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”
Dosing: A Word of Caution
• For minimal and moderate sedation, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely
• ____ (midazolam)
• ____
benzodiazepines
fentanyl
Dosing: A Word of Caution
• Certain agents may induce deep sedation and/or general anesthesia rapidly, even at small doses
- These drugs are not appropriate for minimal and/or moderate sedation and their use may be restricted to those dentists with GA training (Dentist Anesthesiologist and/or Oral Surgeon)
- ____
- Ketamine
- ____
- Precedex ® (dexmedetomidine) alpha2 agonist, need to titrate carefully • ____ opiod
- Volatile agents (sevoflurane, isoflurane, desflurane) very potent
- ____ (i.e. methohexital)
propofol
etomidate
remifentanil
barbiturates
NPO Guidelines
- In some of the cases in the Goodson and Moore article, what went wrong was that they weren’t following the NPO Guidelines - References Case 8 in the article
- For outpatient office visits, the ASA office guidelines make it clear that for elective procedures (like in dental office) we never see a patient on a ____ stomach
- Stick to these because they will be used against you in litigation
- Sedation relaxes ____ tone, lose gag and ____
- She goes on a tangent telling you how important it is to follow
- ____ is an example of NOT a clear liquid
- light meal is something like toast, but once you add butter it gets dicey
full
lower esophageal
cough reflex
orange juice
Anesthesia Monitoring Parameters • \_\_\_\_ • \_\_\_\_ • \_\_\_\_ • \_\_\_\_
oxygenation
ventilation
circulation
temperature
Anesthesia Monitoring
• ____ personnel
• Oxygenation: ____
• Ventilation: capnography and/or precordial stethoscope
• Must have ____ if intubated
• Circulation: ____ (EKG,) blood pressure, and pulse oximetry
• ____
qualified pulse oximetry capnography electrocardiography temperature
Vital Signs
- The following vital signs should be recorded (pre-op, intra-op, and post- op) for any sedation/anesthetic:
- ____(SpO2)
- ____
- ____
- ____
- ____
- For adults, ____
- For children, ____
oxygen saturation
blood pressure
heart rate
respiratory rate
height & weight
BMI
percentile BMI
Monitoring Methods: Ventilation • \_\_\_\_ communication • Look, listen, feel • \_\_\_\_/pretracheal stethoscope • Capnography
verbal
precordial
• So again, stethoscope gives a lot of quality info on ____
breathing
Capnography is line in white - blown up wave form on right
• immediately tells you if patient stops breathing because line goes flat
• measures CO2 as it is ____
• Phase I - the patient is ____ (no CO2 coming out)
• Phase II-IV is act of ____
• Sometimes capnograph is more valuable than precordial if there is too much noise in the room
• NEED TO HAVE ____ IF INTUBATING PATIENT - has mentioned this multiple times
exhaled
inspiring
exhaling
capnography
Capnography: Rapid Detection of Apnea
• This is what happens with capnogram
• doesn’t have as much of a distinct ____ form if not intubated
• but moment the patient stops breathing the capnograph goes to zero - ____ begins
◦ blood gas starts to go down but pulse oximeter has a delay. The pulse oximeter won’t drop until it detects enough hypoxia which is why it is not a great measure for ventilation
wave
hypoxia
What about pulse oximetry? Pulse oximetry is a monitor of ____, not ventilation.
