Sedation course Flashcards
What don’t the sedation guidelines define?
Regimen selection criteria, guarantee success
What are the NPO guidelines for sedation?
Clear liquids- 2hrs; human milk- 4hrs; infant formula- 6hrs; nonhuman milk- 6hrs; light meal- 6hrs
Monitoring requirements for moderate sedation?
parenthesis answer is for deep sedation
-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)
Difference between single-operator and two operator models
Single- dentist administers the medication and performs the procedure
Two- anesthetist administers the medication
Requirements for sedation in Ohio
-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
Ohio definition of conscious sedation
-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
site visits for sedation
Prior to issuing sedation license, on-site evaluation of facility equipment, personnel, conscious sedation techniques,
Limitations of sedation license OH
-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
Anatomic differences for pediatric pts vs. adults
-Proportionally larger occiput
-Smaller diameter airway (increases resistance)
-High metabolic oxygen demand
-Excess adipose tissue on neck and check (decreases lung compliance)
What critical age is listed in our literature for sedation above which are less significant physiologic changes
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
The most common potential sedation-induced life-threatening events involve which body system?
Respiratory system
Which of the following monitors is required for deep sedation but not for moderate sedation?
Capnography and ECG
Practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure
True
According to the AAPD sedation best practice guideline, what is the minimum fasting period of consuming cow’s milk or orange juice with pulp?
6 hrs
What is the recording interval for documenting vital signs during moderate sedation?
Every 10minutes
What is the recording interval for documenting vital signs during moderate sedation?
every 5 min
Which of the following is not a characteristic of restrictive lung disease in obese children?
-increased airway resistance
-shallow, rapid breathing
-GREATER OXYGEN RESERVOIR
-increased risk of atelectasis
Significance of RSV infection in airway assessment for sedation
-associated with long-term respiratory morbidity, recurrent wheezing, asthma, decreased lung function and possible allergic sensitization
ASA class III physical status, URI, obesity and history of OSA/snoring is associated with which sedation outcomes?
Increased probability of failing sedation approximately 2x as often as not having these risk factors
Temperament associated with successful sedations
-higher levels of self-control
-lower levels of activity
-more outgoing
Children with which ASA classification are suitable candidates (in terms of medical condition status) for pediatric dental sedation?
-ASA I
-ASA I, II****
-ASA I, II, III
-ASA I, II, III, IV
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?
3 years old
Obese patients require higher doses of sedative to achieve the same level of sedation
False
Why is tonsil size an important selection criterion for pediatric dental sedation?
the ability to maintain airway patency is potentially compromised in children with large tonsils
Which child temperament type would seem to have the lowest chance at a successful sedation?
Challenging
Which sedative medication is most frequently associated with an adverse event happening at home or in an automobile?
Chloral hydrate
Dental specialists have the greatest frequency of negative outcomes associated with the use of how many sedative medications?
3 or more sedating medications
Negative outcomes during conscious sedation are likely related to…?
Skills or lack of skills and knowledge or a lack of knowledge of the individuals who administered the drugs for procedural sedation
How to detect subtle physiologic changes during sedation?
Adequate monitoring
Clinicians seem to lack adherence to this rule
When to postpone elective sedation?
URI- mucus-filled secretions or non-clear breath sounds (postpone for 2-4 weeks)
NPO violations
Why is it especially important to calculate local anesthetic maximum recommended dose via weight when using sedative medications?
Benzodiazepines may mask the symptoms of LA overdose
Most common adverse event of conscious sedation is?
Emesis and excessive sleep
All of the following are associated with negative outcomes with sedation medications except…
-Administering 3+ medications
-Administering drugs with longer half-lives
-ADMINISTERING DRUGS BY IV
-Administering drugs by non-medical personnel
-Administering drugs with nitrous oxide
Which of the following is NOT part of the discharge criteria according to the AAPD following oral sedation?
