Wednesday, February 27, 2013

Effects of Midazolam on asthmatic children


Resident: Matthew Freitas
Author(s): Kil et al.Journal: Pediatric Dentistry; 2003. 25. 137-142.

Main Purpose:
-To examine the safety and efficacy of midazolam in asthmatic pediatric patients undergoing dental treatment.

Methods:-24 children, 17 males and 7 females were selected for this study. 
-Children aged 1-6 years old with a diagnosis of mild-intermittent, mild-persistent, or moderate-persistent asthma in need of routine restorative work or extractions with sedation for behavior management. 
-NPO 4 hours prior to tx-A preoperative assessment: asthma score, respiratory rate, pulse rate, and oxygen saturation. Each child was given 0.5mg/kg of midazolam orally. After 10 minutes, the child was separated from the parents and pulse oximeter monitor was affixed to the patient. Respiratory rate, pulse rate, and oxygen saturation were all monitored in 5 minute intervals throughout dental treatment. And then again at the end of the dental treatment.At the end of the dental treatment, asthma score, pulse rate, and respiratory rates were recorded.
-The dental operator assessed the sedation outcome using a behavior assessment. Oxygen saturation, pulse rate, and respiratory rates were also recorded 30 minutes after treatment.

Results:
-Oxygen saturations remained normal and consistently above 95% throughout the entire procedure for all but 2 patients.
-2 children had oxygen saturations that fell down to 94% at some point during treatment, however, O2 sat increased after their heads were tilted back to open the airway.
-Asthma scores remained the same. 
-Oxygen saturation and respiratory rates stayed relatively constant throughout treatment. 
-The pulse rate rose continuously from 5 minutes through 15 minutes; local anesthetic injection and initiation of treatment likely the cause of increased pulse.
-12 subjects had excellent behavior, 5 subjects had satisfactory behavior, and 7 subjects had unsatisfactory behavior. 5 patients required the use of the papoose board due to uncooperative behavior.

Summary:
-Sedation with midazolam, when given orally at a dose of 0.5mg/kg, produces little to no adverse effects on asthmatic patients presenting with mild to moderate symptoms.
-Most patients were treated with minimal difficulty.
-Midazolam is a safe and effective means of sedation for patients with mild to moderate asthma.

Tuesday, February 26, 2013

A Survey Study of Sedation Training in Advanced Pediatric Dentistry Programs: Thoughts of Program Directors and Students

Kyung-Hong Cal Kim

A Survey Study of Sedation Training in Advanced Pediatric Dentistry Programs: Thoughts of Program Directors and Students

Authors: Stephen Wilson, John E Nathan

Pediatric Dentistry V33/No4 Jul/Aug 2011

Purpose:
To survey program directors and students of AEPD programs in the United States on sedation issues.

Methods:
-Two separate surveys targeting program directors (PD) and students and recent graduates of AEPD programs
-Distributed via e-mail (SurveyMonkey) in summer, 2009

Results/Discussions:
PDs
-38 of total 76 program directors responded (49% response rate)
-PDs “routinely” used protective immobilization with sedation (81%)
-Majority (45%) of responses revealed any form of sedation for patient care was used for 0 to 10% of the time (0-10% > 10-25% > 25-40% > 40-60%)
-Estimated number of sedations performed per week in their program: 0-5 (36%)
-Average number of routes (IN,PO,IM,IV): 3
-Those respondents who had academic experience and had graduated from training programs more than 16 years ago were significantly more likely to have experience with the IV route
-Mean number of GA cases performed per year: 90 (vs 127 by students)
-Reasons for the use of N2O/O2 in conjunction with other sedation routes of administration: Potentiating effect at the onset of tx (100%) > Adjunctive effect when oral agents are ineffective (76%) > titratable effects (55%)
-68% of PDs indicated that they abandoned the regimen that failed in favor of an alternative modality (GA) > Selected a different regimen (19%) > different route of administration (10%) > adjusted doses (3%)

