2. Sedation Flashcards
What are the advanced behavior guidance strategies
- Protective stabilization
- Sedation
- General anesthesia
What are the four stages of Piaget’s stages of cognitive development
- Sensorimotor stage
- Preoperational stage
- Concrete operational stage
- Formal operaitons
Describe the Piaget’s sensorimotor stage
- Birth to 24 months
- Little to no meaningful verbal communication
- Hyperaware of people around them
- Perceptive to non-verbal communication
- **Key feature= object permanence (meaning they understand objects exist even if they can’t physically see them in that moment)
Describe the Piaget’s preoperational stage
- 2-5 years
- Begin to use language
- Can form mental symbols
- Language is concrete and literal
- Limited logical reasoning
- Egocentric view of the world
Describe the Piaget’s Concrete operational stage
- 6-11 y/o
- Increased logical reasoning
- Still have hard time with abstract ideas
- Benefit from concrete instructions
Describe the Piaget’s formal operation stage
- 11+ years
- Can think about abstrations and hypothetical concepts
- Reason analytically
What are the three classifications of temperment classified by Chess and Thomas and describe each
Easy temperment
- Mostly positive mood with mild/moderate intensity
- Adapts quickly
- Approaches new situations
Difficult temperment
- Withdraws from new situations
- Slow adaptability
- Negative emotion of high intensity
Slow to warm up temperment
- Shy
- Slow adatability
- Negative emotional expressions of low intensity
At what age do kids start to warm up to strangers (separate from parents)
school age
What are the typical fears of an infant/todler
- Strangers
- Loud sounds
- Sudden movements
- Falling
Lap exams should be done for what ages
infants/toddlers (good for parental involvement)
At what age can kids be managed with language
pre-school age
What are the different variables associated with uncooperative behavior
- Dental fear (realistic v.s theoretical)
- Demographics (race, gender, household,etc.)
- Coping skills (generally increases with age and varies among individuals)
- Pain (Subjective, anxiety upregulated pain)
- Parental anxiety
Difference between realistic and theorized dental fear
Realistic is they have had the bad experience themselves and theorized is when someone tells them a bad experience
Define minimal sedation
- Drug induced state (Still conscious)
- Responds normally to verbal commands
- impaired cognitive and coordination
- Ventilation and CV function unaffected
Moderate sedation definition
- Respond to purposeful commands (Still conscious)
- No intervention required to maintain airway
- Spontaneous ventilation adequate
- CV function usually maintained
Deep Sedation
- Still conscious
- Can’t be easily aroused (respond to repeated purposeful or painful stimuli)
- Ability to maintain airway and ventilation may be impaired
- Spontaneous ventilation may be inadequate
- May be partial or complete loss of protective airway reflexes
General anesthesia definition
- Unconscious
- Not arousable
- Ability to maintain airway often impaired
- CV function may be impaired
Routes of sedation agents
- Inhalation *
- Oral**
- Nasal
- Rectal
- Submucosal
- Intramuscular
- IV
What are the disadvantages of oral sedation and advantages
Advantages
- Often well tolerated
- No pain
Disadvantages
- Most variable
- Can’t titrate
- Reversal is tough
- Recovery time may be prolonged
Why is oral sedation highly variable
dependent on absorption of GI mucosa
Recovery time of oral sedation is dependent on
metabolism of the drug
What are common pharmacologic classes of oral sedation meds
- Anti-histamines
- Benzodiazepines
- Sedative hypnotics
- Narcotics
Antihistamines used for oral sedation include
- Hydroxyzine
- diphenydramine (benadryl)
- promethazine (phenergan)
Benzos used for oral sedation are
- Diazepam (valium)
- Midazolam (versed)
What sedative hypnotic drug is used in oral sedation
chloral hydrate
Narcotics used for oral sedation are
- Meperidine (Demerol)
- Sufentanil (intranasal)
What is the antagonist of narcotics
naloxone (narcan)
Narcan is given (IV/IM)
both
Benzo antagonist is
flumenazil
Flumenazil is administered how
IV
What ASA classification should a child be for sedation
ASA I
ASA II with consideration**
Uncontrolled asthma are (good/bad) candidates for sedation are
bad
T/F LA is still needed with sedation
t
Describe the 5 different classifications of tonsil size
- Keep in mind child tonsils are larger than adult tonsils**
- 0= Surgically removed tonsils
- 1= Tonsils hiden within tonsil pillars
- 2= Tonsils extending to the pillars
- 3= tonsils are beyond the pillars
- 4=Tonsils extend to midline
Caution should be used with sedation with kids that fall under the classification of _ tonsils
3 and greater
Sedation contraindications
- Patient able to be managed with basic behavior management
- ASA III and greater (and some ASA II)
- Extensive treatment plan (should do general anesthesia)
- Recent illness
Sedation complications
- Compromised airway (hypoventilation, hypoxemia, apnea, hypotension and cardiopulmonary arrest)
- Seizure
- Allergy
- Failure to sedate (kids start crying/ become hyperactive)
Instruction to parents for sedation
- Notify of changes in child’s health (recent illness ie.)
