3- sedation and treatments under GA

What does the decision as to whether a patient should be treated with sedation depend on? (5)

age of the child

degree of surgical trauma involves

perceived anxiety

complexity of the operative procedure

medical status of the child

ASA physical status classification

Sedation levels

What is conscious sedation?

Drugs produce state of depression of CNS allowing treatment to be carried out

Verbal contact with patient is maintained, retains protective reflexes, able to understand and respond to commands

Before conscious sedation instructions (give verbally and writing in advance)

Include possible side effects

Escort should be over 18 and able bodied

Fasting not required before nitrous oxide inhalation or IV Midazolam

2-4-6 for oral sedation = 2 hrs fast for clear fluids, 4hrs for milk, 6hrs for solids

How should you monitor a sedated child?

Clinical monitoring- alertness, verbal contact, skin colour, response to stimuli, ability to keep mouth open, swallow, maintain independent airway, normal radial pulse

Use of pulse oximeter- except for nitrous oxide sedation

10 management rules of unexpected loss of consciousness

1. Stop operative procedure immediately

2. Ensure mouth is cleared of all fluids by using high-volume suction

3. Turn the patient on their side in the ‘recovery position’

4. Consider administration of 100% O2

5. If IV sedation is being used- leave the cannula in place so that emergency drugs can be administered

6. Consider monitoring pulse, bp and respiration. Be ready to start resuscitation

7. Dentist should stay with patient until full signs of being awake

8. Follow up the patient by review within 3 days

9. Document the incident fully

10. Inform patient’s general medical practitioner about the incident

What are the drugs and routes of conscious sedative drugs?

Oral- dosage determined by body weight, flavoured drink may be added to sedative

Inhalation

IV

Transmucosal- nasal, rectal, sublingual

Why is fasting required before oral sedation?

Variable absorption from GI tract

Affected by rate of gastric clearance, amount of food in stomach, time of day

Midazolam (oral)- usage, indications, contraindications, dosage, antagonist

Not specifically licensed for oral admin- unpredictable in children- CNS be paradoxical making them hyperactive

For ASA 1 or 2, under 30kg, short procedures (single extraction)

Same as IV sedation

0.3-0.7mg/kg , max 20mg

Flumazenil- give 0.3mg, if degree of consciousness not achieved in 60secs- give another 0.1mg at 60sec intervals- max 2mg

What other drugs are used for oral sedation?

Choral hydrate- sedative hypnotic

May cause nausea, vomiting due to gastric irritation or myocardial depression and arrhythmia

Depresses bp and respiratory rate

Use with hydroxyzine and promethazine hydrochloride- have anti-emetic, antihistamine, antispasmodic effect

Ketamine- powerful- dissociation but maintains protective reflexes- side effects include hypertension, vivid hallucinations, physical movement, risk of laryngospasm

Nitrous oxide inhalation sedation- conc, what type of child, 7 indications

20-50% conc nitrous oxide

Child must be able/ willing to collaborate (breathe in and out of nose) mainly in school age children- no lower age limit- depends on development

mildly anxious children

unpleasant procedure

medically compromised

needle phobia

gag reflex

other sedation methods contraindicated

alternative to GA

What safety features of dedicated dental machines (for nitrous oxide)?

Oxygen cylinder is black in UK, turquoise in the USA, white in Spain.

Nitrous oxide cylinder is blue

Pin index system ensures that the nitrous oxide cylinders cannot be inadvertently fixed to the oxygen delivery side

Nitrous oxide is cut out if the oxygen cylinder empties completely

No less than 30% oxygen can be given

10 steps in inhalation sedation technique?

Carry out the safety checks

Select the appropriate size of nasal mask

Connect the scavenging pipe

Set the mixture dial to 100% oxygen

Settle the patient in the dental chair whilst reassuring them

Turn the mixture dial vertically to 90% oxygen (10% nitrous oxide)

Turn the mixture dial to 80% oxygen (20% nitrous oxide). Wait for 60 seconds. Above this level consider whether further increments

At the appropriate level of sedation, start dental treatment

To bring about recovery turn the mixture dial to 100% oxygen for 2 minutes

The patient should breathe room air for a further 5 minutes before leaving the dental chair

8 Signs of a sedated child

reduced body and facial tension

reduced frequency of blinking

slowed responses

laughing/giggling

glazed eyes

relaxed feet

tingling in the fingers and toes (parasthesia)

visual changes

Environmental pollution

Potential damage to reproductive, hepatic, renal, CNS and hemaopoeitic systems

Regular use in unventilated room can cause megaloblastic anaemia, distal renal tubule calcification, neuropathy, problems with conception and pregnancy

How to combat environmental pollution?

2 types of scavenging systems- passive and active- incorporate nasal mask

What does IV sedation usually involve the use of and indicated when? (4)

Midazolam (BDZ)

Usually confined to mature adolescents

emotionally mature adolescents

an unpleasant or complicated procedure

treatment too lengthy for GA

ASA I or II

What should be included in the information leaflet for conscious sedation?(5)

preop prep including fasting

overview of the proposed treatment- benefits, minor and major risks

Sedation procedure

Adult escort should bring the child patient—no other child should accompany them

Postop arrangements- suitable transport home, postop care and pain control

What is general anesthesia? Major vs minor risks?

Controlled unconsciousness when you feel nothing

Drugs injected into vein or gases inhaled- carried to brain and stops recognising messages

Major risk - 1:400,000

Minor risk- pain, headache, sore nose or throat, nausea, upset, anxiety

2 indications of GA for Paeds

Patient too young, anxious or uncooperative

Surgeon needs guarantee of completely still patient (complex procedure)

What must you monitor for GA?(4)

good oxygen saturation

blood pressure- systolic and diastolic blood pressure

electrocardiogram (ECG)

carbon dioxide output