Tuesday, February 21, 2017

Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 25 year follow-up survey

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Michael Hatton                                                                  Date: 2/21/17
Article Title: Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 25 year follow-up survey  
Author(s): Wilson S, Houpt M 
Journal: Pediatric Dentistry
Date: 2016
Major Topic: Sedation
Type of Article:  Survey Research
Main Purpose: Survey of the members of the American Academy of Pediatric Dentistry on their usage of sedative agents.
Summary:

The Survey:
A 31 question survey, similar surveys sent in 1985, 1991, 1995, and 2000, was emailed to members of the AAPD, with a resonse rate of 44% - a total of 1,642 responses. Of the respondants, the majority was board certified, 58%. The questions covered  geographic location of the practitioner, types of training program attended and lengths of time in practice, use of nitrous oxide and other sedative agents, ages of patients seen and special needs status, reasons for changes in the use of sedation over the past five years, use of restraints during sedation, methods for monitoring patients during treatment, typical doses and effects of drugs used, and the prevalence of any undesirable side effects.

Key Findings:
Nitrous oxide was used for over 50 percent of patients. Protective stabilization during sedation was used by 72 percent of respondents, a decline from previous surveys. The vast majority of providers preferred oral sedation to non-oral administration methods – 93%. Benzodiazepines and nitrous oxide were the most frequently used sedatives.

Changes from Previous Surveys:
Fewer percentages of respondents were from university-based programs, and more respondents were from combined hospital/university programs; and the respondants from the university programs were less likely to perform sedations. Practitioners in the West and Southeast are most likely to perform sedations; a slow decrease trend over time is noted in the Midwest, and the Northeast remains quite stable, with fewer sedations. Practitioners who practiced five years or less, or who practiced for 20 years or more, were performing larger percentages of sedation.

A trend for higher percentages of patients in practices receiving nitrous oxide continued from the 2000 survey. The percentage of respondents indicating that they did not use other sedative agents, with or without nitrous oxide, continued to increase compared to previous surveys; concurrently, those sedating larger percentages of patients with sedatives and nitrous oxide also continued to increase.
                                                                             
Benzodiazepines remain most popular but are closely followed with combinations involving chloral hydrate and Demerol. While the respondents’ selection of dosages of drugs was predominantly consistent with published values, there were several individuals who selected doses or dosages that were disconcerting (e.g., eight individuals indicated their dosage range of hydroxyzine was between 21 to 30 mg/kg). It is likely that these responses were miss-clicks entered when responding to the survey question or misunderstanding of the question.
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Balancing efficacy and safety in the use of oral sedation in dental outpatients

       
Resident’s Name: Brian Darling Mentor: Dr. Mindy                                               Date: 2/22/17
Article Title: Balancing efficacy and safety in the use of oral sedation in dental outpatients
Author(s): Dione RA, et al.
Journal: Journal of the American Dental Association
Date: 2006
Major Topic: Oral sedation
Type of Article: Paper from enteral sedation in dentistry workshop
Main Purpose: This paper aimed to describe the conclusions drawn from a workshop on enteral sedation in dentistry.
Key Points: (2 lines Max):
Most serious adverse events are related to avoidable respiratory complications.
·      Dental anxiety has remained relatively stable for the past 50 years despite advancements in anesthesia, materials, and techniques.
·      Dental fear and anxiety usually begins during childhood, persists throughout adulthood, and leads to individuals avoiding dental care and having diminished oral health.
o   Recent studies in USA have ranges of 10-19% of individuals having high levels of dental fear/anxiety
·      People would visit the dentist more if they were given a drug to lower anxiety
·      Always remember the possible interactions and additive effects local anesthetics will have with sedative agents
o   Increased risk of respiratory depression when combining opioids with local anesthetics
·      Drug interactions and overdoses are the main reasons for adverse event
·      Respiratory complications are the most common reason for serious adverse events
·      Triazolam
o   Not tested on individuals less than 18 years old
o   Benzodiazepine
o   Recommend: 0.25mg oral initial dose 1 hour before appointment
§  In office sublingual dose can be administered if needed
§  Re-assess at 30-45 minutes and can administer another sublingual dose dependent on sedation level
§  Use 20-30% of nitrous for local anesthetic administration and then remove afterwards
§  Make eye contact with patient and assess their level of sedation (1 being relaxed and 10 being excited) and assess speed in answering and quality of sedation
§  Can administer another 0.5mg if no clinical effect and 0.25mg if slight sedation
o   Someone must drive patient
·      Oral is safest route of administering sedatives
o   Protective effects from vomiting mechanism, first pass elimination, muted anaphylactic response
o   Reduced distributional influences
o   Adverse effects can be recognized and addressed sooner
·      Recommend a specific airway management course to supplant or replace ACLS course
·      Recommended developing a more objective discharge criteria for children to avoid adverse events associated with resedation at home
o   Require children to be able to continuously maintain a patent airway and remain spontaneously awake without stimulation

Guidelines on Discharge Criteria:
·      There are many scaled to evaluate recovery
·      Simple evaluation tool may be the ability of the child to remain awake for at least 20 minutes in a quiet environment


Remarks:
1- I wonder what the implications for triazolam use may be in anxious teenagers. I would think it could probably be used cautiously with them even though the package insert says the safety and use on individuals younger than 18 has not been established.  
2- I also curious how triazolam and diazepam compare.
Triazaolam is more like midazolam than diazepam, it is more hypnotic and breaks down in the same way as midazolam. Triazolam has less active metabolites than diazepam has, hence there are less post sedation effects.

