5. Anesthetic Practices in Adults & Pediatrics Flashcards
Utilization of Dentist Anesthesiologists in Pediatric Residency Programs
• 98% of pediatric dentistry residency programs provide patient care with ____ sedation (excluding nitrous oxide)
• 98% of pediatric dentistry residency programs provide patient care with deep sedation-GA
• 69% in the ____ only
• 29% in both the ____ and ____ settings
mild-moderate
OR
clinic-based
OR
Utilization of Dentist Anesthesiologists in Pediatric Residency Programs
- 37% of pediatric dentistry programs utilize clinic-based ____ (in addition to hospital-based deep sed/GA)
- 88% of those programs utilize the services of a Dentist Anesthesiologist (DA) in the clinic based setting for deep sed/GA
deep sed/GA
Utilization of Dentist Anesthesiologists in Pediatric Residency Programs
• 43% of pediatric dentistry programs utilize a ____
dentist anesthesiologist
Utilization of Dentist Anesthesiologists by Board-Certified Pediatric Dentists
• Over 70% of respondents provide some form of sedation in their practices
• <20% provide ____ sedation
• 20-40% utilize the services of a ____
• 60-70% would utilize a dentist anesthesiologist if one were available
IV
dentist anesthesiologist
- you can see a lot of pediatric dentists give in-office sedation but not many give IV sedation on their own - that’s probably for good reason
- a good proportion use a dentist anesthesiologist and even more would use if it was more available
- the difference between the graphs is ____ of practitioner and years in practice
- stars represent statistically significant data
age
Utilization of Dentist Anesthesiologists by Board-Certified Pediatric Dentists
• 88% of respondents in the ____ administered some form of sedation
• 39% in the West, IV sedation by themselves (operator-anesthetist model)
• 59% in the West used DA
• 78% in the West would use a DA
if available
southwest
Utilization of Dentist Anesthesiologists by Board-Certified Pediatric Dentists
• In EVERY region of the country, there is a consistently higher desire for a dedicated ____ than the number of pediatric dentists practicing the operator- anesthetist model
dentist anesthesiologist
Trends in GA Utilization by Board-Certified Pediatric Dentists
• GA mostly used in hospital and dental office
• primary anesthesia provider was mostly a ____ or
nurse-anesthetist - coming in second was dental anesthesiologist
• by far, ____ (oral or nasal) was major anesthesia delivery model
• for people who did ____ airway sedation (model D) most of them were
DA
physician anesthesiologist
intubation
open
Dr Estabrooks’ List of Top Ten List of Error’s Leading to Catastrophes:
- Trying to intubate even when the patient is ____ and can be ventilated.
- Failure to understand that a patient can have a NSR on the EKG without a ____ (PEA)
- Poor ____ of the resuscitation
- ____ of documentation of medical status
- ____ trained assistants
- Hoping things will get better, failure to react in a ____ manner
- Failure to follow accepted ____ for resuscitation – establishing an airway
- Not knowing what the ____ is telling them
- Failure to recognize the ____ demise in a timely manner
- Failure to recognize a ____ patient
breathing pulse documentation lack poorly timely protocols monitor pending higher risk
Definitions of Urgency
• Elective treatment can be delayed up to ____ year
• Time sensitive treatment can be delayed ____ weeks • Urgent treatment might be delayed ____ hours
• Emergent must be seen ____
1
1-6
6-24
ASAP
Common causes for anesthesia-related cardiac arrests
- ____ (36%)
- respiratory (27%)
- ____-related (20%)
- equipment problems (5%)
CV
medication
____ Events Accounted for 77% of the Critical Incidents
even though the cause of death might be ____, the critical incident is sparked by ____ demise by pediatric patients because they’re otherwise healthy so they become hypoxic and stop breathing –> heart stops beating –> hypoxic brain damage….so its really about the airway!
respiratory
cardiovascular
respiratory
Critical Incidents
• ____% Previously healthy (ASA I and II)
• ____% Elective surgery
• ____% Occurred during the maintenance phase of anesthesia
Compared to adults, ____ respiratory events are more common and result in a greater morbidity (brain damage, 30%) and mortality (death, 70%) in previously healthy children
80
73
80
pediatric
Hindsight is 20/20
• Read the 2 articles by Goodson and Moore (JADA, 1983) & (Anesthesia Progress, 1985) these speak to standard of care
now
• These mistakes MUST not happen again
• Some of these case reports would border on criminal by today’s standards and have resulted in:
• Increased educational ____ (patient selection, airway management, drug selection, dosing, emergency response)
• Increased monitoring ____
• Clarified ____ of level of sedation
• Improved ____ techniques and safer drugs
requirements
requirements
definitions
monitoring
What Went Wrong?
