paediatric sedation

Question 1

paediatric pt assessment has 4 parts

Answer 1

• History
• Pt factors
• Goals
• Tx plan

Question 2

pt history for sedation

Answer 2

• 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

Question 3

3 pt factors influencing sedation

Answer 3

understanding

cooperation

coping style

related to each other

Question 4

paed pt understanding

Answer 4

depend on age and stage of development

Question 5

paed pt cooperation

Answer 5

do they want this? (hypnotic suggestion helpful), will they sit still for it?

Question 6

paed pt coping styles can be

Answer 6

monitor or blunter

Question 7

paeds DFA assessment tool

Answer 7

• 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

Question 8

4 methods of pain and anxiety management for children in dental setting

Answer 8

1. NPBM (non pharmacological behavioural management)
2. LA
3. Sedation
4. GA

Question 9

examples of non pharmological behavioural management

Answer 9

hypnosis, CBT, tell show do

Question 10

I.S sedation in paeds

Answer 10

• 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

Question 11

indications for IS sedation in paeds

Answer 11

• 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

Question 12

contrindications for IS sedation in paeds

Answer 12

• 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

Question 13

how to explain IS Sedation to child

Answer 13

Tingling, dreamy, floaty feeling

Back to normal 10mins after tx

Question 14

things to tell pt and parent before IS for consent

Answer 14

• 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

Question 15

what to do during IS tx

Answer 15

• 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)
• 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

Question 16

after IS tx

Answer 16

give post-op instruction

praise child on how well they have done

Question 17

IV sedation in paeds

Answer 17

• 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

Question 18

indications for IV sedation

Answer 18

• 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

Question 19

contraindications to IV sedation

Answer 19

• 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

Question 20

IV sedation in paeds

Answer 20

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

Question 21

important aspects to emphasise for paeds IV sedation

Answer 21

• Accompanied by someone over 18years of age, be there before and after – not safe left alone
• Car and taxi for travel

Question 22

oral and transmucosal sedation in paeds

Answer 22

• Midazolam
• Less controlled
• Cannulation
• Advanced technique children
• Rare cases
  
  • SC requirements, extreme needle phobias