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Nationwide Peds Dental Residency > Sedation course > Flashcards

Sedation course Flashcards

1
Q

What don’t the sedation guidelines define?

A

Regimen selection criteria, guarantee success

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2
Q

What are the NPO guidelines for sedation?

A

Clear liquids- 2hrs; human milk- 4hrs; infant formula- 6hrs; nonhuman milk- 6hrs; light meal- 6hrs

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3
Q

Monitoring requirements for moderate sedation?
parenthesis answer is for deep sedation

A

-Personnel should be trained in PALS (1 level higher is trained in PALS)
-Responsible practitioner - should be skilled in obtaining vascular access (skilled in obtaining vascular access)
Monitoring- ECG and capnography recommended (ECG and capnography required)
Other equipment- suction equipment, adequate oxygen source/supply (both of these + defibrillator required)
Documentation- recorded every 10 min (recorded every 5 min)

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4
Q

Difference between single-operator and two operator models

A

Single- dentist administers the medication and performs the procedure
Two- anesthetist administers the medication

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5
Q

Requirements for sedation in Ohio

A

-Documentation of completion of post-doctoral training program
-Current PALS
-Medical history form, sedation record
-Drug control program
-Proof of permanent residence in OH
-Properly equipped facility checklist

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6
Q

Ohio definition of conscious sedation

A

-Minimally depressed level of consciousness that retains the patient’s ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command, caused by pharmacologic or non-pharmacologic method or a combination thereof
-should carry a margin of safety wide enough to render unintended loss of consciousness unlikely

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7
Q

site visits for sedation

A

Prior to issuing sedation license, on-site evaluation of facility equipment, personnel, conscious sedation techniques,

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8
Q

Limitations of sedation license OH

A

-No administration of ultra-short acting barbiturates, propofol, perenteral ketamine
-Any other method that would render the patient deeply sedated/generally anesthetized
-Unless he/she holds a valid general anesthesia permit

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9
Q

Anatomic differences for pediatric pts vs. adults

A

-Proportionally larger occiput
-Smaller diameter airway (increases resistance)
-High metabolic oxygen demand
-Excess adipose tissue on neck and check (decreases lung compliance)

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10
Q

What critical age is listed in our literature for sedation above which are less significant physiologic changes

A

2 years old
- gastric pH reaches adult values by 2
-1-2 yrs all isoenzyme activites are similar to those of adults
-tubular reabsorption does not reach adult levels until age 2

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11
Q

The most common potential sedation-induced life-threatening events involve which body system?

A

Respiratory system

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12
Q

Which of the following monitors is required for deep sedation but not for moderate sedation?

A

Capnography and ECG

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12
Q

Practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure

A

True

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13
Q

According to the AAPD sedation best practice guideline, what is the minimum fasting period of consuming cow’s milk or orange juice with pulp?

A

6 hrs

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14
Q

What is the recording interval for documenting vital signs during moderate sedation?

A

Every 10minutes

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15
Q

What is the recording interval for documenting vital signs during moderate sedation?

A

every 5 min

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16
Q

Which of the following is not a characteristic of restrictive lung disease in obese children?

A

-increased airway resistance
-shallow, rapid breathing
-GREATER OXYGEN RESERVOIR
-increased risk of atelectasis

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17
Q

Significance of RSV infection in airway assessment for sedation

A

-associated with long-term respiratory morbidity, recurrent wheezing, asthma, decreased lung function and possible allergic sensitization

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18
Q

ASA class III physical status, URI, obesity and history of OSA/snoring is associated with which sedation outcomes?

A

Increased probability of failing sedation approximately 2x as often as not having these risk factors

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19
Q

Temperament associated with successful sedations

A

-higher levels of self-control
-lower levels of activity
-more outgoing

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20
Q

Children with which ASA classification are suitable candidates (in terms of medical condition status) for pediatric dental sedation?

A

-ASA I
-ASA I, II****
-ASA I, II, III
-ASA I, II, III, IV

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21
Q

RSV hospitalization before which age is associated with long term respiratory morbidity, such as recurrent wheezing, and asthma, decreased lung function, and possibly allergic sensitization?

A

3 years old

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22
Q

Obese patients require higher doses of sedative to achieve the same level of sedation

A

False

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23
Q

Why is tonsil size an important selection criterion for pediatric dental sedation?

