paediatric sedation Flashcards
paediatric pt assessment has 4 parts
- History
- Pt factors
- Goals
- Tx plan
pt history for sedation
- Pain
- Timing of pain
- Options for them
- E.g. excruciating toothache not aided by analgesics, but too anxious to be assessed – options limited compared to child who is asymptomatic and has a grossly carious tooth
- Nature of anxiety
- What causes it? Broad or narrow?
- Past experience?
- Dental history
- Try to phrase questions in positive light
- Medical history
- Fitness for sedation
3 pt factors influencing sedation
understanding
cooperation
coping style
related to each other
paed pt understanding
depend on age and stage of development
paed pt cooperation
do they want this? (hypnotic suggestion helpful), will they sit still for it?
paed pt coping styles can be
monitor or blunter
paeds DFA assessment tool
- Adapted faces version of Modified Child Dental Anxiety Scale MCDASf
- 9 questions
- Score 9-45
- No dental anxiety = 9
- Extreme dental anxiety/phobia = >31 or 5/5
4 methods of pain and anxiety management for children in dental setting
- NPBM (non pharmacological behavioural management)
- LA
- Sedation
- GA
examples of non pharmological behavioural management
hypnosis, CBT, tell show do
I.S sedation in paeds
- combination of pharmacology and behaviours
- hypnotic suggestion to frame child into a positive state
- Nitrous oxide and oxygen
- No smell/taste
- Low tissue solubility – rapid onset and recovery
- Min alveolar concentration is 110 – imp to get anaesthesia with N2O alone at normal pressure in pt who is oxygenated
- Safe
- Titrate to each child’s needs
indications for IS sedation in paeds
- Age
- Happy to sit in chair, understand nasal breathing
- Anxiety level – mild to moderate
- Management of gag reflex
- If only – try relaxation first
- Medical considerations
- Previous dental history
- Had they had it before
- Dental needs
contrindications for IS sedation in paeds
- Age (under 4 lack understanding, up to 6 – need to assess individual)
- Anxiety level (extreme)
- Medical considerations
- Learning disabilities, nasal blockage, claustrophobic etc
- Previous dental history
- Previous unsuccessful I.S
- Dental needs
- Anterior region (particular maxillary)
- Pt choice
how to explain IS Sedation to child
Tingling, dreamy, floaty feeling
Back to normal 10mins after tx
things to tell pt and parent before IS for consent
- Check understanding
- Written pre-op and post-op instructive
Tingling, dreamy, floaty feeling
Back to normal 10mins after tx
Still need LA if tx requires
Block nose is a no
Pregnancy accompanier cant be in surgery
Need accompanied out after
Can go back to school – no contact sports, bike, scooter
what to do during IS tx
- Keep talking to pt
- Agree to pt will reply by nodding or thumbs up/down
- Avoid speaking – mouth breathing
- Continual behavioural management – relaxation, voice tone, picture waves/happy place (discuss prior)
- Agree to pt will reply by nodding or thumbs up/down
- Ensure child avoids mouth breathing
- Get child to place on comfortably but then you check placement and seal
- Monitor
- Look at reservoir bag – match their tidal breathes
- Maximum when child reports ‘tingling’ or starts giggling/becomes over-excited
- STOP if ears ringing or sore head
after IS tx
give post-op instruction
praise child on how well they have done
IV sedation in paeds
- Achieved by titration of appropriate sedative drugs in clinically monitored environment
- Midazolam (not so much in paeds)
- Propofol
- Post procedural amnesia is common
- Pro – not pleasant proceuder
- Con – trying to praise them to reduce anxiety
indications for IV sedation
- Age (12+)
- Anxiety level – moderate to severe, generalised dental phobia or needles in mouth (not generalised needles)
- Medical considerations – asthma (inc anxiety), previous cannulation
- Previous dental history
- Dental needs
- High volume tx, no previous experience for ortho XLA
contraindications to IV sedation
- Under 12s
- Mild anxiety or severe needle anxiety
- Medical considerations
- Intellectual impairment, psychiatric disorders etc
- Dental needs
- Monitors can’t deal due to amnesia
- Lack of control gone away
IV sedation in paeds
Target controlled infusion (TCI) sedation
- Low dose for sedation
- Administered by anaesthetist
- Computer driven system
- Deliver and maintain a pre set plasma concentration of propofol
- Rapidly equilibrates in brain, continuously tritated by anaesthist to maintain
- Useful for very long and very short procedures
- Mean rapid onset and recovery
important aspects to emphasise for paeds IV sedation
- Accompanied by someone over 18years of age, be there before and after – not safe left alone
- Car and taxi for travel
oral and transmucosal sedation in paeds
- Midazolam
- Less controlled
- Cannulation
- Advanced technique children
- Rare cases
- SC requirements, extreme needle phobias
