Walk through how you would manage a potential airway obstruction
Sedation
- Reposition the airway
- Jaw thrust
- Insert oral airway
- Call for help
- Nasal trumpet
- Insert supraglottic device such as LMA
- Tracheal intubation
- Surgical airway
Walk through how you would manage a laryngospasm
Sedation
- Positive pressure ventilation
- Deepen sedation (eg propofol)
- Call for help
- Give muscle relaxant (Succinylcholine+atropine unless contraindicated-chronic renal failure, malignant hyperthermia, muscular dystrophy)
- Tracheal intubation
- Surgical airway
Walk through how you would manage apnea
Sedation
- Bag/mask ventilation
- Reposition airway
- Jaw thrust
- Insert oral airway
- Call for help
- Insert nasal trumpet
- Insert supraglottic device such as LMA
- Tracheal intubation
- Surgical airway
What are the goals of sedation for restorative treatment?
Sedation
- To protect the patient’s safety and welfare
- Modify behavior to allow safe completion of procedure
- To minimize physical discomfort and pain
- To control anxiety and minimize psychological trauma, maximize potential for amnesia
- Return pt to a state that is safe for discharge free of medical/dental supervision
What are indications for sedation?
Sedation
- Fearful/anxious patients for whom basic behavior management techniques were not successful
- Patients who cannot cooperate due to lack of psycological/emotion mature and/or mental, physical or medical conditions
- Patients where sedation may protect developing psyche and/or reduce medical risk
What are contraindications to sedation?
Sedation
- Cooperative patient with minimal dental needs
- Predisposing medical history or physical conditions where sedation is inadvisable
Who are poor candidates for sedation?
Sedation?
- High BMI >85th percentile
- High mallampati and brodsky scores
- Abnormal airway (cleft palate, premature birth with intubation)
- Short neck (eg down syndrome)
- Midface deficiency, obstruction
- Medical history contraindications - OSA, arnold chiari malformation (at greater risk for respiratory depression), ASA III and above
What documentation is necessary prior to proceeding with a sedation appointment?
Sedation
- Informed consent for treatment
- Informed consent for use of protective immobilization
- Review of Pre- and Post-operative instructions , including anticipated changes in behavior after sedation
- Medical/health evaluation
What documentation is necessary prior to proceeding with a sedation appointment?
Sedation
- Informed consent for treatment
- Informed consent for use of protective immobilization
- Review of Pre- and Post-operative instructions , including anticipated changes in behavior after sedation
- Medical/health evaluation
What are the NPO guidelines for sedation/GA?
Sedation
Clear fluids/liquids 2hrs
Breast milk 4 hours
Infant formula, non human milk 6 hours
Light meal (ie toast and clear liquids) 6 hours
Heavy meal 8 hours
Describe the ideal positioning of a child in a papoose during sedation.
Sedation
- Need to make sure the airway is patent, avoid airway obstruction or chest restriction
- One hand or foot must be exposed
- Child should never be left unattended
What needs to be included in the patient’s health evalution prior to sedation?
Sedation
- Age of patient including gestational age at birth
- Weight
- Medical history - Review of symptoms including hx of OSA, ASA classification
- Medications that the patient is taking - dose, route of administration
- Food/drug allergies
- Previous history of surgeries, sedation and/or GA including any complications
- Vitals: HR, BP, O2 at room air, RR, temperature
- Any family history of muscular dystrophy, malignant hyperthermia
The AAPD recommends the SOAPME acronym in preparation for sedation procedures. Elaborate on this.
Sedation
S - Suction
O - Oxygen
A - Airway (bag valve mask, nasopharyngeal/oropharyngeal airways, LMA, laryngoscope blades)
P - Pharmacy (all BLS drugs as well as antagonists)
M - Monitoring (pulse ox, end-tidal CO2 monitor, blood pressure, stethoscope)
E - Equipment, like defibrillator
The patient presents for their sedation appointment. Consent forms have been completed. Describe your next steps that you need to assess prior to completing the procedure under sedation.
Sedation
- Verify that 2 adults are present with private transportation. Need name and relationship to patient
- Review medical history
- Review medical consult
- Ask if there has been any recent respiratory illness
- Verify NPO status
- Assess airway - Mallampati, Brodsky, auscultate lung sounds
- Take baseline vital signs (HR, BP, O2, RR, temperature)
- Record patient’s weight
- Record patient’s pre-sedation cooperation level
What monitoring is required during and after deep sedation?
Sedation
- Independent observer trained in PALS, must be anesthesiologist, nurse anesthetist or second OMFS
- Baseline vitals
- Vitals recorded every 5 mins (HR, BP, RR, O2), ECG and capnography required
- Behavior during sedation
- Dental procedure start time and end time
After:
* Time in recovery room
* Vital recorded every every 5 mins for deep then every 10 once child starts to wake
* Child has met discharge criteria
* Discharge time
What monitoring is required during and after moderate sedation?
Sedation
- Observer is present to monitor patient but can also assist in interruptable tasks, should be trained in PALS
- Baseline vitals
- Vitals recorded every 10 mins (HR, BP, RR, O2, capnography/expired CO2 and ECG recommended); Precordial stethoscope is strongly recommended
- Behavior during sedation
- Dental procedure start time and end time
After:
* Time in recovery room
* Vital recorded every 10 mins for moderate sedation
* Child has met discharge criteria
* Discharge time
What monitoring is required during and after deep sedation?
Sedation
- At least 2 indivudals must be present with the patient throughout the procedure; 1 of them must be an independent observer who, at minimum, must be trained in PALS, can get IV access, draw up + administer rescue medications and have advanced airway skills. This person MUST be either a physician or dental anesthesiologist, certified nurse anesthetist or second oral surgeron
What are the discharge criteria for a patient after sedation?
Sedation
- Cardiovascular function and airway patency is stable
- Protective airway reflexes are intact
- Patient is easily arousable
- Patient can talk
- Patient can sit up unaided
- Pre-sedation responsiveness is achieved
- State of hydration is adequate
Another simplified tooth is that the patient can stay awake for at least 20 minutes in a quiet room
How would you describe the difference between minimal, moderate, deep sedation and general anesthesia?
Sedation?
Minimal: Patient able to respond normally to verbal commands
Moderate: Patient able to respond purposefully to verbal commands or after light tactile stimulation
Deep: Drug-induced depression of consciousness to a state where patient is not easily arousable but can respond after repeated verbal or painful stimulation
General anesthesia: Patient does not respond to painful stimulation
What are indications for use of nitrous oxide?
Behavior Management
- Fearful, anxious child
- Gag reflex
- Local anesthesia not sufficient, raise pain threshold
- Mild to moderate asthma
- Cooperative patient but procedure is anticipated to be a little longer
What are contraindications for use of nitrous oxide?
Behavior Management
- Severe asthma
- COPD
- URI
- Cancer - Tx with bleomycin sulfate
- Untreated Vitamin B12 deficiency (vegans; B12 needed myelin and DNA synthesis but N2O has been linked to irreversible inactivation of B12)
- MTHFR deficiency
- Emotional disturbance
- 1st trimester of pregnancy
- Recent/Recurrent middle ear disturbance
- Glaucoma, recent (within 3 months) eye surgery
- Recent (within 14 days) ENT surgery
