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DS4101 > W11 - Sedation/GA in Kids - Mistry > Flashcards

W11 - Sedation/GA in Kids - Mistry Flashcards

1
Q

4 Sedation techniques available for dental treatment

A
  1. Nitrous oxide
  2. GA
  3. Oral sedation
  4. IV sedation
  5. Combo
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2
Q

What is RA?

A

Relative analgesia

Ex. Nitrous oxide

  • Partial analgesic affect
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3
Q

Features of NO (3)

A
  • Conscious sedation
  • Pt can breathe on their own
  • Anxiolytic and analgesic
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4
Q

Features of Stage 1 Plane 1 - NO (6)

A

Moderate sedation and analgesia

  • Increased pain threshold
  • Normal vitals
  • Reflexes unaffected
  • Feeling relaxed and less scared
  • Paraesthesia (tingling in fingers, lips)
  • Can communicate and cooperate
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5
Q

Features of Stage 1 Plane 2 - NO (feeling, reflexes) (7)

A

Dissociation sedation and analgesia

  • like plane 1 but further relaxation
  • Reduced blink rate
  • Pharyngeal reflex is reduced
  • Laryngeal reflex intact
  • “floating” euphoric sensation
  • Can maintain open mouth
  • Possibility of amnesia and time warp
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6
Q

How do stage 1 plane 1 and 2 differ from each other in terms of reflex?

A

Both planes will remain with laryngeal reflex

  • Pharyngeal reflex is reduced in plane 2
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7
Q

What clinical tips can be done to help monitor pts dosage of Nitrous oxide?

A

No glasses - assess their eyes and blink rate

No bite block - ask if they can keep their mouth open (if not, has gone beyond plane 2)

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8
Q

Features of Stage 1: Plane 3 - NO

A

Total analgesia (not advised for dental practice)

No longer relative analgesia

  • Pt may not be able to open mouth
  • May be sleepy/sweaty/nauseous
  • May not respond to words or pain
  • Reduced pharyngeal and laryngeal reflexes
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9
Q

Features of stage 2 - NO (6)

A

Excitement or Delerium

  • Not advised for dental surgery
  • Excitement or struggling
  • Pharyngeal and laryngeal reflexes significantly reduced
  • Increased vitals (BP, HR, Resp)
  • Dilated pupils
  • Could have loss of consciousness
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10
Q

Features of stage 3 and stage 4 (NO)

A

Stage 3 - surgical anesthesia (GA)

Stage 4 - respiratory paralysis → death

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11
Q
A
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12
Q

Properties of N2O gas

A
  • Non irritating
  • Non flammable
  • Colourless
  • Sweet smelling
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13
Q

What makes N2O have quick onset and recovery (2)

A

Gas is relatively insoluble in blood

Primary saturation of blood and brain takes 3-5 min (induction)

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14
Q

How does the body metabolise N2O

A

It doesnt

  • No biotransformation in body
  • Excreted unchanged via the lungs (99%) at a similar rate to absorption
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15
Q

Effects of N2O on CNS (2)

A
  • Acts directly on opioid receptors
  • Acts of RAS - controls emotions

Produces:

  1. Analagesia
  2. Euphoria
  3. Amnesia
  4. Anxiolytic
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16
Q

Physiological effect of N2O on the CVS (3)

A
  • No clinically significant difference to heart rate at therapeutic doses
  • Reduced heart rate of first stage could be due to peripheral vasodilation or anxiolytic effect
  • Peripheral vasodilation - flushing
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17
Q

Effects of N2O on resp

A

No direct effect

Non irritating

Caution with emphysema / COPD

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18
Q

Conditions to be mindful of with N2O

A

Emphysema

COPD

GIT (N2O can cause nausea)

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19
Q

Is N2O safe for pregnancy?

A

Yes generally

BUT

Passes readily through placenta

Avoid in first trimester (but not contraindicated)

20
Q

Indications for N2O (3)

A
  • Mild to mod anxiety (not severe)
  • Sensitive to gag reflex
  • Intolerance to long appointments
21
Q

Contra-indications for N2O (7)

A

Airway blockage (cold, obstructive passage)

Precooperative child (<3 yo)

Uncooperative / severe behavioural problems

Intellectually disabled

Psychiatric disorders

Conditions with trapped gas

Significant medically compromised patients

22
Q

What are some significant medically compromised scenarios where N2O is contraindicated?

