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Week 1 > Pharmacologic Behavior Management Techniques > Flashcards

Pharmacologic Behavior Management Techniques Flashcards

1
Q

Why do we need pharmacologic management?

A
  • Safey treat very anxious, fearful, uncooperative patients
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2
Q

Reasons for uncooperative behavior:

A
  • Very young age
    • ex. Pre-cooperative
  • Lack cognitive/emotional developement
    • ex: child with special needs
  • Child’s temperament
  • Parenting Style
    • lack of expectations or discipline
  • PTS in medical/dental setting
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3
Q

NC Law: Nitrous Oxide under age 13

A
  • only sedative agent that can be administered under age of 13
  • only need dental liscense, no special permit
  • need informed consent
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4
Q

NC Law: Sedative agent other than Nitrous Oxide under 13 y.o.

A
  • Falls under:
    • Moderate Pediatric Conscious Sedation
      • OR
    • General Anesthesia
  • Grey Areas:
    • Anxiolysis
    • unsupervised premed to children outside office before appointment
      • discouraged by AAPD
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5
Q

Goals of Pharmacologic Management

A
  • Protect the patients safety and welfare
  • minimize:
    • physical discomfort and pain
    • psychological trauma
  • Maximize:
    • amnesia
  • control:
    • anxiety
    • behavior or movement
  • Return patient to a physiologic safe state for discharge
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6
Q

Moderate Pediatric Conscious Sedation Permit: requirements

A
  • required for sedation of patients under 13
    • other than nitrous oxide
  • obtained from NC board of Dental Examiners
  • Include:
    • supervision of CRNA or other personal that administers sedative medications
      • employed or contracted
    • Thorough knowledge of agents
    • Proper training
    • planned and documented rational for use of sedation
      • risk-to-benefit analysis
    • Thorough Medical History and Physical Evaluation
    • informed consent
    • facility with all necessary equipment to handle an emergency
    • Properly trained employees
      • monitoring technique
      • emergency response-PALS or ACLS certification
    • Available mobile emergency medical services
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7
Q

Nitrous Oxide

A
  • least regulated
  • Very effective, but relies on proper patient selection
    • not Moderate to Severe Anxiety
  • in NC, only sedative agent administered in pedo without addtional training or liscense
  • Physiologically safe when administered with oxygen
  • most common side effect-Nausea
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8
Q

Advantages of Nitrous Oxide and Oxygen delivery by inhalation

A
  • Safety
    • impossible to lose consciousness or maintain airway
  • Rapid Onset and Recovery Time
    • due to low blood:gas solubiliity
  • Titratable
    • low blood:gas solubility allows for maximum effect with minimal discomfort
    • 35-50%
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9
Q

Nitrous Oxide: Disadvantages

A
  • Equipment cost
  • lack of patient acceptance
  • Weakness of agent
    • moderate to severe anxiety
  • Contraindications
    • acute otitis media
    • active pulmonary infection
  • Potential Chronic Toxicity
    • dentist and staff
  • Potentiation
    • when used in combo with another sedative agent- can take patient into deeper level than wanted
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10
Q

Sedation Patient Selection

A
  • Successful:
    • mild to moderate fear or anxiety who cooperate
  • Unsuccessful
    • extreme anxiety and uncooperative
    • combative
    • defiant
    • resistant
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11
Q

Dental Anesthesiology

A
  • 2012 ADA voted to be newest recognized dental specialty
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12
Q

Minimal Sedation

A
  • Aka Minimal Conscious Sedation
  • 13 y.o. or older
  • admin: oral or rectal routes
    • 1 pharmacological agent
    • 1 or more doses
    • Does not exceed Maximum recommended dose
  • can combine with nitrous oxide
  • used for behavioral management
  • Minimal depressed levels of consciousness
  • patient retains ability to:
    • independently and continuously maintain an airway
    • respond normal to tactile stimulation and verbal command
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13
Q

Minimal Sedation Regulation in NC

A
  • Requires moderate sedation permit
    • no additional permit needed
    • Moderate Pediatric Conscious Sedation-Pedo dentists
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14
Q