Students
-135 students/recent graduates (17%)
-7 PGY-1, 74 PGY-2, 53 PGY-3 or recently graduated
-Students agreed that success of sedation is acceptable if restraint is needed to accomplish treatment objectives.
-60% agreed or strongly agreed with the statement of having a strong comfort level in the selection of drugs based on their training
-50% disagreed or strongly disagreed with the statement of having a strong comfort level in the selection and use of various routes of drug administration
-40% indicated they agreed or strongly agreed with the statement of having a strong comfort level working in each of minimal, moderate, and deep levels of sedation.
-93%/7% felt their training experience with inhalation N2O/O2 was excellent or adequate
-45%/39% felt their training experience with oral sedation was excellent or adequate
-Similar to PDs, midazolam PO was the most frequently reported drug and route used
-Majority of students would use sedation more in practice compared to that of their program experiences.
-6 students (4 PGY-2 and 2 recently graduated) indicated that they had NO experience with oral sedation: Some students of AEPD programs may not meet minimal accreditation standards

-Mean percent success of sedations at their programs reported by faculty was higher (68%) than students (67%)
-Study supports an ongoing perception of significant variability in training with little evidence of organized dentistry or academics addressing this situation, which may lead to widespread changes in state board regulation of sedation permits and more stringent control of sedation.
-Modifying accreditation standards, developing sedation training centers or programs accommodating students who lack significant opportunities and resources for sedation experiences, and identifying experienced practitioners as mentors during rotations are suggested solutions.
-Majority of respondents estimated that 25% or less of the patients required sedation, excluding N2O/O2, and 10 patients or less were sedated per week.
-Age ranges of children reportedly sedated were primarily between 2 and 9.
-Pervasive use of midazolam with and without other agents and in the dosages reported in this study suggests that, as a whole, the depth of sedations in training programs are “lightening.”

Comparison of 3 Routes of Flumazenil Administration to Reverse Benzodiazepine induced Desaturation in an Animal Model

Resident: Jeff Higbee
Article: Comparison of 3 Routes of Flumazenil Administration to Reverse Benzodiazepine induced Desaturation in an Animal Model
Journal: Pediatric Dentistry – 28:4 2006
Author: John H. Unkel, DDS, MPA, et al

Purpose:
The purpose of this study was to examine intralingual (IL) and submucosal (SM) delivery of fl umazenil as viable alternatives to immediate intravenous (IV) administration for reversing benzodiazepine sedation in an animal model.

 Methods:
- A dog animal model was chosen based upon comparable body weight to children (12-17 kg) and the ease of oral access in this species.
- This was a “before and after” study.
- Blood samples were obtained (at 0, 2, 4, 8, 15, and 30 minutes) for high performance liquid chromatography (HPLC) analysis of fl umazenil and midazolam, and oxygen saturation values were recorded.

Results / Key Points:
- Both IL and SM delivery of fl umazenil were determined to be viable alternatives to immediate IV administration for reversing benzodiazepine-induced oxygen saturation (SaO2) desaturation.
- For fl umazenil to be able to reverse the SaO2 desaturation, the plasma levels must be greater than 5 ng/ml, which was exceeded by the IL and SM drug delivery.

Assessment:
This was a good article because I believe that the most important aspect of sedation is to know how to handle the emergencies that can occur.  This article provides several methods of reversing the effects of a very commonly used oral sedative medication. 

Pinkham chapter 8 Pain Reaction Control: Sedation


The guidelines emphasize that the goals of sedation are to

  1. facilitate the provision of quality care
  2. minimize the extremes of disruptive behavior
  3. promote a positive psychological response to treatment
  4. promote patient welfare and safety
  5. return the patient to a psychologic state in which safe outcome is possible
Minimal and moderate sedation – depressed level of consciousness in which the patient retains the ability to maintain a patent airway independently and continuously and to respond appropriately to light physical stimulation or verbal command.

 Deep sedation – a controlled state of depressed consciousness or unconsciousness from which the patient is not aroused easily.  It can be accompanied by a complete or partial loss of protective reflexes.

General anesthesia – a controlled state of unconsciousness accompanied by a loss of protective reflexes.

 -Must be careful to monitor your patients so they don’t slip from moderate to deep sedation because they may lose their protected reflexes and the Dr may not be prepared for it.

-Must rely on the guidelines as the standard of care for minimal and moderate sedation.

