Tonsillar Grading
Brodsky 3+ = tonsils take up >50% of pharyngeal space => no sedation
Goals of sedation
- Ensure pts safety and welfare
- Minimize discomfort and pain
- Control anxiety and minimize psych trauma
- Maximize amnesia
- Control movement to complete procedure safely
- Return pt to pre-sedation level for safe discharge
- Obtain informed consent and document according to local, state and institutional regulations
Management of apnea
- Bag/mask ventilation
- Reposition airway
- Jaw thrust
- oral airway
- call for help and insert nasal trumpet
- insert LMA
- tracheal intubation
- surgical airway
Management of Laryngospasm
- Pos pressure ventilation
- Deepen sedation, give propofol
- Call for help, give muscle relaxant (succ)
- Tracheal intubation
- Surgical airway
Management of Airway Obstruction
- Reposition airway
- Jaw thrust
- Oral airway
- call for help and insert nasal trumpet
- insert LMA
- Tracheal intubation
- surgical airway
Discharge Criteria
- Pre-sedation level of consciousness attained for special needs and young children
- RR and rhythm, HR and ox sat WNL
- CV function and airway patency satisfactory and stable
- Pt easily arousable, can talk, protective reflexes intact
- Pt can sit up on their own (Age appropriate)
- Hydration adequate, can drink
- No nausea, vomiting, dizziness
The longer the half-life of meds the longer the post-op monitoring. Watch for re-sedation
What to ask prior to administering sed meds
- allergies
- current prescription or OTC meds
- medical illnesses
- previous hospitalizations or surgeries
- Review of systems
- weight
- Hx of sedation of GA and any complications, fam hx of malig hyperthermia
- airway eval, brodsky 1-2+ only, OSA, snoring
- ASA
- NPO status
6-36 months: (2hrs clear liquids, 4 hrs breastmilk, 6 hrs light meal, formula, non-human milk)
>36 months: no solids or milk 8 hrs - 2 adults with child?
- Name and address of parents and PCP
Common complications w/ sedation
- Hypoventilation/apnea
- Airway obstruction
- allergic rxns
- laryngospasm
- aspiration
- Cardiopulmonary involvement
Everyone should have BLS and trained in airway rescue techniques and primary provider PALS
Must have portable O2 source and bag valve mask apparatus
Treatment of LA Toxicity
- Call for help
- Ventilate 100% O2
- Resuscitate if needed: airway/ventilation support or chest compressions if no pulse
- Seizure management: IV Midazolam 0.1-0.2mg/kg
- 1.5mL/kg 20% lipid emulsion bolus over 1min to trap unbound LA –> infusion 0.25mL/kg/min until circulation restored for 10 min
Equipment and personnel for moderate sed
Personnel: observer monitors pt and helps tasks (PALS)
Responsible practitioner: can rescue from apnea, laryngo, airway obstr, open airway, suction secretions, provide CPAP and bag-valve-mask ventilation, RECOMMENDED that 1 practitioner skilled in IV access in kids (PALS)
Monitoring: Pulse ox, ECG RECOMMENDED, HR, BP, Resp, Capno RECOMMENDED
Equipment: suction, O2 source
Documentation: Name, route, site, time and dosage of all drugs administered, continuous O2 sat, HR, capno (RECOMMENDED) every 10 MINUTES
Emerg checklist: Rec’d
Rescue Cart: Required
Recovery area: record vitals every 10 MINUTES until pt awakens, then increase
Equipment and personnel for deep sed
Personnel: NEED 2 PEOPLE: INDEPENDENT observer only monitors pt (PALS), in dental facility can be physician anesthesiologist, CRNA, oral surgeon, dental anesthesiologist, in a hospital usually nurses w/ experience
Responsible practitioner: can rescue from apnea, laryngo, airway obstr, open airway, suction secretions, provide CPAP and bag-valve-mask ventilation, tracheal intubation, cardiopulmonary rescucitation REQUIRED 1 practitioner skilled in IV access in kids (PALS)
Monitoring: Pulse ox, ECG REQUIRED, HR, BP, Resp, CAPNO REQUIRED
Equipment: suction, O2 source, DEFIBRILLATOR REQUIRED
Documentation: Name, route, site, time and dosage of all drugs administered, continuous O2 sat, HR, CAPNO (REQUIRED!! tells you if they are breathing before pulse ox) every 5 MINUTES
Emerg checklist: Rec’d
Rescue Cart: Required
Recovery area: record vitals every 5 MINUTES until pt awakens, then increase to 10-15
Contraindications for sed
- ASA III or IV
- Brodsky >2+
- Mallampatti >2
- Anatomic abnormalities: Micrognathia, large tongue, short neck, limited cervical spine or TMJ mobility
- Craniofacial abnormalities, high BMI
Pt selection
- Medical and dental history: previous anesthesia complications, family hx of malignant hyperthermia, asthma
- Physician consult or H&P clearance for OR
- Physical assessment: mallampati classification, tonsils, snoring, sleep apnea, weight
- Informed consent: discuss risks/benefits with parents
- Review NPO, routine meds with sip of water, no URTI within 2 weeks, 2 parents to appointment is ideal, car seat for up to 4ft 9 in
Basic Equipment
S (size appropriate suction) O (positive pressure O2) A (airways) P (pharmacy, drugs and emerg drugs) M (monitors: pulse ox, end tidal CO2, BP, ECG, stethoscope E (equipment: defib)
Procedure steps
- Reassess airway and listen to chest sounds
- Verify NPO
- Make sure papoose isn’t restricting airway
- Time based documentation: Medication name, route, site, time, dosage, effect, Level of consciousness, HR, BP, RR, oxygen saturation all monitored until patient discharged, Any adverse events and treatment for it
- Meet discharge criteria
- Give post-op instructions: procedures done, anticipated behavior changes, car safety, 24hr contact #, activity limitations, diet, OH, pain meds, nausea, F/U
Dentist needs to be able to rescue pt from
One level deeper of sedation than intended
dentist is required to provide ________ while awaiting EMS
life-support
Emerg cart equipment
oral and nasal airways, bag-valve-mask, LMA, laryngoscope blades, tracheal tubes, face masks, BP cuffs, IV catheters
Documentation during tx
- Time Out prior to sedation to confirm pts name, procedure and site
- Calculate dosages prior, adjust for obese pts to amts based off ideal weight
- Time based record of all drugs (name, route, site, time, dosage, pt effect, Confirm dose verbally before admin)
- Continuous monitoring of ox sat and HR, caponography or precordial stethoscope. HR, RR, BP, Ox Sat, expired CO2 levels recorded at min of every 5-10 min. Check papoose for chest restriction and make sure hand or foot exposed
Check head position continuously to ensure airway patency - Document vital signs at appropriate intervals during recovery until discharge criteria met
- Adverse events and tx should be documented
Documentation post treatment
Dedicated recovery area, document time and condition of child at discharge,
level of consciousness and ox sat have met discharge criteria
Can child remain awake for at least 20 min = simple eval tool
Deep Sedation
depression of consciousness, can’t be easily aroused but respond purposefully after repeated verbal or painful stimuli (pushing away the painful stimuli), ventilation may be impaired and may need assistance in keeping airway open, CV function usually maintained, partial or complete loss of protective airway reflexes
Need at least 2 people w/ PALS