Moderate Sedation

A
  • 3 subcategories
    • Moderate Conscious Sedation
    • Moderate Conscious Sedation limited to oral routes and nitrous oxide inhalation
    • Moderate Pediatric Conscious Sedation
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15
Q

Moderate Conscious Sedation

A

Subcategory of moderate sedation

  • Drug induced depressed consciousness
  • Patients respond to verbal commands, either alone or w/light tactile stimulation
  • Admin:
    • 13+ y.o.
    • oral, nasal, rectal, or parenteral routes (PORN)
    • Multiple pharm agents
    • multipile doses w/in 24 period
    • Can use w/Nitrous oxide
  • Used for Behavioral control
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16
Q

Moderate Conscous Sedation limited to oral routes and nitrous oxide inhalation

A
  • drug induced depressed consciousness
  • responds purposefully to verbal commands, alone or w/light tactile stimulation
  • Admin:
    • 13+
    • Oral route and nitrous oxide inhalation
    • single or multiple pharm agents
      • single or multiple doses w/in 24 hrs
  • Used for behavioral control
17
Q

Moderate Pediatric Conscious Sedation

A
  • drug induced depressed consciousness
  • respond purposefully to verbal commands, alone or w/light tactile stimulation
  • Admin:
    • 13+
    • oral, nasal, rectal, parenteral (PORN)\
    • single or multiple pharm agents
    • single or multiple doses w/24 hr period
    • can use w/nitrous oxide
18
Q

Educational requirement for Moderate Conscious Sedation or Moderate Pediatric Conscious Sedation Permit

A
  • Dentist must meet 1:
    • Option1:
      • 60 hrs didactic training including:
        • Pediatric Advanced Life Support (PALS)
        • Intravenous conscious sedation
      • Manage 10 pts supervised w/ intravenous sedation
    • Option 2:
      • Pre-doctoral dental or post-grad program w/
        • intravenous conscious sedation equivalent to one above
    • Option 3:
      • Internship or residency w/:
        • intravenous conscious sedation equivalent to one above
  • Moderate Pediatric Conscioius Sedation requires in addition:
    • Board approved pedo dental degree
    • pediatric residency program
      • OR
    • equivalent hours of CE dental anesthesia
19
Q

Facility Requirements for Moderate Conscious Sedation Permit

A
  • Operatory big enough for:
    • emergency equipment and personal
    • effective management of emergencies
  • CPR board or dental chair w/o enhancements
  • Lighting
  • Suction equipment
    • non-electric back-up suction
  • Positive Oxygen Delivery system
    • Full face mosk for adults and peds
    • back-up E-cylinder
    • portable Oxygen tank seperate from central system
  • oral and nasal airways
    • various sizes
  • BP monitor
  • Pulse Oximeter
  • Automatic External Defibrillator (AED)
  • IV set up
  • Syringes
  • Tourniquet and Tape
20
Q

Emergency Medications Required for Moderate Conscous Sedation Permit

A
  • Epinephrine
  • Atropine
  • Narcotic Antagonist (Naloxone)
  • Antihistamine
  • Corticosteroid
  • Nitroglycerine
  • Bronchodilator
  • Antiemetic
  • Benzodiazepine antagonist (Flumazenil)
  • 50% dextrose
21
Q

Additional Requirements for Moderate Conscious sedation permit

A
  • Maintenance of sedation records for 10 yrs
  • Demonstrate:
    • Proper monitoring
      • sedation & recovery
    • Drug dose calculation and admin
    • Medical Emergencies management
    • Sterile Technique
    • CPR certified personel use
      *
22
Q

Moderate Conscious Sedation Permit: emergency management of what situations

A
  • Laryngospasm
  • Bronchospasm
  • Emesis and aspiration
  • Respiratory depression and arrest
  • Angina pectoris
  • MI
  • Allergic reactions
  • Convulsions
  • Syncope
  • Bradycardia
  • Insulin Shock
  • Cardiac Arrest
23
Q

Deep Sedation

A
  • Drug Induced depressed consciousness w/partial loss of protective reflexes
  • Can’t maintain airway independently
  • can’t respond purposefully to verbal command
24
Q