 Routes of administration

  1. Inhalation – advantages are rapid onset and recovery time with easy titration and dose control with a lack of serious adverse effects.  The disadvantages are that it is a weak agent, lack of patient acceptance, inconvenience, potential chronic toxicity, potentiation, and equipment problems.
  2. Enteral – advantages are convenience, economy, and lack of toxicity.  The disadvantages are variability of effect, and onset time
  3. Parental
    1. Intramuscular route- advantages are absorption and technique advantages.  The disadvantages are onset, effect, trauma, intravenous access, and liability costs
    2. Subcutaneous route – the advantages are site and disadvantages are technique, tissue slough, and liability costs.
    3. Intravenous route – advantages are titration, test dose, and intravenous access.  The disadvantages include technique, potential complications, patient monitoring, and liability costs.

 Pharmacological agents for sedation

  • Sedative-hypnotics: principle effect is sleepiness.  They fall into two categories,
            1 Barbiturates such as pentobarbital, methohexitol and secobarbital. 

2 Nonbarbituates such as chloral hydrate and paraldehyde

  • Antianxiety agents: the primary effect is to remove or reduce anxiety.  These are primarily benzodiazepines such as diazepam, midazolam, triazolam.   Sometimes these are combined with antihistamines to dry out the patient and to deppen the level of sedation.
  • Narcotics: mainly for analgesia but also sedate.  They can cause nausea and vomiting. Ex fentanyl, morphine, meperidine
  • Ketamine: this is a dissociative agent which produces a cataleptic state with profound analgesia and amnesia.

Comparison of Chloral Hydrate, Meperidine, and Hydroxyzine to Midazolam Regimens for Oral Sedation of Pediatric Dental Patients

Resident: Mackenzie Craik

Article: Comparison of Chloral Hydrate, Meperidine, and Hydroxyzine to Midazolam Regimens for Oral Sedation of Pediatric Dental Patients.

Authors: Jyoti Chowdhury, BDS, MPH1 Kaaren G. Vargas, DDS, PhD

Publication:  Pediatric Dentistry, 2005.


Purpose: The purpose of this retrospective study was to compare the effects of oral administration of a combination of chloral hydrate (CH) 25 mg/kg, hydroxyzine (H) 1 mg/kg, and meperidine (M) 1 mg/kg to midazolam 0.65 mg/kg using 50% nitrous oxide (N2O) on behavioral and physiological parameters of young children sedated for dental procedures.  Factors associated with sedation effectiveness were identified, including age, preoperative behavior, and type of procedure.

Methods: Records of 116 sedation sessions of 66 healthy, uncooperative children ages 24 to 60 months at The University of Iowa Centers for Disabilities and Development were reviewed. Patients received 1 of the 2 regimens. Intraoperative behavior was rated using a dichotomous scale. Physiological variables including heart rate and oxygen saturation were recorded at baseline and at 10-minute intervals of the session. 

Results: Overall, 81% of sessions were rated successful. Sedation sessions using CH+H+M combination had significantly higher success rate (P<.01, odds ratio=3.38, 95% confidence interval=1.06 to 7.15) compared to sessions with midazolam. Sedation success was not associated with age, preoperative behavior, or type of dental procedure performed. Physiological variables were within the normal range for both regimens, although midazolam regimen recorded higher heart rates.

Conclusions: CH+H+M combination using 25 mg/kg CH resulted in significantly more effective sedation sessions compared to midazolam. Both regimens used 50% N2O and were found to be safe. 

Assessment:  Interesting that the Chloral Hydrate cocktail is shown to be much more effective sedating patients than midazolam.  Is the reason for the decline in Chloral Hydrate use and increase in Midazolam use strictly related to predictability and safety?

