1991 Child development and behavior guidance Flashcards
Theories of Child Development
Maturational Theory: Hall & Gesell
developing children will develop their cognitive skills on their own with no influence from their environment.
Psychoanalytic Theories:
behavior shaped by unconscious processes
Psychosexual Theory: Freud
Stages of Psychosocial Development: Erikson
(trust vs mistrust, autonomy vs shame, initiative vs guilt, industry vs inferiority, identity vs role confusion, intimacy vs isolation, generativity vs stagnation, ego vs despair)
Behaviorism:
relationship between stimulus and response
Pavlov, Watson, Skinner
Pavlov – classical conditioning-reflex, Skinner – operant conditioning and selective reinforcement
Social Learning Theory: Bandura
modeling
Cognitive Theory:
individuals think and choose
Jean Piaget
children think differently than adults
cognitive development proceeds in distinct stages based on age
children learn thru interaction w/ environment
child is an active learner, not a passive responder
thoughts influence future actions and ideas
Stages of Cognitive Development
Stages of Cognitive Development
Sensorimotor Stage (Birth-2 years)
- coordination of sensory experiences w/ physical motor actions
Pre-operative Stage
Concrete Operational Stage
Formal Operational Stage
Which Stage of Cognitive Development is characterized by:
- child learns to represent objects with words, drawings
- egocentric thinking
- magical beliefs
and at what age is this occurring?
Pre-operative Stage
Age 2-6
The Concrete Operational Stage is characterized by what and at what age is it occurring?
Age 7-12:
- appropriate use of logic
- solve problems that apply to actual objects
- elimination of egocentrism – awareness of others
According to the Stages of Cognitive Development, kids are capable of abstract thought and reasoning at what age?
>12 years
Formal Operational Stage
capable of abstract thought and hypothetical reasoning
What talking and understanding does a birth – 3 month old do?
Startles to loud sounds,
smiles/quiets when spoken to/recognizes your voice
sucking changes w/sound
coos, babbles
cries differently for different reasons
A 4-6 month old can do what?
Follows sounds with eyes
responds to changes in your voice
notices toys that make sounds
likes music
babbling with p, b, m
giggles
vocalized excitement/displeasure
gurgles when alone
7 months – 1 year old likes what type of activities?
- peek a boo
- looks in directions of sounds
- listens when spoken to
- recognizes words for common items cup, shoe, book, juice
- responds to requests like come here, more?
A 7 month – 1 year old does what talking?
Babbles long and short, imitates speech sounds gets attention with speech sounds uses gestures (arms up, waving) 1-2 words: mama, dog, hi
1 year – 2 year milestones are:
ID body parts
simple commands “kiss the baby, where’s your shoe?”
listens to stories, rhymes, songs
points to pictures in books
more words each month
“where’s kitty? What’s that?”
2 word sentences: more juice
2 – 3 year old milestones?
Go-stop, in-out, big-little, up-down
follows requests
enjoys longer stories
words for almost everything
k, g, f, t, d, n
family understands most speech
names objects
3 – 4 year olds
Come when called from another room
hears TV and radio at same loudness as other family members
answers who what where why questions
talks about school or friends’ home
non-family understand speech
4+ word sentences
talks easily
4 – 5 year old milestones?
Can listen to and answer questions about short stories
hears and understands most of what is said at home and school
Sentences with details/adjectives
tells stories
communicates easily with others
may have trouble with l, r, v, z, ch, sh, th
says rhyming words,
letters and numbers
same grammar as rest of family
First line agent in the treatment of acute mild to moderate postoperative pain
NSAIDs
Dosing
(<12yo): 4-10 mg/kg/dose q6-8h prn
Max: 40 mg/kg/day;
12 and up: 200 mg q4-6h prn
Max: 1.2g/day
Tylenol dosage and max.