Deep Sedation Permit Requirements

A
  • General Anesthesia Permit
    • No further exam needed
25
Q

Unintentional Deep Sedation

A
  • Situation has to be infrequent and unintetional
  • important for moderate sedation to be trained to deal with patient
  • Causes:
    • hyper-responder to meds
    • exhaustion/lack of sleep
    • potentiation w/other agents
      • nitrous oxide
26
Q

General Anesthesia

A
  • controlled state of depressed conscioussnes due to pharm agents w/ partial or complete loss of protective reflexes
  • can’t
    • maintain airway
    • respond purposefully to physical stimuli or verbal commands
27
Q

General Anesthesia Permit requirements

A

at least 1

  • 1 year of advanced anesthesiology training
  • Oral Surgeon
  • Diplomate status or eligible for exam by American Board of Oral Surgeons
  • Fellow of American Society of Anesthesiology
  • Dentist admin General Anesthesia 5 yrs before NC law-Feb 1, 1990
28
Q

Sedation Technique: Patient Selection

A
  • unsuccessful behavior guidance
  • ASA 1 or 2 patients
  • Patients below the age of reason
    • pre or uncooperative
  • Extent of treatment needs
  • Older patients w/poor experiences or coping abilities
  • Travel distance of patient/family
    • even w/no behavior problems
  • Developemental delay or compromising medical condition
29
Q

Sedation Technique: Medical History–> Issues to consider

A
  • Respiratory issues
    • asthma
    • allergies
    • acute infection
  • Diseases affecting
    • cardiovacular
    • neuromuscular
    • hepatic
    • renal
  • Current Meds w/OTC
  • Previous sedations or general anesthesia
  • Ventilator use at birth
    • especially for premature
    • suggests bronchopulmonary dysplasia
  • Sleep apnea and/or snoring
    • suggests-airway obstruction
  • Family history of disease or adverse response to medications
    • malignant hyperthermia
30
Q

Sedation Technique: Physical Assessment

A
  • must be done before sedation or GA
  • Includes:
    • General Physical conditions
    • Vital Signs
      • HR, Respiratory Rate, BP
    • Vital Statistics
      • height and weight
    • Airway
      • must have unobstructed airway
    • risk assessment
31
Q

Sedation Technique: Airway

A
  • Vital for patent airway before sedation
  • Upper airway patency checked by dentist
    • tonsils
    • oropharynx
  • Tonsillaar Hypertrophy
    • Obstruction>50%
    • contraindication for conscious sedation
32
Q

Mallampati Score

A
33
Q

Sedation Techniques: Monitoring Principles

A
  • Important Principles:
    • pre-sedation vital signs=baseline
    • early recognition of potential problems
    • during procedure and recovery
  • Monitor:
    • clinical level of consciousness
    • airway
    • Cardiovascular system
    • Respiratory system
34
Q

Presedation preparation

A
  • Written Informed cosent
    • witnessed by 3rd party
    • review alternative tx and risks
35
Q

Presedation instructions

A

Given Verbally and written

  • Dietary Precautions
    • NPO requirements
  • Expectations of:
    • sedation
    • post-op behavior
  • Legal guardian present during procedure
    • 2 adults for recovery and transport
36
Q

Day of procedure:

A
  • Review Medical Hx
    • look for recent changes or trauma
  • NPO status
  • Medication status
  • Presence of acute illness
  • Have patient empty bladder/pee
  • Obtain baseline vital signs
37
Q

Selection of Sedative Medication

A
  • Up to dentist based on multiple variables:
    • desired depth of sedation
    • working time
    • comfort w/medication
    • DDI
38
Q

Commmonly available and used sedatives

A
  • Chloral Hydrate
  • Diazepam (Valium)
  • Midazolam (Versed)
  • Hydroxyzine
  • Meperidine
  • Nitrous oxide and oxygen
39
Q

Discharge Criteria

A

Before they leave office the must:

  • vital signs and airway are stable
  • no Nausea or fever
  • Oriented and aware enough to recognize guardian
  • Can walk (minimally), talk, maintain open airway by supporting head posture
  • well hydrated
  • guradian present
  • Post-op instructions given verbal and written

Week 1 (4 decks)

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