A

the ability to maintain airway patency is potentially compromised in children with large tonsils

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24
Q

Which child temperament type would seem to have the lowest chance at a successful sedation?

A

Challenging

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25
Q

Which sedative medication is most frequently associated with an adverse event happening at home or in an automobile?

A

Chloral hydrate

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26
Q

Dental specialists have the greatest frequency of negative outcomes associated with the use of how many sedative medications?

A

3 or more sedating medications

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27
Q

Negative outcomes during conscious sedation are likely related to…?

A

Skills or lack of skills and knowledge or a lack of knowledge of the individuals who administered the drugs for procedural sedation

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28
Q

How to detect subtle physiologic changes during sedation?

A

Adequate monitoring
Clinicians seem to lack adherence to this rule

29
Q

When to postpone elective sedation?

A

URI- mucus-filled secretions or non-clear breath sounds (postpone for 2-4 weeks)

NPO violations

30
Q

Why is it especially important to calculate local anesthetic maximum recommended dose via weight when using sedative medications?

A

Benzodiazepines may mask the symptoms of LA overdose

31
Q

Most common adverse event of conscious sedation is?

A

Emesis and excessive sleep

32
Q

All of the following are associated with negative outcomes with sedation medications except…

A

-Administering 3+ medications
-Administering drugs with longer half-lives
-ADMINISTERING DRUGS BY IV
-Administering drugs by non-medical personnel
-Administering drugs with nitrous oxide

33
Q

Which of the following is NOT part of the discharge criteria according to the AAPD following oral sedation?

A

-Satisfactory cardiac function and airway patency
-Can talk if age appropriate
-MAY REQUIRE PAINFUL STIMULI FOR AROUSAL
-Can sit up unaided if appropriate

34
Q

Which of the following is generally NOT true for the majority of closed adverse sedation claims?

A

-They were performed in a dental office rather than in a hospital
-the sedation was performed in conjunction with local anesthetic
-THERE WAS ADEQUATE PHYSIOLOGIC MONITORING IN PLACE
-Adverse sedation events are more likely to occur in patients younger than age 4

35
Q

Based on the 2009 Furher et. Al study, at the 6-month post treatment recall, what were the odds of exhibiting positive behavior when treated under general anesthesia vs oral conscious sedation?

A

4.2 time higher

2.3 times lower

3.9 times higher****

1.9 times lower

36
Q

According to the AAPD guidelines, how often must vital signs be recorded for moderate sedation?

A

At least every 10 minutes

37
Q

What does capnography detect?

A

Exhaled carbon dioxide

38
Q

In a normal capnograph exhalation begins at what point? From left to right using a lower case “n” as one wave for a capnograph. A is bottom left, B is upper left, C is upper right, D is lower right. (from week 3 quiz)

A

A

39
Q

What factors may decrease the pulse oximeter’s ability to provide an accurate reading?

A

Cold extremities
Movement
Nail polish
Ambient light

40
Q

A pulse oximeter reads 90%. After visually assessing the sedated patient 30 minutes into the procedure, you notice that the originally squirmy patient has become still, quiet and breathing at a reduced rate. You troubleshoot the monitors, which look properly attached. Should you be concerned for this patient, and why/why not?

A

Yes, the oxygen-hemoglobin dissociation curve suggests hypoxemia that could worsen if not corrected

41
Q

How does a BP cuff misread BP in children when over/under-sized?

A

Oversized cuff- underestimates BP (low reading)
Undersized cuff- overestimates BP (high reading)

42
Q

Where should we be placing pre-cordial stethoscopes?

A

Suprasternal notch

43
Q

Per AAPD guidelines, which of the following conditions is NOT a contraindication for the usage of nitrous oxide?

A

a. First trimester of pregnancy

b. Chronic URI or sinusitis that impair breathing

c. Asthma*****

d. ENT surgery within the past 2 weeks

44
Q

What is the minimum alveolar concentration (MAC) of nitrous oxide?

A

50%

70%

90%

100%

105% **

45
Q

Why does general anesthesia have strict fasting requirements, while nitrous oxide administration does not?

A

Risk of pulmonary aspiration**
Nitrous oxide doesn’t cause nausea
Drugs less affective with full stomach
Risk of vomiting is higher with general anesthesia

46
Q

Which of the following combinations of monitoring is recommended per AAPD guidelines for non interactive but arousable level of conscious sedation

A

-Pulse ox and precordial stethoscope
-Pulse ox, precordial stethoscope, capnograph, BP**
-Pulse ox and capnograph
-Pulse ox, capnograph, electrocardiograph, precordial stethoscope, capnograph, BP

47
Q

What is the effect of nitrous on sedation?

