Sedation Flashcards
The respiratory system is last to develop. Why is this clinical relevant in pediatric dentistry?
Young children have less surface area for gas exchange, therefore, must be aware if doing sedation.
pg 266 handbook
Unlike adults, children can tolerate greater incidences of hypercarbia. Hypercarbia may be associated with onset of cardiac arrhythmias.
a. both statements are true
b. first statement is true. second statement is false.
c. first statement is false. second statement is true.
d. both statements are false
A. both statements are true.
pg 266 handbook
T or F. Children have relatively large functional reserve capacity (FRC) and therefore have relatively larger post-expiration volume.
False.
Children have relatively SMALL FRC and LARGER post-expiration volume.
pg 266 handbook
How does the pediatric airway differ from adult airway? (7)
in the pediatric airway:
- increased airway resistance
- glottis (vocal cords) are positioned more ANTERIOR and cephalad
- narrowest portion of upper airway is at the level of cricoid cartilage (BELOW vocal cords)
- relatively larger tongue and epiglottis
- larger head:body ratio
- less developed mandible
- potential for significant lymphoid tissue obstruction of: nasopharynx, oropharynx, and laryngopharynx.
pg 267 handbook
The extent of treatment under sedation is ultimately determined by what?
By the amount of local anesthesia allowed by weight
pg 267 handbook
Patient selection is important when considering sedation. Name a few selection criteria. (8)
- traditional techniques unsuccessful in managing behavior
- ASA 1 or well-controlled ASA 2
- below age of reason (pre- or un-cooperative)
- extent of treatment (which is ultimately determined by amount of LA allowed by weight)
- needle phobia
- excessively fearful older child
- older child with poor experiences/coping abilities
- distance traveled even for patients w/o behavior problems.
pg 267 handbook
When looking at history prior to sedation, why is birth history important?
Premature birth is a huge risk factor.
If pt is a premie, it means their respiratory system is even less developed than a normally birthed child. Therefore, reduced surfactant and less patent alveoli, which leads to less surface area for qualitative gas exchange.
Premies also have poor qualitative AND quantitative gas exchange.
With premies, there is an increased incidence of early life intubation, altered neural reflex pathways, increased gag reflex and potentially greater risk for laryngospasms.
There are also increased incidences of hospitalizations and ventilator usage.
pg 268 handbook
Besides birth history being a large component of assessing a pediatric patient for sedation, what other medical hx do we look for?
- allergies/asthma/croup
- -atopic triad: asthma, eczema, food allergy (having these three may suggest IGE hyper-responder) - current meds including OTC
- -including depressants and herbal supplements - diseases
- -CV, CNS, pulm, liver, kidney, pregnancy status - malignant hyperthermia risk
- sleep apnea
- -snoring suggests tonsil/airway problem - previous sedations/GA/hospitalizations
- family hx of dz
pg 268 handbook
What is the atopic triad and why is this important?
Atopic triad is when a patient has asthma, atopic dermatitis (eczema), and food allergies.
Having this triad may suggest IgE hypersensitivity.
pg 268 handbook
What are some vital signs/stats we need for pediatric pt undergoing oral sedation?
HR (think RRR-regular rate and rhythm), RR, BP, age, weight, and height
When doing a physical assessment for a patient prior to oral sedation, what do we look for?
- general physical condition
- -gait, wheelchair, coordination - vital signs
- -HR, RR, BP - vital stats
- -age, weight, height - airway
- -tonsils, neck, nose, tongue - mouth breather/nasal speech
- C-spine precautions
- -DS and Arnold-Chiari malformations - midfacial hypoplasia
- -may be suggestive of existing airway co-morbidities - risk assessment
- -ASA status - obesity
- -per CDC, use percentile for ages 2-19 years - communication ability
pg 268 handbook
What are the dietary precautions given to patients prior to sedation?
- No solids/non-human milk/infant formula up to 8 hours prior.
- No breast milk up to 4hrs prior
- No clear liquids up to 2hrs prior to procedure for children over 6 months of age
ASA fasting guidelines:
minimum fasting of 2hrs of clear liquids, 4hrs of breast milk, and 6hrs of formula, non-human milk, and light meal.
pg 269 handbook
Reasons to cancel/defer oral sedation appointment
- active/recent URI
- nasal discharge
- NPO violation
- fever/cough
- recent head trauma
- recent change of note in medical hx requiring consult
* 7. parent change of mind
pg 269-270 handbook
What is the dosage for lidocaine (xylocaine)?
4.4mg/kg with or w/o VC
comes in 2% and 1%
pg 270 handbook
what is the dosage for articaine (septocaine)?
5mg/kg
comes in 4%
handbook says 4-5mg/kg but manufacturer’s instruction says 7mg/kg.