   

AAPD Handbook of Pediatric Dentistry: Chapter 13 Behavior Guidance


Resident: Derek Nobrega
Title: Chapter 13: Behavior Guidance
Authors: Stephen Wilson
Journal: AAPD Handbook of Pediatric Dentistry

The goals of behavior guidance are:
- establish communication
- alleviate fear and anxiety
- deliver quality dental care
- build a trusting relationship between dentist and child
- promote the child’s positive attitude toward oral/dental health and oral health care
Behavior Management Techniques
1. Communication and communicative techniques
-tell, show, do
-distraction
-non-verbal communication
-positive reinforcement
-voice control
-parental presence/absence
-nitrous oxide
2. Advanced techniques – needs consent
-protective stabilization
-sedation
-general anesthesia

Sedation
Goals:
-facilitate the provision of quality care
-minimize the extremes of disruptive behavior
-promote a positive psychological response to treatment
-promote patient welfare and safety
-return the patient to a physiologic state in which safe discharge is possible
Patient Selection:
-traditional techniques unsuccessful in managing behavior
-patient is ASA I or ASA II
-patient below age of reason
-extent of treatment
-needle phobic, excessively fearful older child
-older child with poor experiences or coping abilities
-distance traveled, even for patients without behavior problems
-developmental delay or compromising condition/medical problem

Level of Sedation
Cognitive Function
Physiological function
Monitoring
Personnel
Minimal
May be impaired
Not affected
Observation only, intermittent
Not specified
Moderate
Depression, respondes to light tactile stimulation
Patent self-correcting airway, ventilation and cardiovascular function adequate
O2 saturation, HR, Intermittent BP and respiration, EKG and defibrillator should be available
Person responsible for monitoring other than operator, may do other tasks
Deep
Depression, cannot be easily aroused
Potential loss of airway reflexes, cardiovascular may be affected
O2 saturation, HR, intermittent BP and respiration rate q5min
Person responsible solely for monitoring

Sedation Routes
1. Inhalation – concentration can be titrated, 100% O2 possible
2. Oral – most accepted by children, can’t titrate (not predictable), onset and recovery may be prolonged/variable
3. Intranasal – easily administered to resistant patient, very effective with quick onset/short acting meds, reduces time in office
4. IM – injection painful, can’t titrate, use vastus lateralis/gluteus, intermediate delay of onset and longer duration
5. Submucosal – fear of needle possible, can’t titrate, inject between 1st and 2nd primary molar in maxillary vestibule, intermediate delay of onset
6. IV – very predictable, can titrate, IV may be difficulat to start in children, rapid onset, shorter recovery

Medications
Drug
Type
Physiologic Function
Onset
Other Effects
Other
Nitrous Oxide
Anxiolytic
CNS depression, minimal CV or respiratory effect
Induction 5min, recovery 10 mins
Sweating, nausea, GI discomfort, vomiting, inhibition of airway reflexes

Relative contraindicated during wheezing (mod-severe asthma), nasopharyngeal obstruction, TB
Chloral Hydrate
Sedative/ hypnotic
CNS Depression
Onset 30-60mins, peak 60 mins, duration 5 hours, working time 1 hour
Gastric Irritation
10-50mg/kg orally up to 1 g
No reversal agent
Diazepam (Valium)
Benzo-diazepine sedative/hypnotic
CNS depression, minimal CV or respiratory effect
Onset 45-60 mins, peak 60 mins
Amnesia, ataxia
Flumazenil reversal 0.01mg/kg up to 1mg
Contraindication – narrow angle glaucoma
Midazolam (Versed)
Benzo-diazepine sedative/hypnotic
CNS depression, minimal CV or respiratory effect
Onset 15 mins, 30-40 min working time
Amnesia
Flumazenil reversal 0.01mg/kg up to 1mg
3-4X potency of valium
Hydroxizine (Vistaril)
Antiemetic/
Antihistamine
CNS Depression, anxiolytic, broncho-dilator
Onset 15-30 mins, duration 2-4 hours
Analgesia, Dry mouth
Often used with chloral hydrate or meperedine
Meperidine (Demerol)
Narcotic
CNS, CV, respiratory depression
Onset 30 mins, peak 1-2 hours, duration 2-4 hours
Sedation, analgesia, lowers seizure threshold. Dizziness, xerostomia, sweating, nausea, vomiting, seizures, respiratory depression
Naloxone reversal (0.1mg/kg)

Combinations utilized for different pharmacologic and synergistic effects. Deepr sedation may result. Often used under 3 years old.