oxygenation
Pulse oximetry is not a reliable real-time monitor of ____ status, especially in a child that is ____
• remember what i said - this is a normal 10kg child. By the time they reached a sat of 90%, this is
a 30 second to 1 minute delay and have dropped hemoglobin saturation by a lot
ventilatory
desaturating
The Dangers of Sedating a Pediatric Patient from a Remote Location: Caution Regarding Premedication
• In a lot of the Goodson and Moore articles the patients were sedated at home in an inappropriate venue, then driven to the office where they were sedated even more - a dangerous idea since parent is not a ____ and can’t monitor
medical professional
The Dangers of Sedating a Pediatric Patient from a Remote Location: Caution Regarding Premedication
- Any infant or child should not be left in a car seat ____ (even in normal daily circumstances)
- Deaths have been reported for infants and preschool aged children due to car seat ____ (without sedation) due to loss of airway (neck flexion)
- Any child who is to be sedated requires an immediate pre-op assessment as well as monitoring by a trained health care professional from the time of drug administration continuously until ready for discharge
unmonitored
immobilization
Providers Must Remain Vigilant in the Postoperative Period
• In this study the children are given a triple combination of meperidine, chloral hydrate, and hydroxizyne or just versed
◦ of the children with triple combo - 12 fell asleep in the car and 10 of them had trouble waking up
◦ with versed 1 kid fell asleep and they wereeasy to wake up
• Better to go to ____ to get PO sedation then dentist office to get more oral sedation than to do it at home
• Doctor can mistake disinhibition of at-home sedation as inadequate sedation
• No longer in ADA guidelines to give at-home sedation, children need to be ____ by trained
personnel
doctor
monitored
Flumazenil
- Mechanism of action: competitive inhibition (antagonism) at the benzodiazepine site at the ____ Receptor
- Indications: reversal of ____ induced respiratory depression and/ or central nervous system depression
- Contraindications
- ____ to flumazenil or benzodiazepines
- Patients to whom benzodiazepine has been administered to treat a serious condition such as ____
- Patients with signs of a cyclic antidepressant overdose (____ and seizures)
GABAa benzodiazepines hypersensitivity seizures arrhythmias
Flumazenil
- Dosing
- 0.01-0.02 mg/kg (max dose 0.2mg) IV or IM
- May repeat up to ____mg per minute
- ____ mg max total dose
- Monitor recovery for at least ____ hours after most recent dose of flumazenil
The more important thing is that the flumazenil wears off faster than ____, even aster than midazolam , so you want to…reads last bullet point
0.2
1
2
benzodiazepines
Sublingual Flumazenil: Does NOT ____
• Total dose to reversal varies with depth of sedation
•0.2mg is in a volume of 2 mL
• Latent period too ____
• Reversal not statistically different from placebo
• Most patients respond to 0.6-1mg (6-10mL)
• Too ____ to inject sublingually
• Can worsen an already compromised ____
• Consider ____ injection
work long large airway intramuscular
Sublingual Flumazenil: Does NOT Work • Fallacy to think IM or SL is “Safer” • \_\_\_\_ absorption • Sublingual anatomy – highly vascular • Potential for \_\_\_\_ • Worsen an already compromised \_\_\_\_ • Over-sedated child • \_\_\_\_ mouth • Unable to access buccal \_\_\_\_ or sublingual area for injection
unpredictable hematomas airway clenched vestibule
Naloxone
- Mechanism of action: competitive inhibition (antagonism) of ____ receptor (mu)
- Indication: to reverse opioid induced ____ and/or central nervous system depression
- Contraindication: ____ to naloxone
opioid
respiratory depression
hypersensitivity
Naloxone • Dosing • 0.01 mg/kg IM, IV, SQ • May repeat after 2-3 min • Max dose \_\_\_\_mg • Monitor for at least \_\_\_\_ hours after the most recent dose of naloxone
2
2
A Comment on Reversal Agents
- Giving reversal agents ____ to routinely decrease depth of sedation is not ____
- Reversal agents reserved for emergency
- Reversal agents have side effects
- Once a reversal agent is given, can’t give more ____… chasing your own tail!!!
IV
acceptable
sedatives
Oral Drug Administration (PO)
• Most common
- Advantages
- Easily ____ by pts
- Ease of ____
- Relative safety??
- Adverse effects such as ____, idiosyncrasy, allergy and side effects can occur with PO as with any route
- Severity of adverse effects less with ____
- But life-threatening reactions can still occur with ____ as with any route (cardiac arrest and anaphylaxis have occurred with oral meds)
accepted administration overdose PO PO
Oral Drug Administration (PO)
• Disadvantages
• Long ____ period the onset to clinical effect
• ____ drug absorption
• ____ effect
• ____ duration of action
• Inability to ____ to achieve desired drug effect
latent unreliable first pass prolonged titrate
Oral Drug Administration (PO)
• Disadvantages
• Impossible to ____ = long latent period + continued drug
absorption
• Can ____ predict when that peak drug level hits the bloodstream
• “guess-timate” ____ dose for a patient
titrate
not
predetermined
What is Titration?