**should not be used on children under 4yo
pg 270 handbook
With LA overdose, what do you expect to see in a lidocaine vs septocaine overdose?
lidocaine overdose causes CNS and CV effects, whereas septocaine overdose causes CNS, CV, and immune effects.
pg 270 handbook
What does a vasoconstrictor do in LA?
epi (one type of VC used in LA) prolongs action of the anesthetic by constricting bv.
It also prevents rapid systemic uptake of LA.
**can lead to increased potential for post-tx soft tissue trauma from biting or scratching.
pg 270 handbook
What are some effects of LA overdose?
CNS excitement followed by depression
- seizures
- disorientation
- LOC
CVS depressed
- decreased myocardial contractility
- decreased cardiac output
- CVS collapse
pg 270 handbook
For a minimal level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
- cognitive fxn MAY be impaired but physiological fxn is not affected
- monitor by observation only with no need for specified personnel.
pg 271 handbook
pg 305 guidelines
For a moderate level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
- cognitive fxn is depressed but pt responds to light tactile stimulation; physiological function is patent with self-correcting airway and ventilation/CV fxn is adequate.
- Must monitor O2 sat, HR, BP, RR, capnography recommended, and (EKG and defib should be available)
There must be a specific person responsible for monitoring other than operator that may do other tasks.
pg 271 handbook
pg 305 guidelines
For a deep level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
- cognitive fxn is depressed and pt cannot be easily aroused; physiologically, there is potential for loss of airway reflexes and CV may be affected
- Must monitor O2 sat, HR, BP, and RR EKG, capnography rec’d. Must have a specific person responsible SOLELY for monitoring
pg 271 handbook
pg 305 guidelines
T or F. In moderate sedation, patient cannot be easily aroused but responds purposefully after repeated verbal or painful stimulation.
FALSE.
In DEEP sedation, patient cannot be easily aroused but responds purposefully after repeated verbal or painful stimulation.
In minimal and moderate sedation, patient is independently and continuously maintaining airway and responding to verbal commands along with light tactile stimulation. They also have intact cough, swallowing, and gag reflex with minimal effects on CVS and resp system.
pg 271 handbook
pg 305 guidelines
What is the fatal trio in emergencies?
hypovolemia, hypoxia, and hypercapnia.
Hypovolemia–make sure pts are NPO but not overly NPO
hypoxia–important to recognize respiratory obstruction/distress immediately and if persists, can lead to hypercapnia, which can make pt more prone to cardiac arrhythmia.
pg 272 handbook
What are the different sedation routes?
inhalation, oral, IN, IM, submucosal, IV
pg 272-273 handbook
What are some advantages of inhalation sedation route (nitrous)?
delivery system has a minimal 25% O2 fail safe feature, scavenger system, titratable
pg 272 handbook
What are some advantages/disadvantages of oral sedation?
Advantages–most accepted by children as there are no needles involved
Disadvantages–non-titratable, taste can be nasty so can cause aspiration (require partial patient cooperation), onset/recovery may be prolonged/variable absorption, and cannot add more meds after initial dose.
pg 272 handbook
Characteristics of nitrous oxide.
- CNS depressant–minimal CV/resp effect
- anxiolytic–minimal analgesia
- chronic exposure/abuse can lead to peripheral neuropathies
pg 273 handbook
What are some relative contraindications for nitrous?
- wheezing (mod-severe asthma)
- nasopharyngeal obstruction
- TB
- CF
- SCD (due to lowered O2 tension in blood)
- acute OM
- methionine synthetase deficiency
–nitrous irreversibly inhibits this enzyme, thereby raising homocysteine levels which is associated with vascular events and prolonged recovery.
high homocysteine levels occur when vitamin deficient such as B6 or B12. Homocysteine helps to process amino acids. - first tri pregnancy
pg 273 handbook
What are some side effects of nitrous?
sweating, nausea, GI discomfort, vomiting, inhibition of airway reflexes
pg 274 handbook
What are some common medications used in OCS?
chloral hydrate (sedative/hypnotic)
BDZP (sedative/hypnotic)–diazepam, midazolam
antihistamines–hydroxyzine
narcotics–meperidine
pg 274 handbook
what is the brand name of diazepam?
Valium; it is a sedative/hypnotic; a BDZP
pg 274 handbook
Brand name of midazolam?
Versed; sedative/hypnotic; a BDZP
pg 274 handbook
brand name of meperidine?
demerol; narcotic
pg 275 handbook
Effects of chloral hydrate
- CNS depression (minimal CV or respiratory effect)
- -similar to nitrous - mucosal and GI irritant
pg 274 handbook
Where is chloral hydrate metabolized and into what? What organ excretes it?
metabolized to trichlorethanol in the liver and excreted by kidney
pg 274 handbook
what is the onset, peak, working time, and duration of chloral hydrate?
onset: 30-60min
peak: 60min
working time: 60mins
duration: 5hrs
pg 274 handbook