Children <12:
10-15 mg/kg/dose q4-6h prn
Max: 90 mg/kg/day, not to exceed 2.6g/day
12 and up:
325-650 mg q4-6h
Max: 4g/day
Tylenol overdose is a common pediatric emergency, therefore it must not be given prior to ___ hours after the last dose was administered
SIX
Opioid analgesics provide analgesia for moderate to severe pain but have side effects including ____ and _____
Sedation
Respiratory depression
Concomitant admin of ibuprofen can reduce the amount of opioid analgesic required for pain control
Care must be exercised with codeine use in pedo pts due to…
Genetic polymorphism of the liver cytochrome enzyme which causes some patients to be “ultra-rapid” metabolizers of codeine (therefore convert codeine to high levels of morphine QUICKLY)
only a non-commercially available lab test can tell (virtually no way to identify these ultra fast metabolizers)
Some patients are also poor metabolizers of codeine – under respond to the drug
What are the two most validated pain scales according to AAPD guidelines?
T/F Hand-guarding by dental assistant is considered active restraint.
T. head-holding, hand-guarding, and therapeutic holding are considered active immobilization. Can be done by parent, dentist, auxiliary – need consent.
T/F
The use of mouth prop in a compliant child is considered protective stabilization.
False
“Although a mouth prop may be used as an immobilization device, the use of a MP in a compliant child is not considered protective stabilization.
T/F Protective stabilization should be used only when less restrictive interventions are not effective.
T.
It should not be used as a means of discipline, convenience, or retaliation. It should not induce pain for the patient.
Under what circumstances should you terminate use of immobilization?
- Parental request (bring tx to safe conclusion & end)
- Severe emotional stress or hysterics, stop to prevent physical or psychological trauma
What are 4 contraindications to protective stabilization?
- cooperative, non-sedated patients
- medical, psychological, physical conditions that interfere with safe immobilization
- pts with hx of physical or psychological trauma due to restraint (unless no other alternatives are available)
- pts with non-emergent tx needs in order to accomplish full mouth or multiple quadrant dental rehabilitation
What are 5 indications for protective stabilization?
- Pt requires immediate diagnosis and/or urgent limited tx and cannot cooperate due to emotional and cognitive developmental levels or lack of maturity or medical and physical conditions
- Emergent care is needed and uncontrolled mvmts are risk to pt, staff, dentist, or parent w/o protective stabilization
- Previously cooperative pt becomes uncooperative during appt in order to protect safety and expedite completion of treatment
- Sedated pt require limited stabilization to help reduce untoward movement (may become uncooperative during tx)
- Pt with SHCN with uncontrolled movements that would be harmful or significantly interfere with quality of care.
What 8 things do you need to include in your documentation for protective stabilization?
- Indication
- Type
- Informed consent
- Reason for parental exclusion during protective stabilization (when applicable)
- Duration
- Behavior evaluation/Rating during stabilization
- Any untoward outcomes (skin markings)
- Management Implications for future appts.
What are some risks associated with protective stabilization?
Loss of dignity, physical or psychological harm, violation of patient’s rights
When trauma is of sufficient intensity, frequency, or duration, subsequent neurodevelopment may be altered and become maladaptive.
Parents experience distress when children are restrained.
Minor bruises and scratches. Fewer injuries from passive immobilization compared to active, fewer injuries from planned passive immobilization compared to its use in emergent situations.
Overheating
May compromise airway patency because of inadequate neck extension, especially young children or sedated patients – use neck roll
What % of mothers in one study believed that they should have been with their child when he/she was placed in rigid stabilization board to increase child’s security and/or comfort?
92%.
90% recognized that immobilization protected the children from harm
What are the contraindications to epi?
Hyperthyroidism
What is contraindicated in patients receiving tricyclic antidepressants
Levonordefrin and norepinephrine
Epi dose should be kept to a minimum as well
dysrhythmias can occur
What are the three lengths of needle sizes?
Long 32 mm
short 20 mm
ultrashort 10 mm
Gauges range from 23- thru 30-
blood can be aspirated thru all of them, but more difficult when smaller gauge needles are used
Needles should not be bent if they are to be inserted into soft tissues to a depth of greater than ___ mm or inserted to their hub for injections to avoid needle breakage.
5
What is contraindicated in patients with bisulfite allergies
Local anesthetics with epinephrine since there’s a bisulfate preservative in local with epi
Why consider using LA during GA procedures?
Using LA has been reported to reduce pain post-op after GA and has been found to reduce the maintenance dosage of inhalation anesthetics for pts undergoing GA
(but see next slide re: epi and GA)
When do you have to be cautious when using Epi under GA?