• Titration: administration of small ____ doses of a drug until a desired clinical action is observed
• Titration allows us to control the drugs actions and give enough to get desired effects and minimize ____ (which are dose related)
• Titration is possible via ____ routes ONLY
• ____ is NOT inhalational
incremental
adverse effects
inhalational and intravenous
intranasal
Oral Drug Administration (PO)
• Disadvantages
• Once administered, its impossible to quickly improve drug actions if the initial dose is ____
• Once administered, its impossible to quickly ____ any adverse effects
inadequate
reverse
Oral Drug Administration (PO)
- Disadvantages
- Prolonged ____ of action
- Usually ____ hours
- Will require dentist to ____ until ready for discharge
- Lots of ____ time spent watching for recovery from PO drugs
duration
3-4
monitor
chair
Oral Drug Administration
- Commonly used for pediatrics
- ____
- Hydroxyzine
- ____ – no longer manufactured
- Meperidine – not approved on formulary for PO sedation at many hospitals
- ____ – not recommended, long half lives
• Adults - ____
midazolam
chloral hydrate
diazepam
triazolam
Parenteral Drug Administration
• ____
• ____
• ____
inhalational
intravenous
intramuscular
Inhalation (IN) (Pulmonary)
- N2O – Advantages
- Most ____ onset
- More rapid than IV because you breathe in and it gets to blood then brain
- Latent period extremely ____
- Can observe clinical effects in 15-30 seconds
- Ability to ____ up and down
- Intravenous: easy to titrate up (increase dose and increase effect) but can’t titrate down (decrease effect and depth of sedation.)
- Very quick ____
- Can drive and go home alone if only receiving N2O
rapid
short
titrate
recovery
Inhalation (IN) (Pulmonary)
• Inhalation vs Intravenous
• Inhalation: Ability to ____ up and down
• Intravenous: easy to titrate up (increase dose and increase effect) but can’t titrate ____ (decrease effect and depth of sedation.)
titrate
down
Inhalation (IN) (Pulmonary)
• N2O – Disadvantages
- Not very potent
- Need to give at least ____% oxygen a
- 70% N2O may not be enough
- Pt ____ required
- Accepting nasal hood
- ____ v mouth breathing
- Uncooperative or pre-cooperative children
- Size/cost of equipment
- Training/expense to safely administer N2O/ O2
- Potent ____ gas
30
cooperation
nose
greenhouse
Intravenous (IV)
- Advantages
• Most predictable and effective ____
• ____ latent period
• Usually 20-25seconds
• Can rapidly ____ effect
• ____ latent period + enhanceable = titratable
• 2-5 minutes for ____ to desired level of sedation
sedation short enhance short titration
Intravenous (IV)
- Disadvantages
• Require cooperation for ____ access
• Inability to reverse once injected into the ____
• (Remember, NOT all drugs have antagonist agents)
• ____ onset
• Potential for accentuated desirable and undesirable drug effects
• Overdose, side-effects, allergic reactions
• Need to ____ the entire team
IV
veins
rapid
train
Intravenous (IV) • IV sedation is the most \_\_\_\_ sedation technique • But, it is not panacea • Some patients need deep sedation/GA: • Extreme \_\_\_\_ • Severe strong gag reflex • Pre-\_\_\_\_ children • Non-cooperative special needs patients • Patients taking chronic \_\_\_\_ and/or opioids
effective
phobia
cooperative
benzodiazepines
Intravenous (IV)
• Moderate sedation
- Supplemental oxygen
- Local anesthetic
- ____: anxiolytic, amnestic
- Single agent protocol
- ____
- Small ____ doses of short acting, potent opioids (fentanyl)
- Only if severe pain, invasive procedure
- Caution: ONLY ____, no amnesia/anxiolysis, potent respiratory depressant
- May also use ____ /oxygen
benzodiazepines
midazolam
incremental
analgesia
nitrous oxide
Non-Sedating Adjunctive Intravenous Agents
- Glycopyrrolate
- ____
- Potent reduction in saliva
- Mild ____
- Doesn’t cross BBB (non-sedating)
- Dexamethasone
- ____
- Anti-inflammatory (preemptive)
- Potentiates anti-____ effects of ondansetron
- Ondansetron
- ____ Antagonist
- Anti-emetic
- Ketorolac
- ____
- Analgesia
anticholinergic
tachycardia
corticosteroid
emetic
5-HT3
NSAID
Glycopyrrolate - I am remissed to do any sedation or GA without it
• it causes mild ____ which is good because a lot of the anesthetics cause bradycardia so i
like to keep my patients a little tachycardia
• broncho-dilator and ____
