Week 13 Flashcards
Week 13
Pediatric dentistry
Sedation for pediatric procedures outside the operating room
Same-day surgical procedures
Cote Ch 46,47,48
Anesthesia for Pediatric dentistry
- A diverse and potentially challenging pediatric patient population require anesthesia for dental care.
- Failed attempts at sedation or local anesthesia due to lack of patient cooperation.
- Physically or mentally delayed or medically compromised
- Coexisting diseases – testing?
- i.e., _______(1) disorder → phenytoin → gingival hyperplasia → excessive bleeding
- Routine Care
- Dental Caries
- Orthodontic (braces) or pathology
- Facial Cellulitis
- Oral-facial trauma
- Re-implantation
Answers:
1. seizure
Numbering Teeth
(SEE ILLUSTRATIONS)
Pre-medication and/or sedation
- Use of local anesthetics
- Does Not use this as much for pediatric pts.
- Local may cause distress, (bites lips)
- Inhalation induction vs IV induction
- Usually an Inhalation unless you really want to do IV for some reason
- Airway management
- Nasotracheal intubations
- Oral _______(1) tube
- Flexible LMA
- It’s an option if your dentist is willing
- Also depends what they need to do because it can restrict access
- Throat packs
- common - document when its placed and removed
Frequent source of malpractice claims
Especially when the procedure is in the office and the dentist is providing anesthesia
Careful examination to note excessively loose teeth
Can obstruct easily (excess sedation, laryngospasm)
Soft suction not yankauer
Document
discussion regarding possible
tooth loss during the procedure.
Anesthesia and Sedation Outside the OR (NORA)
- As you read the chapter, please review the following topics:
- Requirements for “outside” locations
- Magnetic resonance imaging
- CT, radiation therapy
- Angiography and embolization
- Use of intravascular contrast media
- Requirements for “outside” locations include appropriate anesthesia equipment and monitors, adequate space, and experienced ancillary providers to provide assistance as needed.
- Generally, these outside locations are ______(2) designed with the needs of anesthesia providers in mind.
- Remember, these area are often designed for STAFF conveniences, without taking Anesthesia into consideration at all
- RAE
- not
JCAHO Definitions
Minimal sedation (anxiolysis)
- A drug-induced state during which patients respond normally to _______(1).
- Although cognitive function and coordination may be _______(2), ventilatory and cardiovascular function are _______(3).
Moderate sedation/analgesia or “Conscious Sedation”
- A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by _______(4) stimulation.
- Airway and CV _______(5)
- Often Doctors will ask for this but actually be looking for more anesthesia closer to _______(6)
Deep sedation/analgesia
- A drug-induced depression of consciousness during which patients _______(7) be easily aroused but respond purposefully following repeated or painful stimulation.
- Reflex withdrawal is not considered a _______(8) response.
- Ventilatory function and airway patency may be _______(9).
- Spontaneous ventilation may be _______(10).
- CV function is usually maintained.
General anesthesia
- a drug-induced loss of consciousness during which patients are not arousable, even by painful stimuli.
- The ability to independently maintain ventilatory function is often _______(11).
- Patients require assistance in maintaining a patent airway and _______(12) may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
- CV function may be _______(13).
Answers:
1. verbal commands
2. impaired
3. unaffected
4. light tactile
5. maintained
6. general
7. cannot
8. purposeful
9. impaired
10. inadequate
11. impaired
12. positive pressure ventilation
13. impaired
Goals of Sedation
- To ______(a) the patient’s safety and welfare
- To ______(b) physical discomfort and pain
- To control anxiety, minimize psychological trauma, ______(c) potential for amnesia
- To control behavior/movement to allow safe completion of procedure
- To return patient to _______(1) clinical state for safe discharge from medical supervision
Complications of Sedation & General Anesthesia Outside the OR
- Apnea
- Airway obstruction
- Inadequate ventilation
- Coughing
- Vomiting
- Hypoxia
- Inadequate sedation
Red Flags for Sedation
- Apnea
- Unstable cardiac disease
- Respiratory compromise
- Craniofacial defect
- History of a difficult airway
- Active gastroesophageal reflux or vomiting
- Hypotonia and lack of _______(2) control
- Allergies to sedatives
- Prior failed sedation
- Tremors
Procedures Requiring Sedation or General Anesthesia Outside OR
- Endoscopy
- Emergency Room
- Radiation therapy
- Nuclear magnetic resonance
- CT Scans
- Bone marrow biopsies
- Cerebral angiography
- Heart catheterization
- Eye examinations
- Bronchoscopy
- Lumbar punctures
- Burn treatments
- ICU treatments
- Neurodiagnostic procedures (MRI)
Answers:
1. baseline
2. head
a. guard
b. minimize
c. maximize
Magnetic Resonance Imaging
- An MRI is indicated to detect soft tissue, ligament and tendon injuries, spinal cord injuries, brain tumors, etc.