Epi can produce dysrhythmias when used with halogenated hydrocarbons like halothane
(the myocardium is sensitized to epi)
Therefore the anesthesia care provider needs to be aware of the concomitant use of LA w/ epi – type and dosage
LA documentation
“Must”: type and dosage of the LA (including dosage of the vasoconstrictor), sedative drugs doses if applicable
“May”: type of injection given, needle selection, ptreaction
“Should”: weight pre-op, post-injection instructions reviewed with pt/parent
T/F:
Adverse drug reactions develop about 20 minutes after the injection.
FALSE.
Develop either DURING the injection or within 5-10 minutes.
T/F:
LA anesthetic causes a biphasic reaction in the CNS and CVS (excitation followed by depression).
True.
The CVS is more resistant to LA than the CNS.
What are some of the CNS subjective and objective indications/signs of LA toxicity?
Early SUBJECTIVE indications of toxicity involve the CNS and include dizziness, anxiety, and confusion. This may be followed by diplopia, tinnitis, drowsiness, and circumoral numbness or tingling.
OBJECTIVE signs may include muscle twitching, tremors, talkativeness, slowed speech, andshivering, followed by overt seizure activity. Unconsciousness and respiratory arrest may occur.
What are the CVS signs of LA toxicity?
Initially, heart rate and BP may increase.
As plasma levels of LA increase, vasodilation occurs followed by depression of the myocardium with subsequent fall in BP. Bradycardia and CA may follow.
(biphasic)
(not seen until there is a SIGNIFICANTLY elevated LA blood level)
Allergy to LA may manifest as…
Urticaria, dermatitis, angioedema, anaphylaxis, photosensitivity, fever
remember, not dose dependent
What causes paresthesia?
- Trauma to the nerve, e.g. from the needle during injection
- Hemorrhage in or around the nerve
How long does it take for paresthesia cases to resolve?
8 weeks
A vasopressor-containing LA should not be used when treatment extends to 2+ quads in a single visit.
False.
Use of a vaso recommended especially when treatment extends to two or more quads in a single visit – to decrease risk of toxicity
Which anesthetic has an end product that can induce methemoglobulin formation?
What does methomoglobulindo?
Prilocaine
Methemoglobin reduces the oxygen carrying capacity of the blood.
In patients with subclinical methomoglobinemia or with toxic doses, prilocaine (>6 mg/kg) can induce methomoglobinemia symptoms (gray or blue cyanosis of lips, mucous membranes, nails; resp and circulatory distress).
Prilocaine contraindications
Methomoglobinemia
SCA
anemia
symptoms of hypoxia
patients receiving APAP or phenacetin*
*banned by FDA in 1983, analgesic fever-reducer
Patients with these conditions may require a medical consultation to determine the need for a LA without vasoconstrictor:
Cardiovascular disease
thyroid dysfunction
diabetes
sulfite sensitivity
patients taking MAOIs, TCAs or phenothiazines
Are amide anesthetics contraindicated in pts with a family hx of malignant hyperthermia?
NO
The local anesthetic with the highest potency is
- Articaine
- Lidocaine
- Mepivacaine
- Procaine
Answer: A. Articaine (Septocaine)
Table- Articaine 17, Lido 4, Mepivacaine 1, Bupivacaine n/a, procaine 1
Lipid solubility of a local anesthetic appears to be related to its intrinsic potency. The estimated lipid solubilities of various local anesthetics are presented in Table 1-6. Increased lipid solubility permits the anesthetic to penetrate the nerve membrane (which itself is 90% lipid) more easily. This is reflected biologically in the increased potency of the anesthetic. Local anesthetics with greater lipid solubility produce more effective conduction blockade at lower concentrations (lower percentage solutions or smaller volumes deposited) than do the less lipid-soluble local anesthetics.
(Malamed 24)
Malamed, Stanley. Handbook of Local Anesthesia, 5th Edition. Mosby, 072004. .
The local anesthetic with the longest duration of action is
- Bupivacaine
- Lidocaine
- Mepivacaine
- Prilocaine
- Procaine
Answer: A. Bupivacaine
How many mg/mL in 2% solution of lidocaine?