Pre-sedation Preparation
Informed Consent – in writing with witness
Pre-sedation Instruction – verbal and written
Dietary Restrictions – no solid foods, non-human milk, and infant formula for 6 hours; no breast milk 4 hours; clear liquids up to 2 hours before procedure for children aged 6 months and older
Day of Sedation Assessment – review med history, NPO status, URI/nasal discharge/large tonsils, fever/cough, recent head trauma, bladder empty, baseline vital signs

Monitoring
Monitoring airway – keep chin elevated, listen for airway sounds from pre-tracheal stethoscope, watch oxygen saturation on pulse oximeter, chest movement, patient color, capnograph for moderate-deep sedation
Monitoring CV system – heart rate, blood pressure
Monitoring Respiratory System – mirror fogging, chest movement, listen for sounds through stethoscope, oxygen saturation on pulse oximeter, patient color, capnograph for moderate-deep sedation

Discharge Criteria – vital signs and airway stable, no nausea/fever, oriented to surroundings, recognized guardian, can walk, talk and support head, sydrated, post treatment instructions in writing, guardian availabl

Monday, February 25, 2013

Pinkham Chapter 7-Pain Perception Control

  • General anesthesia-Renders patient unconscious by depressing CNS. Whenever GA is administered it must be done so in the proper setting
  • Local anesthesia-Primary mechanism of action is through interaction with sodium channels which inhibit depolarization and transmission of pain. They are weak bases and are supplied as a salt.  Only the free-base form is effective and can permeate the nerve cell
  • Esters-Not widely used anymore for injectables but are used for topical.  Examples are cocaine, novocain, and benzocaine.
  • Amides-Very widely used now. Examples are lidocaine, marcaine, and mepivicaine
  • Potency-Concentrations vary depending on the chemistry of the agent.  Care is needed to be sure to calculate dosages according to concentration
  • Onset time-Time is required for the free base to penetrate the nerve.  Care should be taken not to start the procedure too early. 
  • Duration-Increased protein binding and the use of vasoconstrictor  will extend duration
  • Block vs. Infiltration-Blocks generally take longer to set in and last longer
  • Vasoconstrictors-Used to prolong anesthesia and keep agent localized.  Concentrations of 1:100k are recommended for children.  Care should be taken not allow agent into direct circulation
  • Toxicity-Overdose is rare but can be avoided with weight based calculations.  Symptoms include seizures, dizziness, generalized CNS depression, loss of spontaneous respiration
Analgesics
  • Aspirin-Can be used for children but care must be taken with patients who bleeding is anticipated and with reyes syndrom
  • Acteomenophin-Most commonly used analgesic for children.  Dosage should be weight based.  Excessive use will cause liver damage
  • NSAIDs-Have antiinflammatory properties which tylenol does not.  Are widely used but have not been as well studied as tylenol
  • Narcotics-Primary narcotic for children is Codeine which is frequently mixed with tylenol.  Side effects include nausea, constipation, and sedation.  Care must be taken when prescribing narcotics as deaths due to overdoses have been documented.

Nasal versus oral midazolam sedation for pediatric dental patients

Resident: Elliot Chiu
Title: Nasal versus oral midazolam sedation for pediatric dental patients
Journal: Journal of Dentistry for Children 2004
Author: Lee-Kim et al

Main purpose: To evaluate and compare intranasal (IN) and oral (PO) midazolam for effect on behavior, time of onset, maximum working time, efficacy, and safety

Methods:
-40 anxious dental patients aged 2-6 were sedated randomly with 0.3mg/kg IN midazolam or 0.7mg/kg PO midazolam
-5 providers - residents and fellows
-The dental procedure was videotaped and rated by a blinded and calibrated evaluator
-Behavior was assessed every 5min using Houpt's behavior rating for sleep, movement, crying, and overall behavior

Results: 
-Overall behavior was similar
-Mean onset was 3x faster with IN
-Mean working time was 10min longer with PO
-IN exhibited more movement
-No significant difference in vital signs (O2 sat, HR, RR, BP)

Assessment
Good study, but a couple flaws include there being multiple operators and assistants, and neither one was blinded to the route of admin.

