Wednesday, February 24, 2016

Pain Perception Control Chapter 7

Resident’s Name: Semantha Charles Date: 02/24/2016
Article Title: Pain Perception Control Chapter 7
Book: Pediatric Dentistry, Infancy Through Adolescence, 5th Edition
Author: Paul S. Casamassimo, DDS, MS, Henry W. Fields, Jr., DDS, MS, MSD, Dennis J. McTigue

Key Points
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
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.

Adverse events and outcomes of conscious sedation for pediatric patients: Study of an oral sedation regimen

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:             Leslie M Slowikowski                                                                        Date: 02/24/2016
Article Title: Adverse events and outcomes of conscious sedation for pediatric patients: Study of an oral sedation regimen
Author(s): Pattarawadee Leelataweedwud, DDS, MS William Vann Jr., DMD, MS, Ph.D
Journal: JADA
Date: November 2001
Major Topic: Adverse sedation events in Pediatrics
Type of Article: Retrospective chart view
Main Purpose: To look at adverse events in a specific oral sedation regimen
Key Points/Summary: Review of charts from years 1992-1997 using the drug regimen chloral hydrate (50milligrams per kilogram), Meperidine (1.5 mg/kg) and hydroxyzine pamoate (25mg). 
Rational for drug regimen:
·      Anxiolytic, analgesic and antemetic effects
·      Chloral hydrate: anxiolytic, sedative and hypnotic properties; wide margin of safety, well studied, 30-60minutes to reach peak effects
·      Meperidine: sedation and analgesia; respiratory depression that can be potentiated from the anxiolytic effect of chloral hydrate; radip onset 10-15 minutes and 1-2 hours to reach its peak
·      Hydroxyzine pamoate: antihistamine and psychotopic agent that possesses antiemetic(over come the histamine release of meperidine, nausea and vomiting of both meperidine and chloral hydrate), anxiolytic, sedative and hypnotic properties, onset with in 15-30 minutes, when combined with other central nervous system depressants it can potentiate the central nervous system depression effect

Records were reviewed from Pediatric Sedation Clinic in the School of Dentistry at the University of North Carolina at Chapel Hill.  Supplemental 100 percent O2 via nasal canula is used to elevate the partial pressure of arterial oxygen PaO2 as an added safety measure.  Dietary restrictions of no milk or food for 8 hours prior to appointment and no clear liquids fours hours prior according to the AAPD guidelines.  Continuous monitoring was completed with use of pulse oximeter, precordial stethoscope and visual observation; capnograhy was adopted in 1995.  111 patient met the inclusion criteria, 195 conscious sedations appointments, children age range was from 24 to 84 months.  Mean wait time was 60 minutes, 72 % were satisfactory, 23 % unsatisfactory, 5 % aborted.  Sedation outcomes were higher for those children who drank all meds from cup.  Average treatment time was 65 minutes for satisfactory and 64 minutes for unsatisfactory.  Adverse events were reported in six for the 195 visits, 3 percent and included postoperative vomiting, true desaturation, true apena and prolong sedations. 

·      Adverse events occurred in only 3 percent of the sedation appointments when a strict sedation protocol was adhered to
·      The regimen yielded 72 % were satisfactory, 23 % unsatisfactory, 5 % aborted sedation appointments
·      Compliance with taking oral medication and waiting time after medication intake were important factors in predicating sedation success

Evidence class: IV

Procedural Sedation and Analgesia in Children

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Christa Rodenas                                                            Date: 2/24/2016