Failure to take patient \_\_\_\_ Failure to comply with \_\_\_\_ requirements • Inappropriate choice of medication(s) • \_\_\_\_ of administration - unpredictable • • Sometimes, combined routes • Injecting sedatives into buccal mucosa, sublingually, or into the tongue can exacerbate a bad airway • Lack of monitoring
Administering ____ in inappropriate locations
Failure to recognize depth of sedation
Failure to ____ an emergency and call for help
Failure to ____ agents or ineffective reversal
Administer medication instead of focusing on ____
history
NPO
route
sedatives
recognize
reverse
circulation-airway-breathing (CAB)
Sedation is a continuum but can be described in several levels
Minimal sedation Response: \_\_\_\_ Respiratory system: \_\_\_\_ Cardiovascular system: \_\_\_\_ Impairment: \_\_\_\_
Moderate sedation Response: \_\_\_\_ Respiratory system: \_\_\_\_ Cardiovascular system: \_\_\_\_ Impairment: \_\_\_\_
normal to verbal command
unaffected
unaffected
cognitive function and coordination
purposeful verbal command and/or light tactile stimulation
unaffected
usually maintained
cognitive function and coordination
Sedation is a continuum but can be described in several levels
Deep sedation
Response: To purposeful command with repeated or ____ stimulation.
Not easily ____.
Respiratory system: May require ____ in airway patency. Spontaneous ventilation may be inadequate
Cardiovascular system: May be ____
Impairment: Depression of ____
General anesthesia
Response: Not arousable, even to ____ stimuli.
Respiratory system: Impaired. Need assistance in maintaining patent ____ and positive pressure ventilation may be required
Cardiovascular system: Usually ____
Impairment: ____
painful arousable assistance impaired consciousness
painful
airway
impaired
unconscious
Minimal and Moderate Sedation
• Should be able to respond to purposeful ____ and light/gentle touch.
• Maintains a patent ____ without assistance
• Maintains ____ function
• Patients whose only response is reflex ____ from repeated painful stimuli would NOT be considered to be minimally or moderately sedated.
commands
airway
cardiovascular
withdrawal
Minimal and Moderate Sedation
• Consistent with the definitions of minimal and moderate sedation, the drugs and/or techniques used should carry a margin of ____ wide enough never to render unintended loss of ____.
safety
consciousness
Deep Sedation
• Can NOT be easily ____
• MAY respond to repeated and/or ____ stimulation
• May need assistance maintaining patent ____
• i.e.: ____ lift or jaw thrust
• Spontaneous ____ may be inadequate
• ____ function usually maintained
aroused painful airway chin ventilation cardiovascular
General Anesthesia
• Not ____
• Not even with painful stimuli
• May or may not need assistance maintaining patent ____
• Ability to spontaneously ____ often impaired
• May need ____ pressure ventilation
• ____ function may be impaired
arousable airway ventilate positive cardiovascular
Rescue
• Sedation and general anesthesia are a ____
• Not always possible to predict how an ____ patient will respond
• Practitioners intending to produce a given level of sedation should be able to diagnose and manage the ____ consequences (rescue) for patients whose level of sedation becomes deeper than initially intended.
• For all levels of sedation, the practitioner must have the ____, skills, drugs and equipment to identify and manage such an occurrence until either assistance arrives (emergency medical service) or the patient returns to the intended level of sedation without airway or
cardiovascular complications.
continuum
individual
physiologic
training
Assessing Depth of Sedation: Mild/Moderate
• ____ communication
• ____ up
• ____ nod
bidirectional
thumbs
head
Levels of Sedation
• Remember, the degree of sedation achieved (i.e. minimal, moderate, deep, general) is NOT due to the
• Whether ____ or non-drug techniques are used
• The ____ drug used
• The ____ of drug administration
• The ____ of airway management device used
• The degree of sedation is a result of the patient’s ____, respiratory, and circulatory system responses to the techniques used
drug specific route type cognitive
ANY Level of Sedation Can be Achieved with ANY Medication via ANY Route of Administration
• Can achieve sedation or GA with any of these drugs
some drugs its really easy to get GA - like propofol, so it has a warning
‣ part 1 of black box warning says: only people ____ should administer drug ‣ part 2 says: only people not involved in procedure should ____ drug
^attorneys can use this against you if you don’t follow!