Wednesday, February 20, 2013

Effectiveness of two nitrous oxide scavenging nasal hoods during routine pediatric dental treatment

Resident Name: Todd Bushman
Article Info:
Effectiveness of two nitrous oxide scavenging nasal hoods during routine pediatric dental treatment
By Chrysikopoulou A, Matheson P, Milles M, Shey Z, Houpt M.
Pediatric Dentistry. 2006 May-Jun;28(3):242-7.

Main Purpose:
This study compared the effectiveness of 2 nasal hoods (Porter/Brown and Accutron) in reducing waste nitrous oxide gas during conscious sedation for routine pediatric dental treatment.
Methods:
Thirty children, ages 3 to 8 years, participated in this study. Fifteen randomly selected children started with the Porter/Brown mask, which was then switched to the Accutron mask, and the other 15 children used the reverse order of masks. Four measurements of ambient nitrous oxide were recorded 5 minutes after each of the following: (1) administration of nitrous oxide; (2) placement of the rubber dam; (3) change of the nasal hood; and (4) reduction of the vacuum. Samples were taken 8 inches above the nose of the patient and in the room 5 feet away from the patient.
Key Points:
Nitrous oxide levels were significantly lower with the Porter/Brown system (31 +/- 40 ppm for the patient and 8 +/- 10 ppm for the room) compared with the Accutron system (375 +/- 94 ppm for the patient and 101 +/- 37 ppm for the room). When the suction was reduced, there was an increase in nitrous oxide levels with the Porter/Brown nasal hood (169 +/- 112 ppm for the patient and 28 +/- 18 ppm for the room), whereas the levels with the Accutron nasal hood remained high.  This study demonstrated that removal of waste nitrous oxide was greater with the Porter/Brown device and that recommended suction levels must be used for optimum effectiveness.
Based on this study’s results, the following conclusions can be made:
1. Scavenging nasal systems differ in their ability to re­move waste nitrous oxide when nitrous oxide conscious sedation is administered to pediatric dental patients. The Porter/Brown system was more effective than the Accutron system.
2. When ambient nitrous oxide levels are higher than rec­ommended safe levels, the levels are high surrounding the patient’s face, and they are also high in the room some distance from the patient.
3. Scavenging systems must be operated with the recom­mended amounts of suction to function effectively.

Assessment of Article:It was a straight forward article that highlighted the benefit of one system over another.  I’m not sure what system we use but we should be aware of the effectiveness of our products.

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Kyung-Hong Cal Kim

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Developed and endorsed by: AAP and AAPD

Reference Manual V31/No6, 09/10

Purpose:
To unify the guidelines for sedation used by medical and dental practitioners, add clarifications regarding monitoring modalities, provide new information from medical and dental literature, and suggest methods for further improvement in safety and outcomes.

Goals of sedation
-To guard the patient’s safety and welfare
-To control anxiety, minimize psychological trauma, and maximize the potential for amnesia
-To minimize physical discomfort and pain
-To control behavior and/or movement so as to allow the safe completion of the procedure
-To return the patient to a state in which safe discharge from medical supervision, as determined by recognized criteria, is possible

Specific Guidelines for Intended Level of Sedation
Minimal (“anxiolysis”)
-Patients respond normally to verbal commands
-Ventilatory and cardiovascular functions are unaffected
-If children are moderately sedated despite the intended level of minimal sedation, moderate sedation guidelines apply

Moderate (“conscious sedation”)
-Patients respond purposefully to verbal commands or following light tactile stimulation
-No intervention required to maintain a patent airway. Spontaneous ventilation adequate
-CV function usually maintained.
-Practitioners should be prepared to increase the level of vigilance corresponding to what is necessary for deep sedation
Personnel
-Practitioners must be capable of providing at the minimum bag-valve-mask ventilation, and training in advanced pediatric airway skills is required.
-Use of moderate sedation shall include provision of a person whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures, if required.
Monitoring/Documentation
-Baseline determination of vital signs prior to administration of sedative medications shall be documented.
-Continuous monitoring or O2 sat and HR and intermittent recording of RR and BP in a time-based record during the procedure.
-The Patient’s vital signs should be recorded at specific intervals after the procedure. If the patient is not fully alert, O2 sat and HR monitoring shall be used continuously until appropriate discharge criteria are met (Simple test: “Ability of the infant/child to remain awake for at least 20 minutes in a quiet environment”)
-Longer period of observation required for patients who received reversal agents (flumazenil or naloxone), due to possibility of resedation. (duration of drug > antagonist)