2% = 20 mg/mL
Therefore, there is 60 mg lidocaine in 3 mL 2% lido
What is the recommended and max dosage of 2% Lidocaine and 3% Mepivacaine?
4.4 mg/kg
Do not exceed 300 mg
How many mg mepivacaine are in a 3% 1.7 mL cartridge?
51 mg
How many mg lidocaine are in a 2% 1.7 cc cartridge?
34 mg
4% cartridge that is 1.7 cc has how many mg medication
68 mg
Max dosage and do not exceed dose for
4% Articaine
4% Prilocaine
4% Articaine 7 mg/kg – 500 mg max
Handbook says 4-5 mg/kg and do not use on children < 4yo
4% Prilocaine 6mg/kg – 400 mg max
Bupivacaine 0.5% has how many mg in 1.7 cc? What is the dosage and maximum?
- 5 mg bupivacaine 0.5% in 1.7 cc
- 3 mg/kg,
Do not exceed 90 mg
How many mg vasoconstrictor in 1.7 cc for
1:50k, 1:100k, 1:200k epi?
1: 50,000: 0.034 mg (=34μg)
1: 100,000: 0.017 mg
1: 200,00: 0.0085 mg
1:20,000 levonordefrin has 0.085 mg levonordefrin for 1.7 mL
What are 3 common ester LA?
Procaine
benzocaine
tetracaine
What are 4 amide LA?
Lidocaine
Mepivacaine
Articaine
Prilocaine (may cause methemoglobinemia)
Bupivacaine
Allergy to one amide does not rule out the use of another amide. Allergy to one ester rules out use of another ester.
Both statements true.
T/F LA are vasoconstrictors
F. Vasodilators – diffuse rapidly away
The duration of action of LA is because of what?
Protein binding
What is the purpose of the vasoconstrictor added to LA?
Constricts blood vessels in the area of injection, which lowers the rate of absorption of the LA into the blood stream, thereby
- lowering the risk of toxicity, and
- prolonging the anesthetic action in that area
The potency of LA is determined by what?
Lipid solubility
The time of onset of LA is determined by what?
pKa closer to physiologic pH means faster onset
(lido, mepiv, prilo)
What is the normal pH of extracellular tissues?
7.4
Active infection lowers the pH to 5 or 6 which inhibits LA action – less free base form crosses into the nerve sheath to prevent conduction of nerve impulses
T/F
Septocaine is safe to use in children under 4 yo
No studies in kids < 4yo
T/F
PDL injections require SBE prophylaxis
True.
In patients with bleeding disorders, which supplemental injection may minimize the potential for post-op bleeding of soft tissue vessels?
PDL injection
IO contraindicated in primary teeth due to…
Potential damage to permanent tooth buds
When is use of PDL or IO injection contraindicated?
Presence of inflammation or infection at the injection site
What type of reaction is an overdose on LA?
Biphasic – CNS excitation and then depression
Early: dizziness, anxiety, confusion, tremors, talkativeness, slowed speech
Later: diplopia, tinnitus, drowsiness, circumoral numbness or twitching
also CVS biphasic reaction (CVS more resistant to LA than CNS)
HR BP may increase,
followed by vasodilation and bradycardia
What is oraverse mechanism of action?
Non-selective alpha-adrenergic blocker & vasodilator
Oraverse aka
Phentolamine mesylate
T/F
You can use Oraverse in a 4 year old
F.
> 6 yo or at least 15 kg
Studies show the reduction of duration of LA after oraversewhat % in maxilla? Mandible?
47% maxilla
67% mandible
There is research demonstrating a relationship between soft tissue trauma and the use of shorter acting LAs.
False
Risk of paresthesia for 0.5%, 2%, 3%, 4% solutions?
0.5%, 2%, 3% – 1:1.2 million
4% – 1:500k (about double)
*Paresthesia more common with 4% solutions of articaine and prilocaine, (and more common than expected from their frequency of use)
*usually involves the tongue (most), then lip
What are concerns of LA with sedation?
