Seda%on Part Deux. Sarah Ahn DDS SBH Pediatric Den1stry

Transcription

1 Seda%on Part Deux Sarah Ahn DDS SBH Pediatric Den1stry

2 Sedation Controlled, pharmacologically induced, minimally depressed level of consciousness that retains the patient s ability to maintain a patent airway independently and continuously and respond appropriately to physical and/or verbal commands Objectives: Control behavior/movement to allow treatment Control anxiety, fear Amnesia

3 Sedation Oral, intravenous, nasal routes Examples of drugs used: Midazolam, Chloral Hydrate, Demerol Documentation: Informed consent Pre- and Post-op instructions Pre-op health evaluation Claims of allergy to sedation meds literature does not support Time-based records Name(s)/dosages/administration routes of drugs (including LA) HR, RR, O 2 saturation, level of consciousness/responsiveness, BP

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5 To Sedate or Not Sedate? TO SEDATE Healthy ASA 1, some 2 mild asthma with no meds, no hospitalizations for a while (within 6wks) Developmentally normal Age: > 20 mths Liver not developed until 15mths Hypovolemia risk lower >10kg Non-premature Dec surfactant Delayed airway development ASA > 2 CNS/Head trauma CV issues Obstructive pulmonary/respiratory disease/issues Asthma Upper respiratory infection (URI) Dec in airway diameter 2-6 wks to resolve, don t sedate min 2-3 wks following URI (6 wks suggested) Syndromes with airway issues Other Rx cold meds High BMI (obese) >85 th percentile Diabetes (type 1) Cerebral Palsy NOT TO SEDATE Mental/emotional issues (possible) ADHD (take meds prior to with sips (<25ml) of clear fluid), Autism

6 To Drug Before Sedation Tx? Procedural sedation must not be administered without direct supervision by trained medical personnel Liability issues Meds (e.g., Benadryl) the night before sedation? Not effective in helping with sedation if young child

7 THE DRUGS

8 Local Anesthetics! Cross blood-brain barrier When combined with sedation, LA dosages must be adjusted and decreased to prevent overdose Calculate the mg/carpules that you can use prior to tx Limits how much tx you can provide Exception: 4% Septocaine with epi Lidocaine metabolites may produce sedation So instead of 4.4mg/kg, use 4mg/kg Mepivacaine is very potent so avoid in kids RULE OF THUMB FOR MAX DOSAGE: 4mg/kg

9 Local Anesthetics! When giving LA injections in your patient s mouth, avoid injecting posterior to the 2M due to the risk of hitting the venous plexus Best to inject between the 1M and 2M Topical anesthesia: compounded topicals (2 types of anes) Associated with deaths EMLA: emulsion of lidocaine 2.5% and prilocaine 2.5% (1:1 ratio) OraVerse Useless if overdose In fact since it causes vasodilation, it will lead to an increase in systemic LA à lead to increased toxicity

10 How does excess LA lead to toxicity? Opioid/antihistamine produces respiratory depression Hypoxemia (dec O2) Hypercarbia (inc CO2) Acidosis (dec ph) Dec protein binding of LA More LA avail to CNS Toxicity

11 Nitrous Oxide (N 2 O) Deepens sedation slightly without adversely affecting resp Aids in settling patient Increase N 2 O (70%) during more unsettling periods (e.g., LA, RDI) Wait 5-10mins for desired effect Dec to 40-50% after settling Potentiation of other sedation meds? Caution with Mep as both are nauseating Supplemental O 2

12 SEDATIVE-HYPNOTICS Three classes: Anti-anxiety benzodiazepines - Diazepam, Midazolam Non-barbiturates - Chloral Hydrate Barbiturates - Pentobarbital

13 Choral Hydrate (CH) Non-barbiturate sedative-hypnotic CNS depression with min CV/resp depression Gastric irritation May result in hypotonic tongue airway! Onset: 30-60mins, peak 60mins, duration 5 hrs Working time: up to 60mins Dose: 25-50mg/kg orally; 1gm max Lower dosage if in combo with other Rx Converted to alcohol via liver No reversal agent No longer mass produced in liquid form in the US (Pharmaceutical Associates Inc) as of April 2012 Avail as capsules; must be compounded into liquid form by pharmacists