Article Title: Procedural Sedation and Analgesia in Children
Author(s): Krauss and Green 
Journal: Lancet
Date: 2006
Major Topic: Sedation
Type of Article: Systematic Review
Main Purpose: To discuss the decision-making process used to determine appropriate drug selection, dosing, and sedation endpoint.
Key Points/Summary:
·      There is no objective way to describe sedation depth and titration to a precise endpoint can be difficult.
·      The Joint Commission on Accreditation of Healthcare Organization (JCAHO) require that practitioners can manage a compromised airway, that those who administer deep sedation can rescue patients from inadvertent general anesthesia and that those administering moderate sedation can rescue patients from inadvertent deep sedation.
·      The practice of procedural sedation and analgesia has three components done in sequence: presedation assessment, sedation for the procedure, and post-procedure recovery and discharge
·      Continuous observation of patients by a health-care provider capable of recognizing adverse sedation events is essential-this person must be able to continuously observe the patient’s face, mouth, and chest-wall motion.
·      Continuous oxygenation (pulse ox), ventilation (capnography), and hemodynamic (blood pressure and ECG) can all be monitored non-invasively in spontaneously breathing patients.
·      The five classes of procedural sedation and analgesia drugs are sedative-hypnotics, analgesics, dissociative sedative, inhalation agent, and antagonists.

Level of Evidence: Level 1

Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 15 year follow-up survey

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: John Kiang                                                                                            Date: 2/24/16
Article Title: Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 15 year follow-up survey  
Author(s): Dr. Houpt 
Journal: Pediatric Dentistry
Date: 2002
Major Topic: Sedation
Type of Article:  Survey Research
Main Purpose: Survey members of the American Academy of Pediatric dentistry was conducted to provide info regarding the use of sedative agents by pediatric dentists

·      All 3,315 active members of the Academy were sent questionnaires regarding the frequent of their use of sedation and 1,778 responded (half of these were trained in a hosp/university setting).

·      Practitioners were questioned regarding their use of sedative agents and the nature of their patients receiving sedation. In addition, they were questioned in regard to their use of restraints and reasons for change in their Use of sedation during the past two years.

·      In regard to the use of nitrous oxide alone, 47% of practitioners responded that they use nitrous oxide less than 11% of the time.

·      In regard to other types of sedative agents, most practitioners use little, if any, sedation.

·      Eighty-two percent use sedation for less than 11% of their patients.

·      Of the 1,778 respondents, 1,224 used drugs other than nitrous oxide.

·      In a typical three-month period, they performed 77,112 sedations. Of that number, 61,662 (80%) were administered by only 478 practitioners who use sedation on the average of once or greater each day.

·      In comparison with previous surveys in 1985, 1991 and 1995, these results demonstrate an overall increased use of sedation by pediatric dentists.

·      However, the increased use is due primarily to an increase in me numbers of practitioners who are heavier users of sedation (once or greater each day).

Pain Reaction Control: Sedation

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: John Diune                                                                        Date: 2/24/16