LA+sedation – both CNS depressants can act synergistically
Narcotics can increase arterial CO2 which can increase CNS sensitivity to convulsions (lowers seizure threshold)
N2O is a
a. PNS stimulant
b. CNS depressant
c. respiratory depressant
b. CNS depression with little effect on the respiratory system (cough reflex protected).
Analgesia – opioid receptors, noradrenergic pathways & GABAA activated – modulate nociceptive processing at spinal level
Anxyolisis – GABAA activation, benzodiazepene receptors
N2O has rapid uptake into serum. Relatively insoluble. Excreted quickly from the lungs.
Minor depression in cardiac output & slight increase in peripheral resistance => maintain blood pressure.
MOA of nitrous oxide
Analgesic effect (minimal) initiated by neuronal release of endogenous opioid peptides with subsequent activation of opioid receptors and descending GABAa receptors and noradrenergic pathways that modulate nociceptive processing at the spinal level
Anxiolytic effect involves activation of GABAa receptor either directly or indirectly thru the BDZ binding site
*also causes minor depression in cardiac output while peripheral resistance is slightly increased, thereby maintaining BP
What are the indications for use of nitrous oxide?
- A fearful, anxious, or obstreperous pt
- Certain pts with SCHNs
- A pt whose gag reflex interferes with dental care
- A pt for whom profound LA cannot be obtained
- A cooperative child undergoing a lengthy dental procedure
What are the five contraindications to nitrous oxide?
- some chronic obstructive pulmonary diseases, severe asthma (wheezing, TB)
- severe emotional disturbances or drug-related dependencies
- first trimester of pregnancy
- treatment with bleomycin sulfate
- methylenetetrahydrofolate reductase deficiency (MTHFR)
- Cobalamin deficiency
Also:
Consult w/ medical specialist before administering nitrous to pts with significant underlying medical conditions:
severe obstructive pulmonary dx, CHF, sickle cell dx, acute otitis media, recent tympanic membrane graft, and acute severe head injury
When is the most significant amt of N2O exhaled by the pt?
Within the first 3-5 mins after terminating administration.
What is the maximum safe level of ambient N2O in the dental environment?
This has not yet been determined.
What type of air should you ventilate your dental operatory with?
Outdoor air.
Exhaust vents away from fresh air intakes.
The typical patient requires ____% N2O to achieve ideal sedation
30-40%
What are some occupational concerns with nitrous oxide?
Long term exposure to nitrous oxide used as a general anesthetic has been linked to bone marrow suppression and reproductive system disturbances.
How does N20 cause damage?
Oxidizing vitamin b12 from the active reduced colbamin to the inactive form. This in turn inactivates methionine synthetase, which needs the active colbamin and folate as cofactors. The inactivation of methionine synthetase decreases DNA production- and interferes with cell proliferation
Which people have adverse reproductive outcomes due to N20?
Vitamin b12 deficient individuals, and those exposed to high n20 levels
What should the exhaust ventilation of n20 from the pts mask be?
Air flow rate of 45L/ min
What two supplemental measure reduce ambient n20 levels?
Rubber Dam, and high volume dental aspiration placed near or within 20cm of pts mouth
What 3 ways does n20 work?
1) endogenous opioids (analgesia),
2) GABA a receptors (analgesia & anxiolytic)
3) noradrenergic pathways (analgesia)
Is nitrous oxide soluble?
Nitrous oxide is 34 times more soluble nitrogen in blood, however it is relatively insoluble and excreted quickly from the lungs
because N2O is 34x more soluble than nitrogen in the blood, diffusion hypoxia may occur
Nausea and vomiting occur in what % of N2O pts?
0.5%
More likely to be observed when titration is not employed
Higher incidence also noted with longer administration of nitrous, fluctuations in nitrous levels, and increased concentrations of nitrous oxide.
Why does diffusion hypoxia occur and what does it lead to?
Diffusion hypoxia occurs as a result of the rapid release of N2O from the blood into the alveoli → dilutes the concentration of oxygen
Leads to headache and disorientation
(avoid by administering 100% O2 after d/c of N2O)
Documentation of N2O
Should include:
Indication for use,
dosage (i.e. %N2O/O2 and flow rate),
duration of procedure, and
post-tx oxygenation procedure
Nitrous oxide equipment must deliver no less than what percentage of oxygen?