- One advantage of an MRI is that it does not use _______(1).
- An MRI can take from ______(a) minutes to ______(b) hours and involve breath holds.
- Magnetic Resonance Imaging Considerations:
- No _______(2) metal objects near the MRI machine or the magnet!
- The magnets are never off, even at night, and turning off the electricity will not affect them.
- They draw most of their power from supercooled _______(3), which must be vented (“quenched”) to shut down the magnet
- a process that has hazards of its own and is very costly ( >$30,000 – 50,000)
- Magnetic Resonance Imaging A Case Study
- The most notorious accident was the death of 6-year-old Michael Colombini in 2001 at the Westchester Medical Center in Valhalla, N.Y. (RIP nerd)
- He was sedated in a scanner after a brain operation when his oxygen supply failed.
- An anesthesiologist ran for an oxygen tank and failed to notice that the one he found in the hall outside was made of steel.
- As he returned, the tank shot out of his hands, hitting Michael in the head. The child was pronounced dead of blunt force trauma.
Answers:
1. radiation
2. ferromagnetic
3. helium
a. 30
b. 4
Computed (Axial) Tomography
- A CT Scan (or CAT Scan) is best suited for viewing bone injuries, diagnosing lung and chest problems, and detecting cancers.
- CT scans are widely used in emergency rooms because the scan takes fewer than _______(1) minutes.
- CT scans expose the patient to _______(2), which may be harmful if there are repeated exposures.
Positron Emission Tomography
- A positron emission tomography (PET) scan is an imaging test that uses a _______(3) substance called a tracer to look for disease or malignancy.
- Cells with increased metabolism will absorb _______(4) of the radioactive tracer.
- A scanner then detects this substance to produce images of organs and tissues inside the body.
Angio/Cath Lab
- Remember that you may not have access to your patient once the case starts
- Lots of cables, machinery and equipment obstructing your access and view
Answers:
1. 5
2. radiation
3. radioactive
4. more
Same-Day Surgical Procedures
- Peripheral procedures that do not involve major violation of the body cavity.
- I’ll violate YOUR body cavity!
- Procedures are typically limited in duration, generally less than _______(1) hours.
- They do not require post discharge monitoring beyond the capabilities of the parents or caregivers
- No need for _______(2) overnight
- Common SDS Operations
- ENT
- Ophthalmology (________(3) is very common)
- General pediatric surgery and urology
- Gastroenterology
- Plastic surgery
- Orthopedics
- Radiology
- Dentistry
- Considerations requiring 23-hour overnight observation (23 OBS)
- Ex-________(4) infants
- Obstructive sleep apnea (OSA)
- ______(5) from facility
- Ability of ________(6) to care for child
Preoperative Evaluation & Planning
- Significant challenge for the anesthesia team
- Pressured to provide “efficient & rapid” care
- Cooperative surgeon’s office
- Handouts
- Telephone interviews
- Websites & email
Preoperative Evaluation & Planning
- Urinalysis?
- Hematocrit and CBC?
- Sickle Cell Testing?
- Heart murmurs and cardiac consults?
- URIs?
- Do you NEED all of these? If so, are they really appropriate for SDS?
Answers:
1. 2
2. pulse oximetry
3. Strabismus
4. premature
5. Distance
6. parents
Upper Respiratory Infections
- Few issues in pediatric anesthesia have been as contentious as those regarding anesthesia for the child with an upper respiratory tract infection (URI).
- The majority of complications in children with URIs are related to the presence of _______(1) and heightened airway _______(2).
- Specific complications include:
- breath holding
- airway obstruction
- Laryngospasm
- Bronchospasm
- arterial oxygen desaturation.
- Studies show heightened airway reactivity in patients with URIs that may persist for up to _______(3) following the infection.
- Viral infections are known to cause morphological and physiological pulmonary changes including:
- sloughing of the respiratory ______(4)
- altered ______(5) beat frequency
- ______(6) airway conductance
- ______(7) forced vital capacity, functional residual capacity, and diffusion rates.