A

Bleomycin chemotherapy - Lungs are fibrosed (contraindicated)

MTHFR Deficiency - metabolic disease assoc w/ hemocystinuria

Caution:

Complex cardiac conditions

Myasthenia gracis

MS

COPD

Severe asthma

23
Q

What pts are at risk for N2O induced bone marrow suppression, neurotoxicity or increased homocysteine levels

A
  • History of B12 or folate deficiency
  • Vegetarians
  • Pts on proton pump inhibitors or H2 blockers
  • MTHFR deficiency

Not contraindicated (except MTHFR) - just take caution

24
Q

Maximum percentage dose of N2O

A

50%

Though Mistry only goes up to 40%

25
Q

Safety Features of N2O equipment

A
  • Min oxygen flow of 3L/min and max flow of 10L/min N2O

or minimum of 30% oxygen

  • Capacity for administration of 100% oxygen (“O2 Flush”)
  • Automatic environemental air intake in event of gas flow supply failure
  • Serviced / checked routinely
  • Scavenging system for expired gases (that way not everyone in the room gets high)
  • One way valve (prevent rebreathing)
26
Q

Requirements for N2O administration (6)

A
  • Credentialed dentists
  • Administrator must be present at all times
  • Always have a chaperone
  • Advanced life support skills
  • Informed consent
  • Record details
27
Q

N2O Technique steps (7)

A

Nasal mask placed

Adjust flow rate

Start with 100% oxygen

Reservoir bag partially inflated but not full

Titrate

Constant monitoring

Rubber dam and HVS

28
Q

What is diffusion hypoxia and how can it be overcome

A

N2O diffuses out of blood and into alveoli rapidly

  • This dilutes availble oxygen in the lungs

Restore via the administration of 100% O2 for 3-5 minutes after N2O termination

  • Give post op instructions and discharge
29
Q

When do complications arise for N2O (3)

A
  1. Over sedation
  2. Lack of monitoring
  3. Interaction with other meds (CNS depressants)
30
Q

Adverse reactions of N2O (6)

A
  • Nausea / vomiting
  • Dizziness
  • Hypoxia
  • Oversedation
  • Volume/pressure on trapped gas filled cavities
  • Bone marrow depression from chronic use (>24h)
31
Q

Occupational hazards of N2O

A

Prolonged exposure can lead to:

Interference with V B12 synthesis

Resulting in haematopoietic and myeloneuropathic disturbances

Ex. impaired RBC production and subsequent anemia, neurological disorders (paraesthesia, ataxia)

Teratogenicity

Reduced fertility

Spontaneous abortions

32
Q

Advantages of N2O (6)

A

Non invasive

Mild analgesic

Anxiolytic/sedative

Minimal impact on reflexes

Easily titrated

Rapid onset/recovery

33
Q

Disadvantages of N2O (6)

A

Requires coop with mask

Mask interferes with procedure

Needs continuous administration

Occupational hazard

Lack of potency

Cost for practice

34
Q

If pt is super anxious or stressed, will N2O work?

A

No - recommend GA

35
Q

Describe the effectiveness of N2O paediatric dentistry

A

In anxious children, the use of N2O for the first few sessions leads to significantly reduced anxiety in following sessions, even without N2O

36
Q

what is oral and IV sedation

A
  • Form of conscious sedation
  • Minimally depressed level of consciousness (can still maintain airway and respond to touch and verbal command)
37
Q

Contraindications of oral sedation

A
  • Pts who are unable to take medication orally
  • Medical issues and interactions
  • Use precautions with kids <6
38
Q

Indications for IV sedation (2)

A

Anxious

Invasive procedures of short duration

Children 12+

39
Q

Contraindications of IV sedation

A

Inability to tolerate IV access

Medical issues and interactions

Children <6

40
Q

Sedative agents (5)

A

Benzos (midazolam, diazepam/valium)

Antihistamines

Opioids

Ketamine

Barbituates

41
Q

What is GA? Features? (3)

A

Induced state of unconsciousness

  • Accompanied by partial or complete loss of reflexes
  • Inability to maintain airway
  • Unresponsive to physical stimulation and verbal command
42
Q

Objectives of GA (5)

A
  • Reduce movement and reaction to treatment
  • Eliminate anxiety
  • Provide safe, efficient, effective care
  • Aid in tx of mentally, physically, medically compromised pt
  • Eliminate pain response
43
Q

Indications for GA (6)

A

Very anxious

Moderately-extremely uncoop

Uncoop due to medical, physical, psycho disability

Extensive surgery

When prompt tx of acute condition is required (ex abscess threatening airway)

Not responsive to behaviour management

44
Q

Contraindications for GA

A

where medical issue risks outweigh the benefits

45
Q

How should you manage pt if theyre going under GA?

What is required?

A

Effort should be made to ensure that only one session is required

  • Need comprehensive workup (radiographs)
  • Comprehensive tx planning
  • Definitive tx (no GICs, should last)
46
Q

Indications and contraindications of Oral sedation (3 and 3)

A

Indications:

  • To be used when parenteral routes are not preferred or not possible
  • Anxious
  • Coop needed for procedures of long duration

Contraindications:

  • Unable to take meds orally
  • Medical issues and interactions
  • Careful with kids <6

DS4101 (43 decks)

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