14 Meperidine (Demerol) Narcotic Sedation, analgesia CNS, CV, Respiratory depression; hypotension Histamine release à avoid submucosal, IM, IV Use Fentanyl Oral or parental (even submucosal) Dosage: 1-2mg/kg; max 50mg Onset: 30mins, peak 1-2 hrs; duration 2-4 hrs Working time: 60mins Reversal agent: Naloxone 0.01 mg/kg (slow reversal) 0.1mg/kg (fast reversal; for severe resp depression; rec by PALS) IV, sublingual Excess can cause pulmonary edema

15 Hydroxyzine (Vistaril, Atarax) Antihistamine CNS depression anxiolytic Analgesia 1-2 mg/kg orally; max 50mg Onset 15-30mins, 2-4 hrs duration Working time: 30-45mins Used with CH or Mep

16 Diazepam (Valium) Benzodiazepine Anxiolytic, sedative hypnotic, anticonvulsant, mild anterograde amnesia Min CV, resp depression Better with older pts; rare with young kids Dosages: 1mg/yr of age or mg/kg 2-5mg (2-5yo), 5-10mg (6-10yo), 10-15mg (11-20yo) Onset 45-60mins, peak 60mins Working time: 30-90mins Reversal: Flumazenil (0.1mg/kg) Submucosal, IM, intranasal, IV (fastest) 2-3mins Excess can cause seizures

17 Midazolam (Versed) Benzodiazepine More reliable/profound amnesia than Diazepam 3-4x more potent than Diazepam Dosages: Oral: 0.25mg to 1.0mg/kg (avg: 0.5mg/kg); max 15mg (20mg if older child) Submucosal: mg/kg Intra-nasal (with atomizer; faster onset): mg/kg Onset: 5mins (usually 15mins) Working time: 20-30mins

18 Midazolam (Versed) Combined use with N2O Sometimes N2O may not help in settling pt à don t wait and just start working Respiratory depression usually seen if >0.75mg/kg dosages, IV route or rapid administration (submucosal) Reversal: Flumazenil (0.1mg/kg) Submucosal, IM, intranasal, IV (fastest) 2-3mins Excess can cause seizures Watch for re-sedation

19 Ketamine Can give orally General anes rx à GA credentials Hypersalivation

20 Primary Factors in! Selecting Rx and Dosages! Dental Needs Temperament Rx (all supplemented with N2O) ultra short easy N2O only; Mid only (exo incisors) difficult Mid (1mg/kg) + N2O (>50%) short easy Mid (0.5mg/kg) + Mep (1mg/kg) (1 quad) difficult CH (20-25mg/kg) + Mep (2mg/kg) + Hyd (2mg/kg) long easy CH (10-25mg/kg) + Mep (2mg/kg) + Hyd (2mg/kg) (>2 quads) difficult CH (30-35mg/kg) + Mep (2mg/kg) + Hyd (2mg/kg) General Anesthesia

21 One Lump or Two (or Three)? Single Rx: Minimize adverse effects Decrease likelihood of drug dosing error(s) Combos of Rx: Potentiate/summate drug effects Complement or expand rx classes or effects (e.g., analgesic with sedative) Increase working time

22 Most Frequently Used Drugs and Combos Midazolam Diazepam Triple combo (CH+Hyd+Mep) CH+Hyd Triple combo (Mid+Hyd+Mep)

23 Which Combo Would You Like? Mild Sedation Combo: Midazolam + Hydroxyzine Indicated for mild-mid fearful child who is potentially cooperative 0.5mg/kg Mid + 1-2mg/kg Hyd Onset: 10-20mins Working time: 30-45mins Less crying than mid alone Possible inc working time Can t reverse Hyd