• very ____ antisialogogue effect without producing any sedation because it doesn’t cross ____
Atropine - with a drug like atropine you don’t get as much dry mouth but a lot of ____
• you might be getting too much tachycardia
• we save this for dangerous ____
tachycardia
anticholinergic
potent
BBB
tachycardia
brachycardias
Deep Sedation/General Anesthesia
- Indications
- Intense ____
- Severe gag reflex
- History of ____ with nitrous oxide, oral, and IV sedation
- Biologic variability
- History of chronic ____ and/or opioid use
- Pre-cooperative
- ____ care
- Large or invasive dental procedure
fear
failures
benzodiazepines
special
Deep Sedation/General Anesthesia
- Advantages
- ____ onset
- Highly effective
- ____
- Disadvantages
- Lose ____
- Lose ____
rapid
reliable
consciousness
airway
Deep Sedation/General Anesthesia: Common Agents
- Supplemental ____
- Local anesthetic
- ____
- Fentanyl
- Propofol
- ____
- Potent respiratory depressant
- ____
- Amnestic
- NOT ____
- Ketamine
- ____
- Dissociative anesthetic
- ____ – pair with benzodiazepine
- Amnesia
- ____
oxygen midazolam GABA anxiolytic analgesic
NMDA antagonist
hallucinations
unconsciousness
Deep Sedation/General Anesthesia: Common Agents
- Volatile inhalational agents
- Sevoflurane, isoflurane, desflurane
- Potent
- Loss of ____
- Triggering agent for ____
- Remifentanil (Ultiva®)
- Ultrapotent
- Ultra ____ acting opioid
- Given by ____ only
- Risks ____, hypotension, apnea
- Dexmedetomidine (Precedex®)
- ____
- Analgesic
- Sedative
- ____ (risks severe bradycardia and hypotension if given by bolus)
- Given by ____ only
consciousness
malignant hyperthermia
short
infusion
bradycardia
alpha2 agonist
sympatholytic
Review of Local Anesthetic Toxicity
• Adverse effects aka drug toxicity
• Is related to the ____
• Is ____ related
• Occurs when the maximum recommended dose has been exceeded
• Severity is proportional to systemic (plasma) levels of medication
mechanism of action
dose
Local Anesthetic Toxicity • Toxicity is mediated by the same mechanism of action • Inhibition of \_\_\_\_ channels • What other tissues are affected? • \_\_\_\_ system • \_\_\_\_ system
sodium
cardiovascular
central nervous
Early Local Anesthetic Toxicity
- Perioral numbness and tingling
- Usually around the entire ____
- Not just the ____ side
- Metallic taste
- ____
- Tinnitus
- ____
- Dizziness
- ____
mouth anesthetized diplopia nausea drowsiness
Early Local Anesthetic Toxicity
- Usually ____
- Usually due to a mild ____
- Usually due to accidental ____ injection
- ____ may mask early signs
- Risk of sudden appearance of late signs of local anesthetic systemic toxicity
self limiting
overdose
intravascular
sedation
Local Anesthetic Toxicity
- As plasma (blood) levels of local anesthetic increase, there are more serious consequences:
- ____
- Increase ____ and heart rate
- ____ and respiratory arrest
- Severe ____ and cardiovascular depression
- Slow ____, irregular heart rhythm, cardiac arrest
- Death
seizures blood pressure unconsciousness hypotension heart rate
Local Anesthetic Overdose: Prevention
- Prevention is key:
- Calculate the MRD : ____- based
- Especially important in children
- Children have deceptively ____ heads
- ____: 1 cartridge per 25-lb body weight
weight
large
clark’s rule
Local Anesthetic Overdose: Prevention
• Use the ____ possible dose • Stay below the ____
• Keep max number of cartridges allowable on tray table to avoid overdose
• Keep used cartridges as well to keep track
• Inject ____ and aspirate
lowest
MRD
slowly
Local Anesthetic Overdose: Management • \_\_\_\_ • Supplemental Oxygen • Monitor \_\_\_\_ • If severe and rapidly progressing, activate EMS • Treat arrhythmias as per ACLS • \_\_\_\_ • Defibrillator • \_\_\_\_ meds • Support airway • Treat \_\_\_\_
C-A-Bs vitals CPR antiarrhythmic seizures
Overdose of a Pediatric Patient: CNS Toxicity
• A healthy five-year-old female patient, weighing ____ lb. was scheduled for multiple extractions. The child received N2O/O2 sedation via a nasal mask, followed by maxillary and mandibular injections of five cartridges of 3% ____ (270 mg). Ten minutes later the child experienced “stiffening and shaking” of all extremities that lasted ten seconds. Two more convulsive episodes occurred and cardiopulmonary arrest ensued. Transport to a local hospital and resuscitation measures were unsuccessful. Death occurred four days later.