-Satisfactory cardiac function and airway patency
-Can talk if age appropriate
-MAY REQUIRE PAINFUL STIMULI FOR AROUSAL
-Can sit up unaided if appropriate
Which of the following is generally NOT true for the majority of closed adverse sedation claims?
-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
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?
4.2 time higher
2.3 times lower
3.9 times higher****
1.9 times lower
According to the AAPD guidelines, how often must vital signs be recorded for moderate sedation?
At least every 10 minutes
What does capnography detect?
Exhaled carbon dioxide
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
What factors may decrease the pulse oximeter’s ability to provide an accurate reading?
Cold extremities
Movement
Nail polish
Ambient light
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?
Yes, the oxygen-hemoglobin dissociation curve suggests hypoxemia that could worsen if not corrected
How does a BP cuff misread BP in children when over/under-sized?
Oversized cuff- underestimates BP (low reading)
Undersized cuff- overestimates BP (high reading)
Where should we be placing pre-cordial stethoscopes?
Suprasternal notch
Per AAPD guidelines, which of the following conditions is NOT a contraindication for the usage of nitrous oxide?
a. First trimester of pregnancy
b. Chronic URI or sinusitis that impair breathing
c. Asthma*****
d. ENT surgery within the past 2 weeks
What is the minimum alveolar concentration (MAC) of nitrous oxide?
50%
70%
90%
100%
105% **
Why does general anesthesia have strict fasting requirements, while nitrous oxide administration does not?
Risk of pulmonary aspiration**
Nitrous oxide doesn’t cause nausea
Drugs less affective with full stomach
Risk of vomiting is higher with general anesthesia
Which of the following combinations of monitoring is recommended per AAPD guidelines for non interactive but arousable level of conscious sedation
-Pulse ox and precordial stethoscope
-Pulse ox, precordial stethoscope, capnograph, BP**
-Pulse ox and capnograph
-Pulse ox, capnograph, electrocardiograph, precordial stethoscope, capnograph, BP
What is the effect of nitrous on sedation?
Mild analgesic effect
Deepens the level of sedation
How much MAC is being delivered with dental nitrous units?
About 0.3-0.5 MAC
Why does nasal administration of midazolam achieve a faster onset than oral administration?
Avoids “first-pass” metabolism and absorbs directly through cribiform plate
Which of the following is not a therapeutic feature of midazolam used for oral sedation in dentistry?
Analgesic
What is a suspected finding when using a narcotic during an oral sedation when compared to a benzodiazepine?
Respiratory depression
Describe the main mechanism of action of flumazenil as a reversal agent for benzodiazepine desaturation.
Flumazenil is a stronger agonist for benzodiazepine receptors
Of the following drugs available below, which may be a poor choice to sedate a child with asthma?
Meperidine alone
Midazolam characteristics
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
Triazolam characteristics
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)
Meperidine characteristics
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
Naloxone characteristics
Opioid antagonist binds mu receptor
Repeat administration as needed due to short acting
With regards to mechanism of action, hydroxyzine is considered to be a/an:
Inverse agonist
To which receptor does hydroxyzine primarily bind for sedative/anxiolytic effects?
H1
What is one disadvantage to using hydroxyzine in pediatric oral sedations?
No reversal agent
Which of the following is a common adverse event seen with choral hydrate when used for oral sedation?
Vomiting
Which of the following explains why chloral hydrate was abandoned in lieu of midazolam in triple combination sedations?
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***
Chloral hydrate characteristics
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
Issues with chloral hydrate
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.
At which receptor does dexmedetomidine act?
Alpha-2
What is the primary benefit of dexmedetomidine over traditional sedatives used in pediatric dentistry like midazolam?
No respiratory depression
Which of the following is a side effect of dexmedetomidine?
Bradycardia
At which receptor does ketamine act?
NMDA
The addition of Ketamine to the Ketamine-Midazolam combination brings what specific characteristic to this regimen that Midazolam lacks?
Analgesic