- Restricted food and liquids prior to sedation
- Loose fitting clothes
- Don’t bring other kids to appointment
- Have two adults some one can monitor child’s breathing
Why are food and liquids restricted prior to sedation
- Reduce risk of aspiration if nauseous
- Better absorption of sedative meds on empty stomach
What are the min. fasting periods for each item
- Infant formula
- Light meal (not fatty food)
- Clear liquid
- Non-human milk
- Breast milk
- Infant formula 6 hr
- Light meal 6 hr
- Clear liquid- 2hr
- Non-human milk - 6hr
- Breast milk - 4 hr
What should you do if the child falls asleep after the appointment
- Check breathing every 3-5 mins
- If snoring occurs reposition the head by lifting chin
How long should a parent watch the child after the appointment
the whole day
What are occasional side effects of sedation
nausea and vomiting
What should be given for post op pain
tylenol or motrin (can also use if child has mild fever and pain afterward)
How should food be reintroduced after sedaiton
- Small amounts of liquids
- Move up to solid foods as tolerated
Minimum of _ number of people are needed when sedating
2 (practioner and assistant)
Roles of practitioner and assitant
Practitioner
- Treatment
- Drug admin.
- Have skills to rescue
Assistant
- Monitor vitals
- Assist in rescue
- Emergency cart
Monitoring of vitals should include
- Pulse oximeter
- BP
- Monitor ventilation (precordial stethoscope or capnograph)
Recording or respiration rate (ventilation) occurs how frequently
every 5 min
BP should be recorded how often
every 5 min
Pulse oximeter is monitored how frequently
continuous
T/F Sedative drugs can be given to children outside the dental facility
f
What on-site monitoring devices are needed for rescue
- Emergency cart
- Must have necessary equipment to resuscitate a non-breathing child non-concious kid
- Must be able to provide continuous life support
- Equipment/drugs checked and maintained
What does SOAPME stand for
S= suction O= Oxygen A= Airway P=Pharmacy (basic life support drugs) M= Monitors E= Equipment (AED/Defibrillator)
Health evaluation before sedation must look at what parameters
- Health history
- ROS
- Age/weight
- Baseline vitals (HR, BP, Respiratory rate, and temp)
- Physical exam (airway eval)
What should be documented during treatment
- Time-based record: Name route, site, dose, and pt effect of administered drugs
- Documents inspired conc. of O2 and N2O during administration
- Continuous monitoring of O2 saturation and heart rate
- Intermittent recording of BP and respiratory rate
Documentation after treatment
- Time and condition of child
- Document O2 sat on room air is safe for discharge
Discharge criteria
- CV function is satisfactory and stable
- Airway patency is satisfactory and stable
- Patient is easily arousable
- Responsiveness is at or very near pre-sedation level
- protective reflexes are intact
- Can talk (return to pre-sedation level)
- Patient can sit up unaided
- State of hydration is adequate
- Can remain awake for at least 20 min in a quiet environment
Young kids are particularly vulnerable to what sedation risks
- Effects on respiratory drive
- Patency of airway
- Protective reflexes
- *Hypoxemia, laryngospasm, pulmonary aspiration, and apnea)
- Common for kids to fall into deeper level of sedation than intended
Max dose of articane
7mg/kg
Max dose of midazolam
0.25 mg - 1mg/kg (max single dose is 20 mg)
What level of conscious sedation is most desirable to achieve
moderate
Treatment under LA should be limited to how many quads
1-2