Deep Sedation
-Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation
Personnel
-There must be 1 person available whose ONLY responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration.
-There must be at least 1 person present who is trained in providing advanced pediatric life support, and who is skilled in airway management and cardiopulmonary resuscitation.
Equipment:
-Electrocardiographic monitor and a defibrillator should be readily available in addition to the equipment for moderate sedation.
Vascular access:
-IV line should be placed at the start of the procedure
Monitoring/Documentation
-Vital signs must be documented at least every 5 minutes in a time-based record
-Use of precordial stethoscope or capnograph for patients difficult to observe to aid in monitoring adequacy of ventilation is encouraged.
-Inspired concentration and duration of inhalation sedation agents and oxygen shall be documented.

Special considerations
-All local anesthetic agents are cardiac depressants and may cause CNS excitation or depression
-Expired CO2 monitoring is valuable to diagnose the simple presence or absence of respirations, airway obstruction, or respiratory depression, particularly in patients sedated in less-accessible locations.
-It is preferable to have 2 or more adults accompany children who are still in car safety seats if transportation to and from a treatment facility is provided by 1 of the adults
-When proper fasting has not been ensured, te increased risks of sedation must be carefully weighed against its benefits, and the lightest effective sedation should be used.



Tuesday, February 19, 2013

Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment

Resident: Elliot Chiu
Title: Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment
Journal: Pediatric Dentistry 2008
Author: Kupietzky et al

Main Purpose: To determine the frequency of vomiting during N2O and assess the relationship between fasting status and vomiting

Methods
-113 children aged 2-13 years old
-Pts randomly assigned to either fasting for their first appt and non-fasting for their second appt or vice versa
-50/50 N2O administered for the entire length
-RDI used for all restorative procedures

Results
-On average in the fasting group, the child at 6 hours before the appt
-Non-fasting group - 1 hour
-Vomiting occurred in only 1 subject during a non-fasting appt. This pt had eaten a heavy lunch followed by a late afternoon snack of chocolate pudding 1 hour prior to treatment.
-No differences found between fasting and nonfasting subjects
-Using the rapid induction method, constant nonfluctuating concentration/flow, and treatment time under 35min, vomiting was found to be less than 1%

Assessment
-Using the author's N2O method, the chance of a pt vomiting is very low, even with "non-fasting" patients

Current Status of Nitrous Oxide as a Behavior Management Practice Routine in Pediatric Dentistry

Current Status of Nitrous Oxide as a Behavior Management
Practice Routine in Pediatric Dentistry

Resident Name: Sadler
Article Info: Current Status of Nitrous Oxide as a Behavior Management Practice Routine in Pediatric Dentistry
Nicholas J. Levering DDS
Journal of Dentistry for Children 78:1, 2011
Purpose: Literature review of nitrous oxide and its history
Key Points:
· History: Nitrous has been used since the mid 1800s and became commonplace in dentistry in the 70s and 80s. It produces non-specific CNS depression and modest analgesia. At concentrations less than 50% the patients remain aware of their surroundings but at higher concentrations it can produce unconsciousness
· Nitrous is widely used in pediatric and adult dental settings. It is particularly helpful for anxious patients who are able to follow instructions.
· Nitrous has a superior safety record. Using nitrous with other drugs should be done cautiously as their effects are often amplified.
· Nitrous is also a greenhouse gas but the amount released as medical byproduct is negligible.
· Nitrous use is more common among younger dentist and less popular with older dentists
· A survey of pediatric dentist under the age of 30 showed 100% had it in their offices
· Parental acceptance of nitrous oxide is extremely high and continues to rise when compared with earlier generations. Also, dentists rate nitrous as their second best behavior management tool after tell-show-do.
· Dental schools do teach nitrous oxide sedation but there is insufficient evidence to show that graduates are competent in its use. 