ketamine really intended for people trained in anesthesia because of ____ - patient can be like lights on no one home - hard to assess how deep they are
“midazolam is really a workhorse drug for ____ sedation”
fentanyl has ____ properties
trained
administer
dissociative anesthesia
moderate
Levels of Sedation: A Note of Caution
• A restless, ____ patient may be disinhibited
• This is a sign of ____
• Fatal error: Administering more sedation to “calm” the patient -> respiratory ____/apnea, hypoxia, ____, arrhythmias, cardiovascular collapse, coma, death
confused
oversedation
depression
seizures
Sedation & Anesthesia: Goals •Patient \_\_\_\_ • Anxiolysis • \_\_\_\_ • Amnesia •Complete \_\_\_\_
safety
analgesia
treatment
Analgesia: Pain Relief
• Local anesthesia provides the foundation for analgesia with or without moderate sedation/GA
• There is no ____
• Exception: True local anesthetic allergy
• 1% ____ (Benadryl®)
• Caution: ____
substitute
diphenhydramine
sedation
Analgesia: Pain Relief
• Narcotic analgesics are opioids
◦ can provide pain relief and some sedation if you give enough but not primary ____
◦ some undesirable effects…reads
‣ really notes “decreased lidocaine convulsive threshold” and notes how this decreases amount of lidocaine that can cause to overdose
‣ reads “others”
• like morphine and meperidine you get histamine release with itching
mechanisms
Nausea/Vomiting and Respiratory Depression are Notable Opioid Side Effects
◦ respiratory depression in black ◦ n/v in black/white ◦ all the way to right is \_\_\_\_ ◦ Seconal is a \_\_\_\_ ◦ opioids like three on left it gets high \_\_\_\_ depression!
saline
barbiturate
respiratory
Meperidine
• has a duration of action 2-4 hours
• has metabolites
◦ ____ is inactive
◦ ____ is active and can last a couple of days
‣ also a CNS stimulant so kids can have ____ while overdosing on meperidine
‣ what is building up with multiple doses –> tremors and death if no intervention
meperidine acid
normeperdine
seizures
Alphaprodine: Specific Risk Factors • \_\_\_\_ as potent as meperidine • Dosage is \_\_\_\_ that of meperidine • More \_\_\_\_ onset • Half the \_\_\_\_ of effect • Volume injected can be on the order of tenths to one- hundredths of a milliliter (less \_\_\_\_ for error)
twice 1/2 rapid duration room
Alphaprodine: Specific Risk Factors
◦ adverse reactions with alphaprodine
◦ lists the x-axis - ones on the right (diazepam and ketamine) have lower adverse
effects with ____
alphaprodine
Analgesia: Pain Relief
• NSAIDs
• Intravenous/intramuscular: ____
• PO: ____
• Acetaminophen
Superior analgesic efficacy without opioid side effects: ____, respiratory depression, and ____ (constipation)
ketorolac
ibuprofen
CNS depression
gastroparesis
Anxiolysis: Reduce Anxiety
- Reduce anxiety and promote relaxation
- ____ are drug category of choice
- Via ____ receptor agonism
- Enhances ____ ion flow via GABA channel
- ____ have some anxiolytic properties
- ____ do not have anxiolytic and amnestic properties
- With escalation of the opioid dose there may be ____, respiratory depression, loss of airway, and loss of memory
- Opioids provide analgesia via ____-opioid receptor agonism
benzodiazepines
GABA
chloride
antihistamines
opioids
unconsciousness
mu
Amnesia: Not Remembering • \_\_\_\_ amnesia = after drug is given • Depth of sedation correlates with likelihood of amnesia • Loss of consciousness more likely to lose all memory of the \_\_\_\_, however, also risk losing \_\_\_\_ • \_\_\_\_ are drug category of choice • \_\_\_\_ do not have amnestic properties • Be careful what you say • Do not encourage/reinforce \_\_\_\_
anterograde procedure airway benzodiazepines opioids memory
Akinesia: Not Moving
- A relaxed and properly (moderately) sedated patient may or may not move, wiggle
- ____ IS OKAY
- Noise = ____
• A patient under ____ sedation or general anesthesia will likely have no movement, or only move in response to painful stimulation
The four A's of anesthesia: • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ = not moving
movement
breathing
deep
analgesia
amnesia
anxiolysis
akinesia
Routes of Administration: Enteral
• The drug absorbed through the gastrointestinal (GI) tract or oral mucosa
• i.e., ____, ____
oral
rectal
Routes of Administration: Parenteral
• The drug bypasses the ____ tract
• i.e., intramuscular (IM), intranasal (IN), intraosseous (IO), intravenous
(IV), subcutaneous (SC), submucosal (SM,) sublingual (SL)
• Inhalational (IH) – a type of parenteral route that involves ____ or ____ agent absorbed through the alveoli
gastrointestinal (GI)
gas
volatile
Dosing: A Word of Caution
• Maximum recommended dose (MRD) - maximum FDA-recommended dose of a drug, as printed in FDA-approved labeling for unmonitored home use.
• Minimal sedation for adults
• No more than the ____ for unmonitored home use, regardless of whether the
dose is given at once or in smaller increments
• Once MRD is exceeded -> ____ sedation rules apply
- minimal sedation for pediatrics
- ____
MRD
moderate
“1 and done”
