Week 13: Pediatric dentistry, sedation, same-day

Question 1

Anesthesia for Pediatric dentistry

• 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., seizure disorder –> _____ –> _______ –> ________

Answer 1

phenytoin –> gingival hyperplasia—> excessive bleeding

Question 2

Anesthesia for Pediatric dentistry

Pre-medication and/or sedation
Use of local anesthetics
Inhalation induction vs IV induction
Airway management
* ________
* ________
* ________
Throat packs

PONV secondary to:

Answer 2

• Nasotracheal intubations
• Oral RAE tube
• Flexible LMA

• Swallowed blood and/or
• Topical fluorides inadvertently swallowed

Question 3

Antibiotics for Subacute Bacterial Endocarditis (SBE) prophylaxis:

Answer 3

Question 4

Anesthesia and sedation for pediatric outside the operating room:

Requirements for “outside” locations include:

Generally, these outside locations are NOT designed with the needs of anesthesia providers in mind.

TEST

Answer 4

• Anesthesia equipment and monitors.
• Adequate space, and
• Experienced ancillary providers to provide assistance as needed.

Question 5

Anesthesia and sedation for pediatric procedures outside the operating

You must have:

Answer 5

Question 6

JCAHO Definitions

Minimal sedation (______)
1. A drug-induced state during which patients:

2. Although _______ and _______ may be impaired, ventilatory and cardiovascular function are unaffected.

Answer 6

anxiolysis;
1. respond normally to verbal commands.
2. cognitive function and coordination

Question 7

Moderate sedation/analgesia or “_____________”
1. A drug-induced depression of ___________ during which patients respond ________ to verbal commands, either alone or accompanied by light tactile stimulation.

2. ______ and _______ maintained

Answer 7

Conscious Sedation
1. consciousness; purposefully
2. Airway and CV

Question 8

Deep sedation/analgesia
1. A drug-induced depression of consciousness during which patients _______ be easily aroused but respond purposefully following repeated or _________ stimulation. __________ is not considered a purposeful response.

2. _______ and _________ may be impaired. Spontaneous ventilation may be inadequate.
3. ________ function is usually maintained.

Answer 8

1. cannot; painful
   * Reflex withdrawal
2. Ventilatory function and airway patency
3. CV

Question 9

• General anesthesia is a drug-induced _______________ during which patients are not arousable, even by painful stimuli.
• The ability to independently maintain ventilatory function is often impaired.
• Patients require assistance in maintaining a patent airway and _________________ may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
• CV function may be impaired.

Answer 9

• loss of consciousness
• positive pressure ventilation

Question 10

Review

Answer 10

Question 11

Goals of Sedation

Answer 11

Question 12

Complications of Sedation & General Anesthesia Outside the OR

Answer 12

Apnea
Airway obstruction
Inadequate ventilation
Coughing
Vomiting
Hypoxia
Inadequate sedation

Question 13

Red Flags for Sedation

Answer 13

Apnea
Unstable cardiac disease
Respiratory compromise
Craniofacial defect
History of a difficult airway
Active gastroesophageal reflux or vomiting
Hypotonia and lack of head control
Allergies to sedatives
Prior failed sedation
Tremors

Question 14

Procedures Requiring Sedation or General Anesthesia Outside OR

Answer 14

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

Question 15

AnMRIis indicated to detect:

One advantage of an MRI is that it does not use ___________

An MRI can take from _____ minutes to _____ hours and involve breath holds.

Answer 15

• Soft tissue,
• Ligament and tendon injuries,
• Spinal cord injuries,
• brain tumors, etc.

radiation.

30, 4

Question 16

Magnetic Resonance Imaging

1. No _______________ objects near the MRI machine or the magnet!
2. The magnets are never off, even at night, and turning off the electrivity will not affect them.
3. They draw most of their power from _________________, 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).

Answer 16

ferromagneticmetal; supercooled helium

Question 17

Potential difficulties in magenetic resonance imaging

Answer 17

Question 18

Monitoring Failure in MRI

Answer 18

Question 19

Computed (Axial) Tomography

• ACT Scan(orCAT Scan) is best suited for viewing:
• CT scans are widely used in emergency rooms because the scan takes fewer than ______ minutes.
• CT scans expose the patient to ________, which may be harmful if there are repeated exposures.

Answer 19

• bone injuries,
• diagnosing lung and chest problems, and
• detecting cancers

5;

radiation

Question 20

Positron Emission Tomography

1. A positron emission tomography (PET)scanis an imaging test that uses a ___________ called a tracer to look for disease or malignancy.
2. Cells with increased ______ will absorb more of the radioactive tracer. A scanner then detects this substance to produce images of organs and tissues inside the body.

Answer 20

1. radioactive substance
2. metabolism

Question 21

Same-Day Surgical Procedures

• _______ procedures that do not involve major violation of the body cavity.
• Procedures are typically limited in duration, generally less than _____ hours.
• They do not require ________beyond the capabilities of the parents or caregivers.

Answer 21

• Peripheral
• 2
• post discharge monitoring

Question 22

Common SDS Operations

Answer 22

ENT
Ophthalmology
General pediatric surgery and urology
Gastroenterology
Plastic surgery
Orthopedics
Radiology
Dentistry

Question 23

Considerations requiring 23-hour overnight observation (23 OBS)

Answer 23

• Ex-premature infants
• Obstructive sleep apnea (OSA)
• Distance from facility
• Ability of parents to care for child

Question 24

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:

Specific complications include:

Answer 24

secretions and heightened airway reactivity.

Breath holding,
Airway obstruction,
Laryngospasm,
Bronchospasm and
Arterial oxygen desaturation.

Question 25

Upper Respiratory Infections

• Studies show heightened airway reactivity in patients with URIs that may persist for up to _____ weeks following the infection.
• Viral infections are known to cause morphological and physiological pulmonary changes including, sloughing of the respiratory epithelium, altered ciliary beat frequency, and decreased airway conductance, forced vital capacity, functional residual capacity, and diffusion rates.

Answer 25

*6

Question 26

Emergence delirium

• __-___yrs of age at highest risk
• S/S:
• Usually lasts ____-____ and resolves spontaneously

Answer 26

*2-6
*Thrashing, crying, screaming, disorientation

*15-20 minutes

Question 27

PACU and beyond

airway complications after PACU

Answer 27

Question 28

PACU and beyond

Cardiovascular complications
* Bradycardia (until proven otherwise is due to ________)
* Tachycardia
* Hypotension (most commonly due to __________)
* Hypertension

Answer 28

• hypoxemia
• hypovolemia

Question 29

complications that require admission

Answer 29

• Inadequate analgesia
• Inability to take adequate oral fluids
• PONV
• Excessive somnolence
• Respiratory deterioration (URIs, etc.)
• Surgical complications

Question 30

Office-Based Pediatric Anesthesia

“Pediatric comorbidities considered high risk for office-based surgical suites”

Answer 30

• Obstructive sleep apnea
• Uncontrolled asthma and/or upper respiratory tract infection
• Neurologic and neuromuscular disorders
• Complex congenital heart disease
• Sickle cell disease
• Increased body mass index (BMI)