10
20
30
40
50
30
30
What % Oxygen is the least that your N2O equipment should deliver?
Never less than 30% O2
Also needs to be capable of delivering 100% O2
Emergency cart should have:
positive pressure oxygen delivery system administering >90% oxygen at 10 L/min for at least 60 minutes (650 L “E” cylinder)
If self-inflating bag valve mask is used for positive pressure oxygen, recommended flow rate is 15 L/min.
Moderate sedation definition
A drug-induced depression of consciousness during which pt responds purposefully to verbal commands (may be accompanied by light tactile stimulation e.g. light tap on the shoulder or face but not sternal rub)
No intervention to maintain a patent airway needed, i.e. spontaneous ventilation is adequate
Cardiovascular function maintained
Deep sedation definition
A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation.
Ability to independently maintain ventilatory function may be impaired – patients may require assistance in maintaining a patient airway, and spontaneous ventilation may be inadequate
Partial or complete loss of protective airway reflexes
General anesthesia definition
A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.
Ability to maintain ventilation is impaired; pts often require assistance in maintaining a patent airway, and positive pressure ventilation may be required d/t depressed spontaneous ventilation or drug-induced depression or neuromuscular function
Cardiovascular function may be impaired
T/F
Reflex withdrawal is a purposeful response.
False.
“Reflex withdrawal, although a normal response to painful stimulus, is NOT considered as the only age-appropriate purposeful response (i.e. it must be accompanied by another response, such as pushing away the painful stimulus so as to confirm a higher cognitive function)”
Risk factors for aspiration
Trauma
decreased level of consciousness
extreme obesity
pregnancy
bowel motility dysfunction
Medications that may enhance or shorten the effect time of sedating medications
Herbal medications
- e.g. St. John’s wort, echinacea
- inhibit cytochrome P450 – resulting in prolonged drug effect and altered (increased or decreased) blood drug []s
- Other drugs that inhibit cytochrome P450 are erythromycin, cimetidine (prolonged sedation w/ midazolam)
Kava may increase the effect of sedatives (potentiates GABA inhibitory neurotransmission)
Valerian may produce sedation thru GABA nt and receptor function
HIV meds, some anticonvulsants, some psychotropic meds may also produce clinically important drug interactions
Can you prescribe and instruct a parent to administer medications intended for procedural sedation at home?
No. Rx meds intended for procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.
Administration at home poses an unacceptable risk.
SOAPME stands for what
Suction
Oxygen
Airways
Pharmacy
Monitors
Equipment (e.g. defibrillator)
What are the documentation requirements for moderatesedation?
- Baseline status/vitals
for the uncooperative or upset child, this may not be possible and a note should be written to document this - Name, route, site, time of admin, dose and patient effect of all drugs
- Patient’s level of consciousness and responsiveness, continuous monitoring of SpO2 and HR,
intermittent recording of RR and BP - Adverse events
- Time and condition of the child at discharge. Documentation that the child’s level of consciousness and O2 sat have returned to a state that is safe for discharge.
*One person must be designated for monitoring – this individual must also be trained in BLS. This individual may be responsible for assisting with interruptive patient-related tasks of short duration.
Documentation requirements for deep sedation/general anesthesia
- Vital signs: pulse, RR, BP, O2 sat recorded at least every 5 minutes until pt meets discharge criteria
- Drugs: name, route, site, time of admin, dose, patient effect of all drugs including LA. When anesthetic gases are administered, the inspired [] and duration of inhalation agents and oxygen.
- Recovery: The condition of the pt, that discharge criteria have been met, time of discharge, and into whose care the discharge occurred.
Encouraged to require the signature of the adult to whom the child has been discharged, verifying that he/she has received and understands post-op instructions
What are the monitoring requirements for deep sedation?
- One person whose only responsibility is to constantly monitor vitals, airway patency and adequacy of ventilation and to either administer drugs or direct their administration.
- Electrocardiographic monitor and pediatric defibrillator should be readily available (in addition to equipment for mod sedation)
- IV line placed at start of procedure (or person capable of placing IV immediately available)
- At least one individual must be present who is trained in and capable of providing advanced pediatric life support and who is skilled in airway mgmt and CPR; PALS training is required.