Article Title: Pain Reaction Control: Sedation
Author(s): Stephen Wilson, Steven I. Ganzberg
Journal: Pediatric Dentistry, Infancy Through Adolescence, 5th Edition
Date: 2013
Major Topic: Behavior management
Type of Article: Text book chapter
Main Purpose: Present sedation concepts, techniques, and medications
Key Points/Summary:
Minimal sedation:
·         Drug induced state where patients respond normally to verbal commands
·         Cognitive function and coordination may be impaired
·         Ventilator and cardiovascular functions unaffected
Moderate sedation:
·         Drug induced depression of consciousness where patient responds purposefully to verbal commands or accompanied by light tactile stimulation
·         Loss of consciousness should be unlikely (being an important aspect of definition of moderate sedation)
·         Drugs and techniques used should allow a margin of safety wide enough to prevent loss of consciousness
·         Minimal requirements for monitoring:
o   Pulse oximeter for monitory oxygenation and pulse rate
o   BP Cuff for circulation
o   Precordial stethoscope or capnograph to monitor ventilation (chest movement and continuous verbal communication acceptable for moderate sedation)
Deep sedation:
·         Controlled state of depression where patient is not aroused easily.
·         May be accompanied by partial or complete loss of protective reflexes
·         Minimal requirements for monitoring:
o   Pulse oximeter
o   BP cuff
o   Capnograph or precordial stethoscope
o   Electrocardiograph
General anesthesia
·         Controlled state of unconsciousness
·         Loss of protective reflexes including inability to maintain an airway independently
·         No response to purposeful physical stimulation or verbal command
Minimal & Moderate VS Deep sedation
·         Must be comprehended thoroughly by those who practice sedating pediatric dental patients
·         Cannot render patient unconscious or unresponsive to verbal prompting or at most minimally painful stimuli
·         Meaning patient is able to maintain patent airway at all times
·         Life threatening situations can occur if respiratory or cardiovascular complications occur during deeper levels of sedation
·         Provider should be sufficiently trained to “rescue” child entering deeper levels of sedation
Preprocedural prescriptions should not be given to younger children (preschool age) – parents saying they can get an RX from pediatrician and have patient take it before coming to appointment
Routes of administration:
·         Inhalational
o   Nitrous oxide
§  Advantages:
·         Very low blood:gas solubility – rapid onset, also rapid decrease in blood levels when discontinued
·         Ease of titration and ability to use rapid “induction” technique
§  Disadvantages:
·         Weak agent
·         Cannot use if patient does not cooperate or cannot breathe through nose
·         Inconvenience due to hardware
·         Contraindications: otitis media and mental health concerns secondary to psychogenic effects of Nitrous oxide
·         Possible chronic toxicity
·         Enteral (oral or rectal)
o   Oral
§  Many states require special sedation permit for oral sedation children <12yo
§  Advantages
·         Convenience, easy to administer
·         No need for special equipment (other than for monitoring)
·         Single medication regimen very safe if carefully calculated
§  Disadvantages:
·         Variability of effect in patients even with same weight
·         Unable to titrate
·         Long onset time relative to other routes
·         Parenteral (intramuscular, subcutaneous, submucosal, intranasal, intravenous)
o   Intramuscular
§  Advantages:
·         Absorption much faster than oral route
·         More predictable than oral route for delivery of all medication, ease of delivery
§  Disadvantages:
·         Onset dependent on absorption and condition of peripheral vascular system
·         Variability of effect
·         Trauma such as hematoma at injection site
·         Potential for more rapid side effects or toxicity than inhalation or oral
·         Special permits for parenteral administration; also higher insurance premiums for providers
o   Subcutaneous
§  Advantages:
·         Intraoral submucosal space injection
§  Disadvantages:
·         Slower absorption than IM, except in oral cavity where vasculature is abundant
·         Higher costs (permits and insurance)
o   Intravenous
§  Advantages:
·         Allows exact titration, absorption is optimal; incremental dosing possible and not dependent on weight-based single bolus dose (as for oral, IM, Subq)
·         Test dose for allergies possible
·         Have IV access for emergencies
§  Disadvantages:
·         Technically intensive
·         Potentially higher risk of complications
·         Higher levels of patient monitoring needed
·         Higher costs
Pharmacologic agents for sedation
·         Sedative-Hypnotics
o   Primary effect is sedation or sleepiness
o   May result in lower pain threshold and remove inhibition resulting in patient more responsive to painful stimuli
o   Acts on reticular activating system (maintaining consciousness)

o   3 categories:
§  Barbiturates – pentobarbital, secobarbital, methohexital
§  Benzodiazepines
§  Non-barbiturates – chloral hydrate, paraldehyde
·         Anti-anxiety Agents
o   Primary site is limbic system (seat of emotions)
o   Higher doses affect reticular system and cortex producing sedation and sleep
o   Flatter dose-response curve than sedative-hypnotics allowing for safer therapeutic index
o   Dose not produce analgesia
o   Reversible (Flumazenil) – may need to be given parenterally in multiple steps
·         Opioids
o   Primary site is opioid receptors
o   Goal of narcotic use is not to achieve sedation, as respiratory depression and apnea will occur at such doses
o   Can raise pain threshold, used as an adjunct to drug
o   Can cause supraadditive respiratory depression in combination with sedative-hypnotics or anti-anxiety durgs
o   Narcotics have steep dose-response curves – careful use to reduce chances of respiratory depression and loss of consciousness
o   Reversible (Naloxone)
·         Ketamine
o   Dissociative agent
o   Produces cataleptic state with profound analgesia and varying amnesia
o   Acts on thalamus and cortex
o   Stimulatory cardiovascular changes (tachycardia, increased BP)
o   Nystagmus and increased salivation
o   May cause delirium and hallucinations
o   Only for use by providers qualified for general anesthesia
Assessment of Article:  Level of Evidence/Comments: