Nedley's Slides - Conscious Sedation I (145-178) Flashcards
Child Development
-Piaget’s Stages of Cognitive Development
Sensorimotor
Preoperational
Concrete operations
Formal operations
-Progression from stage to stage universal and invariant
Sensorimotor
- Under 18 months of age
- Language…minimal
- Fear…sudden noises, new situations, and separation from parents
- Defenses…cry, scream, move away
Pre-Operational (2-4 years)
2-4 years
Language…developing vocabulary and grammar
Fears…not well understood, dark, monsters
Defenses…magical, not rational
**Nedley’s Notes: These ages are probably different than what you’ve seen before; he thinks this is 3-5ish
Pre-Operational (5-6 years)
5-6 years
Language…better, simple vocabulary
Fear…can react with shame
Defenses…moves away from situation, denial
Concrete Operational
7-12 years
Excellent in concrete understanding, abstract less developed
Fear…more realistic, fears loss of control, death
Defenses…more restrained, developing internal defenses
**Nedley’s Notes: kids start going to school and doing math
Formal Operations
12-18 years
Language…Full development
Fears…mirror adult world, getting hurt, world affairs
Defenses…intellectual and rational
N2O/O2 Use in pediatrics Pediatric dentistry (Wilson)
89% of 1758 AAPD respondents use N2O to treat pediatric patients
87% used titration method
Rarely were concentrations higher than 50%
74% do not use any monitors when using N2O alone
Pulse oximeter most common monitor when N2O used with other sedatives
BP cuff and stethoscope also used
(Primosch) 40% N2O improved behavior w/out affecting breath sounds or hemoglobin saturation
**Nedley’s Notes: Wilson did a study; 50% is an arbitrary. number; should be paying attention to patient and monitors at the same time
Pediatric patient considerations for use of N2O/O2 sedation
Patient willing to accept nasal hood…will patient respond to reason
N2O/O2 sedation enough or other sedation methods necessary
Does not require extensive physical evaluation
Tonsils
Middle ear disturbances
Last oral intake
Vomiting is more common in children than adults
Let patients vomit if they need to…clear airway…
Use HVAC suction
**Nedley’s Notes: Patients not laying back and not accepting nasal hood is a SIGN
Having to use rapid induction technique to settle a child is a SIGN
Can cause bad outcome
Main considerations at UTMC when a patient is vomiting during treatment?
Use HVAC suction
Don’t let assistant try to cup vomitus or hold napkin up to patients face. get the vomit OUT.
Administration of N2O/O2 sedation to pediatric patients
Titration is most important concept to follow
Rapid induction…greater than 50% N2O usually in children younger than three to settle a child
N2O has analgesic effects and this should be kept in mind while providing local anesthetics
Let patients touch, squeeze nasal hood prior to placement
Positive reinforcement is usually given for participating rather than how the patient participated
Safety of pediatric patients
Ill advised to let patients fall asleep
Common in children
Discontinue flow of N2O
Monitor…pre-trachial stethoscope, pulse oximeter, both
Nedley’s Notes:
Asleep is used here because it’s out of the book
-most times he won’t decrease nitrous but will just pay attention more vigilantly
-may want to put precordial stethoscope
-worried about silent regurgitation, you don’t hear that percolating up until they’re going to blow
What does the behavior management encompass?
Behavior management encompasses managing the patient, parent and the assistant and yourself
desired appointment length
usually not more than 45 minutes.
Nedley doesn’t really care though as long as the patient and the provider are comfortable
history of controversial literature
Reproductive difficulties
Maximum exposure limit has not been determined
**Nedley’s Notes: Test people and environmental levels of N2O; usually it’s low
Specific biologic issues and health concerns
Inactivation of methionine synthase…involved with vit B12 metabolism…DNA synthesis and cellular reproduction…birth defects?
Chronic exposure to N2O seems to have an effect on reproduction
Deoxyuridine suppression test detects early signs of enzyme inactivation
1st biologic effect seen at 1800 ppm, 400 ppm is reasonable and attainable
Anemias
Neurologic disorders
**Nedley’s Notes: Not sure if the 400 number is true
Current literature regarding N2O-O2 states…
- Use of scavenging masks & suction is the standard of care
- Evacuation flow rate of 45L/min
- Scavenged gas through vacuum into atmosphere
Detection and monitoring of N2O
Infrared spectrophotometry
Time weighted average (TWA)
Badge system
**Nedley’s Notes: If you’re using nitrous here and there your level of exposure is reasonably low
Scavenging N2O
Important to check the whole system Connections Tubing Mask fit Patient talking
Recommendations and preventative measures
Appropriate delivery system with scavenging capabilities, accurate flowmeter, adequate vacuum, variety of mask sizes Assess ventilation system Vent exhaust to outside Fresh air exchange Adequacy of suction system 45 L/min Right mask Correct tidal volume Discourage patient talking Assess ambient air for trace gas amounts Assess cylinder attachments, lines, hosing and bag for leaks Calibrate flowmeter every 2 years (have someone come look at it)
Inhalant abuse can happen in three ways
1) Sniffing or snorting
2) Bagging
3) Huffing
How are inhalants categorized?
Categorized as volatile solvents, nitrites, N2O
Inhalant Abuse
Inhaling chemicals found in household products is common in children and adolescents
Inhalants were second to marijuana as most common used illicit drugs by teenagers
Inhalants are a cheap way to “get high”
Commonly inhaled substances
Typewriter correction fluid Butane, gasoline, propane Paint and paint thinner Rubber cement, model glue Hair spray, cooking spray, deodorant spray Insect repellants N2O
N2O Abuse
Users are usually older Health care professionals Found in several forms Professional offices, hospitals Distribution centers Racing industry to boost performance…sulfur dioxide mixture Whipping cream propellant Aerosol cans of whipping cream Rarely detected in urine tests
Health hazards associated with chronic exposure to N2O
Affects vit B12 cofactor inactivating the enzyme methionine synthetase
Neurologic side effects
Frostbite
Asphyxiation
Health hazards associated with chronic exposure to N2O
Inactivation of methionine synthetase
Involved in DNA production
Megaloblastic hematopoesis and leukopenia result after prolonged exposure
No problem for surgery patients, effects are temporary
Pregnant mothers are at greatest risk (skeletal abnormalities and miscarriages)
Health hazards associated with chronic exposure to N2O: Neurologic side effects
Peripheral neuropathy Tingling and numbness in the extremities Weakness Incoordination Muscle weakness Slowed gait Recovery is slow and sometimes incomplete
Why can you get frostbite with N2O?
Frostbite - b/c temp of gas streaming from cylinder is -55*c
Additional health hazards associated with chronic exposure to N2O
Asphyxiation
O2 concentration drops
Sexual phenomena associated with N2O
Hallucinations
Visualizations
Auditory illusions
Abberations of a sexual nature were reported
Sexual phenomena associated with N2O
Male practitioners, female patients
N2O concentrations higher than 50% used
Have third party present
Addictive Nature of N2O
N2O abuse is low
Partial opioid agonist
Recreational use among youth and health professionals is common
Administration and monitoring
Some states allow hygienists to administer and monitor N2O
Some states allow assistants to monitor
