Nedley's Slides - Conscious Sedation I (145-178)

Question 1

Child Development

-Piaget’s Stages of Cognitive Development

Answer 1

Sensorimotor
Preoperational
Concrete operations
Formal operations

-Progression from stage to stage universal and invariant

Question 2

Sensorimotor

Answer 2

• Under 18 months of age
• Language…minimal
• Fear…sudden noises, new situations, and separation from parents
• Defenses…cry, scream, move away

Question 3

Pre-Operational (2-4 years)

Answer 3

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

Question 4

Pre-Operational (5-6 years)

Answer 4

5-6 years
Language…better, simple vocabulary
Fear…can react with shame
Defenses…moves away from situation, denial

Question 5

Concrete Operational

Answer 5

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

Question 6

Formal Operations

Answer 6

12-18 years
Language…Full development
Fears…mirror adult world, getting hurt, world affairs
Defenses…intellectual and rational

Question 7

N2O/O2 Use in pediatrics
Pediatric dentistry (Wilson)

Answer 7

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

Question 8

Pediatric patient considerations for use of N2O/O2 sedation

Answer 8

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

Question 9

Main considerations at UTMC when a patient is vomiting during treatment?

Answer 9

Use HVAC suction

Don’t let assistant try to cup vomitus or hold napkin up to patients face. get the vomit OUT.

Question 10

Administration of N2O/O2 sedation to pediatric patients

Answer 10

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

Question 11

Safety of pediatric patients

Answer 11

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

Question 12

What does the behavior management encompass?

Answer 12

Behavior management encompasses managing the patient, parent and the assistant and yourself

Question 13

desired appointment length

Answer 13

usually not more than 45 minutes.

Nedley doesn’t really care though as long as the patient and the provider are comfortable

Question 14

history of controversial literature

Answer 14

Reproductive difficulties
Maximum exposure limit has not been determined
**Nedley’s Notes: Test people and environmental levels of N2O; usually it’s low

Question 15

Specific biologic issues and health concerns

Answer 15

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

Question 16

Current literature regarding N2O-O2 states…

Answer 16

• Use of scavenging masks & suction is the standard of care
• Evacuation flow rate of 45L/min
• Scavenged gas through vacuum into atmosphere

Question 17

Detection and monitoring of N2O

Answer 17

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

Question 18

Scavenging N2O

Answer 18

Important to check the whole system
Connections
Tubing
Mask fit
Patient talking

Question 19

Recommendations and preventative measures

Answer 19

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)

Question 20

Inhalant abuse can happen in three ways

Answer 20

1) Sniffing or snorting
2) Bagging
3) Huffing

Question 21

How are inhalants categorized?

Answer 21

Categorized as volatile solvents, nitrites, N2O

Question 22

Inhalant Abuse

Answer 22

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”

Question 23

Commonly inhaled substances

Answer 23

Typewriter correction fluid
Butane, gasoline, propane
Paint and paint thinner
Rubber cement, model glue
Hair spray, cooking spray, deodorant spray
Insect repellants
N2O

Question 24

N2O Abuse

Answer 24

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

Question 25

Health hazards associated with chronic exposure to N2O

Answer 25

Affects vit B12 cofactor inactivating the enzyme methionine synthetase
Neurologic side effects
Frostbite
Asphyxiation

Question 26

Health hazards associated with chronic exposure to N2O

Answer 26

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)

Question 27

Health hazards associated with chronic exposure to N2O: Neurologic side effects

Answer 27

Peripheral neuropathy
Tingling and numbness in the extremities
Weakness
Incoordination
Muscle weakness
Slowed gait
Recovery is slow and sometimes incomplete

Question 28

Why can you get frostbite with N2O?

Answer 28

Frostbite - b/c temp of gas streaming from cylinder is -55*c

Question 29

Additional health hazards associated with chronic exposure to N2O

Answer 29

Asphyxiation

O2 concentration drops

Question 30

Sexual phenomena associated with N2O

Answer 30

Hallucinations
Visualizations
Auditory illusions
Abberations of a sexual nature were reported

Question 31

Sexual phenomena associated with N2O

Answer 31

Male practitioners, female patients
N2O concentrations higher than 50% used
Have third party present

Question 32

Addictive Nature of N2O

Answer 32

N2O abuse is low
Partial opioid agonist
Recreational use among youth and health professionals is common

Question 33

Administration and monitoring

Answer 33

Some states allow hygienists to administer and monitor N2O

Some states allow assistants to monitor