*for office-based deep sedation or GA, an individual experienced in recovery care must be in attendance in the recovery facility until the patient until pt discharged
What additional monitors are needed for general anesthesia?
Temperature monitor
and pediatric defibrillator required
A certified registered nurse anesthetist or anesthesia assistant can function under a dentist with no training in deep sedation/GA.
False
If a certified nurse anesthetist or anesthesia assistant functions under the supervision of the dentist, the dentist is required to have completed training in deep sedation/general anesthesia and be licensed or permitted as appropriate to state law.
What are the rescue requirements of a practitioner?
Skills to rescue patient from deeper level than intended
Emergency kit immediately accessible to provide necessary drugs and equipment to resuscitate a nonbreathing and unconscious child – contents allow for provision of continuous life support while pt is being transported to medical facility
A protocol for ambulance access & activation of EMS must be established and maintained.
What are the specific requirements for moderate sedation rescue for the practitioner?
Bag-valve-mask ventilation
so as to oxygenate a child who develops airway obstruction or apnea
Advanced pediatric airway skills training required
How long after administration can you discharge the pt?
Discharge should not occur before 30 minutes after last medication given
What 4 ways is the airway anatomy different in children than adults?
- Narrow trachea, glottis, nasal passages
- Larger tongue, epiglottis
- Mandible small
- Increased airway resistance
The narrowest part of the pediatric airway is at the:
Cricoid cartilage
(adults: vocal cords)
What are serious risks and rare risks of sedation?
Common & serious: airway compromise, depressed respiration leading to airway obstruction/hypoventilation/hypoxemia/apnea. Laryngospasms
Hypotension and cardiopulmonary arrest may occur (usually from inadequate recognition and treatment of respiratory compromise)
Rare: seizures, allergic rxn.
What are the most common post-GA symptoms?
44% of pts have post-op symptoms
- pain
- agitation
- sleepiness
- sore throat
- nausea/vomiting, unexplained drowsiness
nausea/vomiting most common adverse effect after oral rehab under GA
Pre-op NPO instructions for oral rehabilitation under general anesthesia include
- No breast milk for 4 hours
- No clear fluids for 4 hours
- No formula for 4 hours
- No solids for 4 hours
- Nothing to eat or drink after midnight prior
Answer: a. no breast milk for 4 hours
No clear fluids for 2 hours,
formula for 6 hours, solids for 6 hours,
last one not true
What is true regarding malignant hyperthermia?
- Autosomal recessive
- Extreme hypotension
- Treated with IV ketorolac
- Smooth muscle disorder
- Unexplained increase in CO2
Answer: e. unexplained increase in CO2;
autosomal dominant, extreme hypertension, IV dantrolene sodium 2.5mg/kg, skeletal muscle disorder
Which drug can cause fatal hyperkalemia in patients with undiagnosed muscular dystrophy
Succinylcholine
ASA I
Normal, healthy patient
ASA II
Mild systemic disease
controlled asthma
PREGNANT WOMEN
ASA III
Severe systemic disease
(wheezing child)
ASA IV
Severe systemic disease that is constant threat to life
(status asthmaticus)
ASA V
Moribund pt not expected to survive the operation
ASA VI
Brain dead and organs are being removed for transplant
What is malignant hyperthermia?
Skeletal muscle disorder
hypermetabolic state
Volatile anesthetics and succinylcholine
- induces drastic and uncontrolled sk. m metabolism – overwhelms body’s ability to supply O2, remove CO2, and regulate body temperature
Unexplained increase in CO2, tachycardia, hypertension, skin mottling, muscle rigidity, hyperthermia, hyperkalemia induced arrhythmias
What is the treatment for MH?
IV dantrolene sodium 2.5 mg/kg
monitor and treat metabolic acidosis
hyperventilate with 100% oxygen
cooling blanket
Diagnosis of MH
Sk muscle biopsy
Inheritance of MH
AD
Susceptible if 1st degree relative is susceptible
What are some neuromuscular blockers?
Succinylcholine
Vecuronium,
rocuronium (intermediate)
mivacurium (short-acting)