24 Moderate to Deep Combos: CH combos -- Triple cocktails High CH (50mg/kg) + Mep (1mg/kg) + Hyd (1-2mg/kg) Low CH (10-25mg/kg) + Mep (2mg/kg) + Hyd (2mg/kg) Higher CH deeper sedation Higher Mep more analgesia Ideally want to use capnograph Working time longer than 40mins Settling with N2O highly recommended Airway! Laryngospasm risk Only Mep is reversible CH combos -- Doubles: CH (20-40mg/kg) + Hyd (1-2mg/kg) Onset: 20mins, working time: 1-1.5hrs

25 Moderate to Deep Combos: Midazolam Combos: Mid (0.5-1mg/kg) + Hyd (25mg/kg) + Mep (1mg/kg) Two reversible agents used Shorter duration of onset (than CH) 25-30mins Quicker recovery Possible increase in amnesia? Wilson finds it not as effective at CH combos There is literature to support Note: Diazepam (0.2mg/kg) + Hyd + Mep à no literature yet

26 Other Combos: Mep (1-2mg/kg) + Hyd (1-2mg/kg) Onset: 20-30mins Working time: 60mins? Use with N2O Mep (1-1.5mg/kg) + Mid ( mg/kg) Onset: 20-30mins Working time: 60mins? Use with N2O Good for 7yr old child

27 What If I Can Only Use 2 Drugs? If limited to two drugs, 3-6 yr old child Midaz + Mep Mep + Hyd (Benadryl)

28 IV Sedation Rx: Midazolam is the idea drug Meperidine not ideal but will provide analgesia Fentanyl is common

29 IV Sedation Advantages: Predictable and precise 100% bioavailable Titratable Rapid onset Emergency Rx access Reversible Disadvantages: Requires highest level of monitoring Supplies cost Significant training required Starting IV Montefiore, UCLA, USC Different state permit may be involved

30 Sedation Emergencies Appendix C. Drugs* That May Be Needed to Rescue a Sedated Pa%ent Albuterol for inhala1on Ammonia spirits Atropine Diphenhydramine Diazepam Epinephrine (1:1000, 1:10 000) Flumazenil Glucose (25% or 50%) Lidocaine (cardiac lidocaine, local infiltra1on) Lorazepam Methylprednisolone Naloxone Oxygen Fosphenytoin Racemic epinephrine Rocuronium Sodium bicarbonate Succinylcholine Airway Management Equipment Face masks (infant, child, small adult, medium adult, large adult) Breathing bag and valve set Oropharyngeal airways (infant, child, small adult, medium adult, large adult) Nasopharyngeal airways (small, medium, large) Laryngeal mask airways (1, 1.5, 2, 2.5, 3, 4, and 5) Laryngoscope handles (with extra ba\eries) Laryngoscope blades (with extra light bulbs) Straight (Miller) No. 1, 2, and 3 Curved (Macintosh) No. 2 and 3 Endotracheal tubes (2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, and 6.0 uncuffed and 6.0, 7.0, and 8.0 cuffed) Style\es (appropriate sizes for endotracheal tubes) Surgical lubricant Suc1on catheters (appropriate sizes for endotracheal tubes) Yankauer- type suc1on Nasogastric tubes Nebulizer with medica1on kits Gloves (sterile and nonsterile, latex free) Appendix D. Emergency Equipment That May Be Needed to Rescue a Sedated Pa%ent Intravenous Equipment Assorted IV catheters (eg, 24-, 22-, 20-, 18-, 16- gauge) Tourniquets Alcohol wipes Adhesive tape Assorted syringes (eg, 1-, 3-, 5-, 10- ml) IV tubing Pediatric drip (60 drops/ml) Pediatric bure\e Adult drip (10 drops/ml) Extension tubing 3- way stopcocks IV fluid Lactated Ringer solu1on Normal saline solu1on D normal saline solu1on Pediatric IV boards Assorted IV needles (eg, 25-, 22-, 20-, and 18- gauge) Intraosseous bone marrow needle Sterile gauze pads Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

31 Emergencies

32 So The Future Due to demands of parents and child-rearing practices, sedation will become more common or in demand IV sedation will become more popular Dental anesthesia will have an increasingly important role Be aware of the state s regulations with sedations Personnel Monitoring Follow AAPD guidelines Monitoring personnel Crash cart requirements

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