A

Mild analgesic effect
Deepens the level of sedation

48
Q

How much MAC is being delivered with dental nitrous units?

A

About 0.3-0.5 MAC

49
Q

Why does nasal administration of midazolam achieve a faster onset than oral administration?

A

Avoids “first-pass” metabolism and absorbs directly through cribiform plate

50
Q

Which of the following is not a therapeutic feature of midazolam used for oral sedation in dentistry?

A

Analgesic

51
Q

What is a suspected finding when using a narcotic during an oral sedation when compared to a benzodiazepine?

A

Respiratory depression

52
Q

Describe the main mechanism of action of flumazenil as a reversal agent for benzodiazepine desaturation.

A

Flumazenil is a stronger agonist for benzodiazepine receptors

53
Q

Of the following drugs available below, which may be a poor choice to sedate a child with asthma?

A

Meperidine alone

54
Q

Midazolam characteristics

A

Sedative, anxiolytic, amnesia prior to anesthesia
Schedule IV benzodiazepine
10 min onset, 30-45 min duration
Half-life: ~2-5hrs
Therapeutic dose: 0.5-1mg/kg up to 20mg

55
Q

Triazolam characteristics

A

FDA classified as a hypnotic​, anterograde amnesia (infrequently)
Binds GABA receptor
Half life: 1.5-5.5h​
Peak plasma time: 2h​
Max recommended therapeutic dose: 0.5mg​ (we use about 0.25mg)

56
Q

Meperidine characteristics

A

FDA classified as analgesic and sedative​
Schedule II controlled substance​
Binds mu-opioid receptor
Dosage: 1.1mg/kg-1.8mg/kg​
Half-life: 2-5 hours (can be increased in adults and those with renal impairment due to primary metabolite)​
Peak Plasma time: 40-60 minutes​
could lead to histamine release- pair with hydroxyzine

57
Q

Naloxone characteristics

A

Opioid antagonist binds mu receptor
Repeat administration as needed due to short acting

58
Q

With regards to mechanism of action, hydroxyzine is considered to be a/an:

A

Inverse agonist

59
Q

To which receptor does hydroxyzine primarily bind for sedative/anxiolytic effects?

A

H1

60
Q

What is one disadvantage to using hydroxyzine in pediatric oral sedations?

A

No reversal agent

61
Q

Which of the following is a common adverse event seen with choral hydrate when used for oral sedation?

A

Vomiting

62
Q

Which of the following explains why chloral hydrate was abandoned in lieu of midazolam in triple combination sedations?

A

Chloral hydrate requires compounding by a pharmacy; midazolam does not

Chloral hydrate takes ~1 hour to take effect; midazolam takes ~20 minutes

Errors in dose calculations are greater for chloral hydrate (50mg/kg) than midazolam (1mg/kg)

All of the above***

63
Q

Chloral hydrate characteristics

A

Classified as sedative-hypnotic​

No longer commercially available in US​

Compounding pharmacies can produce this if desired​

Dose: 50-70mg/kg​

Often formulated to 250mg/5mL, so requires large volumes​

Half-life: short, estimated 4-5 minutes​

Metabolites are prolonged: estimated 8-10h​

Peak plasma time: 20-60min​

No reversal agent​

64
Q

Issues with chloral hydrate

A

High doses of CH suppressed patient responsiveness, but not to levels considered physiologically inappropriate. As the dose of CH increased, cardiovascular parameters were suppressed statistically for certain dentally imposed procedures which are otherwise excitatory to very young children.

65
Q

At which receptor does dexmedetomidine act?

A

Alpha-2

66
Q

What is the primary benefit of dexmedetomidine over traditional sedatives used in pediatric dentistry like midazolam?

A

No respiratory depression

67
Q

Which of the following is a side effect of dexmedetomidine?

A

Bradycardia

68
Q

At which receptor does ketamine act?

A

NMDA

69
Q

The addition of Ketamine to the Ketamine-Midazolam combination brings what specific characteristic to this regimen that Midazolam lacks?

A

Analgesic

Nationwide Peds Dental Residency (9 decks)

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