Answers:
1. secretions
2. reactivity
3. 6 weeks
4. epithelium
5. ciliary
6. decreased
7. Decreased
PACU and beyond
- Transport from OR
- ______(a) position
- Assess respiration
- Oxygen administration
- Emergence delirium
- _______(1) of age at highest risk
- _______(2), crying, screaming, _______(3)
- Usually lasts ______(b) minutes and resolves spontaneously
- Some kids can scream for MUCH longer than that and the PACU nurses will ask for sedation
- Disturbing for Staff, PACU and for the ______(c)!
- Review tables 47.4 and 47.6 regarding emergence delirium
Answers:
1. 2-6 yrs
2. Thrashing
3. disorientation
a. Recovery
b. 15-20
c. PARENTS
PACU and beyond
Hypoxemia resulting from hypoventilation, upper airway obstruction, bronchospasm, aspiration, pulmonary edema, pneumothorax, atelectasis, cardiac shunting, pulmonary embolism.
- Hypoventilation resulting from _______(1) ventilatory drive or muscle weakness.
- Airway obstruction
Cardiovascular complications
- Bradycardia (until proven otherwise is due to _______(2))
- Tachycardia
- Hypotension (most commonly due to _______(3))
- Hypertension
- Renal (adequate UOP?)
- PONV
- Pain management
- Temperature management
- Discharge criteria (review tables 47.7, 47.8, 47.9)\
Complications & Admissions
- Inadequate analgesia
- Inability to take adequate oral fluids
- Sometimes the child will just refuse to drink, Parents say it’s normal, CRNA discretion
- PONV
- Similarly, if pt is vomiting but shouldn’t be based on procedure (ie propofol TIVA), could be behavioral and maybe you can just send them home
- Excessive somnolence
- Respiratory deterioration (URIs, etc.)
- Surgical complications
Answers:
1. decreased
2. hypoxemia
3. hypovolemia
Discharge Criteria Tables
TABLE 47.7
Discharge Criteria for Inpatients
- Recovery of airway and respiratory reflexes adequate to support gas exchange and to protect against aspiration of secretions, vomitus, or blood
- Stability of circulation and control of any surgical bleeding
- Absence of anticipated instability in criteria 1 and 2
- Reasonable control of pain and vomiting
- Appropriate duration of observation after opioid or naloxone flumazenil administration (minimum of a.__ minutes after intravenous naloxone and up to b.___ hours after flumazenil)
- Return to baseline level of consciousness unless transfer is to an intensive care unit environment
Discharge Criteria for Outpatients
TABLE 47.8
All Criteria in Table 47.7, Plus the Following:
1. Cardiovascular function and airway patency are satisfactory and stable.
2. The child is easily rousable, and protective reflexes are intact.
3. The child can c.__ (if age appropriate).
4. The child can sit up unaided (if age appropriate).
5. For a very young or handicapped child, incapable of the usually expected responses, the preanesthetic level of responsiveness or a level as close as possible to the normal level for that child should be achieved unless the child is to be transferred to another monitored location.
6. The state of d.___ is adequate.
7. It may be permissible for parents to carry their children e.___ full recovery of gait (parents must be advised that the child is at risk of injury if improperly supervised).
8. Control of pain should be achieved to permit adequate analgesia by the f.___ route thereafter.
9. Control of nausea and vomiting should be achieved to allow for oral hydration (see “Discharge Criteria” in text).
TABLE 47.9
Discharge Criteria for Fast Tracking
Criteria
- Level of Consciousness
- Aware and oriented
- Arousable with minimal stimulation
- Responsive only to tactile stimulation
- Physical Activity
- Able to move all extremities on command
- Some weakness in movement of extremities
- Unable to voluntarily move extremities
- Hemodynamic Stability
- Blood pressure ±15% of baseline MAP value
- Blood pressure 15%-30% of baseline MAP value
Blood pressure >30% of baseline MAP value
- Respiratory Stability
- Able to breathe deeply
- Tachypneic with good cough
- Dyspneic with weak cough
- Oxygen Saturation Status
- Maintains value >95% on room air
- Requires supplemental oxygen (nasal prongs)
- Saturation <90% with supplemental oxygen
- Postoperative Pain Assessment
- None or mild discomfort
- Moderate to severe pain controlled with intravenous analgesics
- Persistent, severe pain
- Postoperative Nausea Symptoms
- None or mild nausea with no active vomiting
- Transient vomiting or retching
- Persistent, moderate to severe nausea and vomiting
*Pediatric patients must score g.__ to bypass the phase 1 (PACU) recovery unit to be admitted directly to the step-down care unit.
MAP, mean arterial pressure; PACU, postanesthesia care unit.
refer to table for fast track scoring system
a. 60
b. 2
c. talk
d. hydration
e. without
f. oral
g. 14