As you have seen successful sedation has a lot to do with knowing the patient (prescreening) and selecting the appropriate drug for the patient. Personally I prefer a lighter sedation and titration with N2O which is easily controlled than adding a second dose of drug to achieve the same sedative effect.
Assessment of Article:  Level of Evidence/Comments: III


Monday, February 20, 2017

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

Department of Pediatric Dentistry - LMC
Resident’s Name: Albert Yamoah, DDS                        Mentor: Dr. Sapir                                                 Date: 02/22/2017
Article Title: Adverse events and outcomes of conscious sedation for pediatric patients: Study of an oral sedation regimen.
Author(s): Pattarawadee Leelataweedwud DDS, MS, Bill Smith DMD
Journal: JADA
Date: November 2001
Major Topic: Adverse events and outcomes in pediatric sedation
Type of Article: Cohort study
Main Purpose: To study adverse events and outcomes for oral sedation regimen of chloral hydrate, meperidine, and hydroxyzine with 100 percent oxygen or O2 supplementation
Key Points:
Under the conditions of this study adverse events occurred in only 3% of the cases when a strict protocol was adhered to; regimen yielded 72% success rate; compliance with taking oral meds and waiting were important factors predicting success
Background:
·       Oral conscious sedation OCS is widely used in pediatric dentistry
·       Dentists are aware that OCS carries risks from potential side effects of medications
o   Nausea
o   Vomiting
o   Respiratory compromise
·       Rationale for Chloral/Meperidine/ Hydroxyzine/O2
o   Potential anxiolytic, analgesic, antiemetic effects
o   Chloral hydrate: anxiolytic, sedative and hypnotic properties; wide margin of safety, well studied, 30-60 minute peak
o   Meperidine: sedation and analgesia; respiratory depression can be potentiated from the anxiolytic effect of chloral hydrate; rapid onset 10-15 minutes and 1-2 hours to reach its peak
o   Hydroxyzine pamoate: antihistamine and psychotopic agent that possesses antiemetic, anxiolytic, sedative and hypnotic properties, onset with in 15-30 minutes, it can potentiate the central nervous system depression effect when combined with other central nervous system depressants
o   Supplemental 100 percent O2 via nasal canula: used to elevate the partial pressure of arterial oxygen PaO2 as an added safety measure
Regimen:
·       Chloral hydrate (50 mg/kg)
·       Meperidine (1.5 mg/kg)
·       Hydroxyzine pamoate (25mg)
·       Supplemental 100 percent O2 via nasal canula
Methods:
·       5-year retrospective study examined 195 records of OCS performed in 111 healthy children aged 24-48 months (mean, 47 months) 
·       Study analyzed age, sex, weight, methods of drug delivery, waiting time after drug administration, treatment rendered, treatment time, adverse events, sedation outcomes and the number of visits needed to complete treatment
Results:
·       Adverse events occurred in 3 percent of all sedations and were minor  
o   Included vomiting, desaturation, prolonged sedation and an apneic event
·       72% of sedations had satisfactory behavioral outcomes
·       23% had unsatisfactory outcomes
·       5% of the cases were aborted because of disruptive behavior
·       Sex was not a significant factor for the success
·       Patient who drank medications and waited longer after medication intake had better sedation outcomes
Conclusions:
·       Minimal minor adverse events occurred with this sedation regimen 
·       Compliance with taking oral medications and waiting time appeared to be important factors in predicting sedation success
Remarks:
1.     No nitrous oxide was used in this study, eliminating any means of titration/ easy way of treating deeper levels of sedation than intended.
2.     The study was retrospective, no selection criteria (behavior, Brodsky, BMI etc.).
3.     The guidelines have changed since the study was conducted (NPO, Monitoring, "Drowsy and sleepy" condition may be considered at the present time as "Deep sedation"!).
4.     All children were secured with immobilizing board- not advised!
5.     All patients who experienced adverse events had "satisfactory outcome"- in some papers this is considered failure due to too deep sedation.
6.     As for your remark, I would ask differently according to our criteria (Houpt's), is difficult treatment considered unsuccessful? No (as long treatment accomplished).
Assessment of Article:  Level IV: Evidence from cohort study
Why aren’t the aborted cases considered unsuccessful?