36
mepivacaine
Local Anesthetic Dosing
As you can see, for a 50 pound child the max amount of cartridges of mepivacaine should be ____ and they gave 5 for a 36 pound kid :(
Mepivacaine has the least inheritantly vasodilating property of the agents so 3% plain solution is thought to have shorter ____ anesthesia duration but this is a mistake…it really only has a shorter ____ duration, so the amount of residual numbness is the same as when you give 2% lido with epi. But because there is no vasoconstrictor and 3% mepivacaine compared to 2% lido then you’re actually going to give more local with every cartridge and OD more easily with small children
2.5
soft tissue
hard tissue
Local Anesthetic Seizures during Pediatric Sedation
• An 8-year-old girl weighing ____ lb. was brought to a private dental office for multiple extractions of primary teeth. The child had no history of drug allergies or significant systemic illnesses. Sedation was initiated with oral promethazine 6.25 mg and nitrous oxide/oxygen sedation 25%/75%. Thirty minutes later, the child appeared to be inadequately sedated and the initial drug regimen was supplemented with intramuscular meperidine 50 mg and nitrous oxide concentration increased to 37.5%. Local anesthesia was administered for all four dental quadrants using ____ cartridges of 3% mepivacaine (324 mg). …
Local Anesthetic Seizures During Pediatric Sedation
• …Five minutes following local anesthesia administration, the child had multiple seizures, followed by respiratory distress. Initial emergency medical management included 100% oxygen, subcutaneous naloxone 0.4 mg and lingual epinephrine 1 mg. Upon arrival, paramedics initiated oral intubation, provided positive pressure ventilation and immediate transport the child to the local hospital. Further efforts for resuscitation were ____.
50
six
unsuccessful
This graph is really interesting because it shows how many times the MRD of LA and how many times the MRD of the opiod
At any point anyone got more than ____x MRD of opiod or local, you are more likely to die
Boxes in white showed patients who survived by being resuscitated and managed airways from an immediately available anestheoligist
3
The “Lytic Cocktail”
• DPT
• ____® (meperidine) -
• ____® (promethazine)
• ____ (chlorpromazine)
• Originally intended to induce deep sedation to facilitate separation of child from parent as child entered the OR
• In an era before ____
• Anesthesiologist present for all aspects of monitoring and airway management
• ____ access and airway (intubation) secured in the OR
demerol phenergan thorazine midazolam intravenous
he “Lytic Cocktail” • DPT • Demerol® (meperidine) • Vagolytic (\_\_\_\_) • \_\_\_\_ release • Normeperidine – active metabolite with long half-life, CNS excitation -> myoclonus and/or seizures • Phenergan® (promethazine) • \_\_\_\_ • Thorazine (chlorpromazine) • \_\_\_\_
tachycardia
histamine
antihistamine
antipsychotic
Multiple Sedatives: Opioid + Antihistamine Oral Sedation Combination
- Enhances ____
- Increased respiratory depression
- Less ____ efficacy
- Both drugs reduce the ____ threshold and increase CNS toxicity of LAST
- Neither are ____ and amnestic drugs of choice (aka benzodiazepines)
- Lack of ____ access
- Can’t ____
- Can’t have a path to quickly administer ____ (reversal drug) in an emergency
sedation
analgesic
seizure
anxiolytic
intravenous
titrate
naloxone
Multiple Oral Sedatives Including Opioids -> ____
This just shows that if you give meperidine and chlorpromazine (antihistamine) you get way more respirator depression
respiratory depression
Opioids, Especially ____ and Meperidine, Lower the Seizure ____ for Local Anesthetics
alphaprodine
threshold
Opioids, Especially Alphaprodine and Meperidine, Lower the ____ for Local Anesthetics
• Opioids cause CNS \_\_\_\_ • Opioids cause \_\_\_\_ depression • Reduce respiratory rate, increase arterial CO2, decrease blood pH (acidosis) • \_\_\_\_: • Reduces seizure threshold • Increases \_\_\_\_ (and delivers more local anesthetic to the CNS) • Decreases \_\_\_\_ binding to LA • Cardiac arrest more likely if acidotic
seizure threshold
depression respiratory acidosis cerebral blood flow plasma protein
Opioids, Especially Alphaprodine and Meperidine, Lower the Seizure Threshold for Local Anesthetics
• Treatment of respiratory depression • MUST monitor \_\_\_\_ and identify respiratory depression • \_\_\_\_ and/or precordial stethoscope
• MUST manage ____
(supplemental O2, jaw thrust, positive pressure ventilation, possible intubation, etc.
• Reversal of ____ may be indicated
ventilation
capnography
airway
opioid