Assessment of Article: A very good review of nitrous oxide and it uses.  I always think its nice to read about what nitrous is good for.  I think it is really nice to hear that it is best for mild-moderately apprehensive children and should be considered even for well behaved children for their first operative appointment to make sure it can be a positive experience.

Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Resident: Mackenzie Craik

Article: Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Publication: Clinical Guidelines

Purpose: The AAPD recognizes nitrous oxide/oxygen inhalation as a safe and effective technique to reduce anxiety, produce analgesia, and enhance effective communication between a patient and health care provider.

Main Points: -Analgesia/anxiolysis is defined as diminished or elimination of pain and anxiety in a conscious patient in a conscious patient.  The patient will however respond normally to verbal commands.
-The analgesic effect of nitrous oxide appears to be initiated by neuronal release of endogeneous opioid peptides with subsequent activation of opioid receptors and descending Gamma-aminobutyric acid type A (GABAA) receptors and noradrenergic pathways that modulate nociceptive processing at the spinal level.
-N20 causes minor depression in cardiac output while peripheral resistance is slightly increased, thereby maintaining the blood pressure.
-Contraindications for N20 use are: 1) some chronic obstructive pulmonary diseases, 2) severe emotional disturbances or drug-related dependencies, 3) first trimester of pregnancy, 4) treatment with bleomycin sulfate, 5) methylenetetrahydrofolate reductase deficiency.
-The response of patients to commands during procedures performed with anxiolysis/analgesia serves as a guide to their level of consciousness.  During N20 administration continual clinical observation of the patient's responsiveness, color, and respiratory rate and rhythm must be performed.
-Nausea and vomiting are the most common adverse effects, occurring in 0.5% of patients.  A higher incidence is noted with longer administration of N20, fluctuations in N20 levels, and increased concentrations of N20.
-Diffusion hypoxia can occur as a result of rapid release of N20 from the blood stream into the alveoli, thereby diluting the concentration of oxygen.  This may lead to headache and disorientation and can be avoided by administering 100% oxygen after nitrous oxide has been discontinued.

Assessment:  This is an excellent overview of N20.  Even though we use it almost every day, there are still many aspects of the treatment that we don't regularly think about, this offers a helpful refresher on the mechanism, and indications/contraindications to using N20.

AAPD Handbook Ch. 14 – Pain Control

Resident: Jeff Higbee
AAPD Handbook Ch. 14 – Pain Control

 Indication:
- Children feel pain but might not be able to report severity or location
- Special consideration should be given to dosages, especially in small children
- The max recommended dose of local must not be exceeded for 1 appointment

 Techniques of Local Anesthetics:
- Maxillary anesthesia
Supraperiosteal infiltration in the mucobuccal fold
Intrapapillary injection for palatal anesthesia
 
- Mandibular anesthesia
Supraperiosteal infiltration
IA nerve block
PDL injection

Maximum Recommended Dosages


If conscious sedation is employed, then dosage of anesthetic should be well below the MRD so that potentiation of cardiorespiratory depressant effects does not put the patient at risk.

-Epi prolongs the action of the local anesthetic by constricting blood vessels and increases the potential for post-tx soft tissue trauma from biting or scratching
- Epi prevents rapid systemic uptake of local anesthetic so it is generally used in dentistry for children


Local Anesthetic Overdose
Causes
- intravascular injection
- excess dosage delivered to patient

Effects
- CNS depression, seizures, disorientation, loss of consciousness
- cardiovascular system

Complications of Local Anesthesia
Soft tissue injury
- accidental lip, cheek or tongue biting or scratching from prolonged soft tissue anesthesia
- more common in very young or developmentally disabled child
-warn patient and parent of possible injury

Analgesia for Children
Pain assessment in the preverbal child or one with limited verbal skills
- physiologic response: increased HR, BP, RR
- behavioral response
- persistent crying
-crying with oral stimulation, eg, sucking, eating, etc.
- inability or refusal to eat or drink
- awakening from sleep

Analgesics Commonly Prescribed for Children
- Acetaminophen
- Ibuprofen
- Naproxen
- Acetaminophen with codeine