulmonary dysplasia)
what is RSV?
-viral infection that affects up to 125,000 children in US each year and is the most common cause of hospitalization during the first 12 months of life
what are the infection rates of RSV?
greater than 90% but only about 2% of kids become symptomatic
what are the identified risk factors for RSV>
- male
- household crowding
- daycare attendance
- gestational age less than 33 weeks
*inconclusive = breastfeeding less than 2 months
= PSE
what is the the #1 cause for bronchiolitis and pneumonia in kids under 1 year of age in teh US
RSV
what is the issue with RSV and oral sedation?
- inc “reactivity” to airway (predisposed to respiratory depression)
- severe RSV infections may predispose child to asthma- hyper reactivity
how many kids does asthma effect?
over 6 million
is the 2nd most common chronic illness of childhood
asthma
*second only to dental caries
what are the asthma meds?
- controllers (B-agonists, leukotriene inhibitors)
- rescue meds (albuterol)
- steroids
what all must happen to have proper informed consent?
- description of procedure
- risk/benefit of procedure
- alternatives to procedure
- understanding by parent
- questions
- witness
for sedation guidlines, what prescriptions outside the office can be given?
- mild anxiolytic agents only (diazepam)
- no chloral hydrate or meperidine
what is the ohio dental practice act pediatric oral sedation under 12 years of age
- must have predoctoral/CE edu with minimum of 60 hrs and 20 cases
- alternatively postdoctural edu
- facility properly equipped
- ACLS or age equivalent (PALS)
what are the 4 parts of the exam for pediatric oral sedation?
- technique
- simulated emergencies
- equipment, record, drugs, facility
- verbal eval
what is the monitoring technology for kid sedation?
- pulse oximetry (HR and SpO2 are continuous)
- pre-cordial stethoscope
- capnography
- BP cuff (periodical)
- trained personnel
what do combinations of orally administered sedative agents do?
inc the risk of an adverse effect
what is the range of N2O?
20-70% (usually around 30-40%)
N2O can produce what?
suppression of airway reflexes at 50% conc
what type of drug is chloral hydrate?
hypnotic
what can chloral hydrate be used with ?
- hydroxine
- N2O
- promethazine
- meperidine
what can 20-35 mg/kg of chloral hydrate cause?
-disinhibition, giddiness, irritability, anger, somnolence
what can 35-50 mg/kg of chloral hydrate cause?
- disinhibition, irritability, anger
* kids act drunk on this!
what happens in the first 20 minutes of a kid being on chloral hydrate?
change in personality (usually more friendly) with hyperactivity dominating
what happens in 20-40 minutes of a kid being on chloral hydrate?
hyperactivity declining and somnolence ensuing
what happens in 40-90 minutes of a kid being on chloral hydrate?
somnolence continuing, arousal related to frequency and adversity of stimuli, dose of drug, patient characteristics, and other drugs
is there a reversal agent for the adverse effects of chloral hydrate?
no
*fallen out of favor recently
what drug class is meperidine?
narcotic
*dose range of 1-2 mg/kg (oral)
what are the effects of meperidine?
- euphoria (great)
- dysphoria (failure)
- analgesia
- mood depression
- irritability
- obtunded responsiveness
what happens in 20-40 minutes of a kid being on mepiridine?
slightly disinhibited, may become dysphoric or euphoric
what happens in 20-90 minutes of a kid being on mepiridine?
dysphoria or euphoria inc in intensity, analgesic effects becoming notable, if they are going to occur
what allows for greater titration to effect for meperidine?
N2O
What is the most commonly used drug for childhood sedation?
midazolam
what is the drug class of midazolam?
benzodiazepine
*0.2-1.0mg/kg (oral)
what are the effects of midazolam?
- mood change
- relaxation
- less reactive to stimuli
- quick onset (5 minutes)
- short duration (20 minutes)
what happens in the first 15 minutes of midazolam?
change in mood with quietness and generalized relaxation inc.
what happens in 15-30 minutes of midazolam?
less intensity of reaction to stimuli and amnestic effects beginning
what happens in 30-60 minutes of midazolam?
and notable effects are declining
*short duration
when is INTRANASAL medazolam used?
- same effects as oral, but faster onset and faster recovery
- used for faster procedures (one ext)
- used in less coop children
- use atomizer
what are the basic principles of pediatric sedation?
- nothing at home
- responsible person
- no redosing
- reduce dose when mixing drugs
- give enough time to work
- dont overuse time
- discharge to criteria, not schedule
what is the most important thing to check before discharging the pt?
ability of child to maintain their airway
emergencies from child sedation most commonly involve what?
-overdose condition including LA or respiratory compromise
what is the max dose for lido for a kid?
4mg/kg
