1
Q
The respiratory system is last to develop. Why is this clinical relevant in pediatric dentistry?
A
Young children have less surface area for gas exchange, therefore, must be aware if doing sedation.
pg 266 handbook
2
Q
Unlike adults, children can tolerate greater incidences of hypercarbia. Hypercarbia may be associated with onset of cardiac arrhythmias.
a. both statements are true
b. first statement is true. second statement is false.
c. first statement is false. second statement is true.
d. both statements are false
A
A. both statements are true.
pg 266 handbook
3
Q
T or F. Children have relatively large functional reserve capacity (FRC) and therefore have relatively larger post-expiration volume.
A
False.
Children have relatively SMALL FRC and LARGER post-expiration volume.
pg 266 handbook
4
Q
How does the pediatric airway differ from adult airway? (7)
A
in the pediatric airway:
- increased airway resistance
- glottis (vocal cords) are positioned more ANTERIOR and cephalad
- narrowest portion of upper airway is at the level of cricoid cartilage (BELOW vocal cords)
- relatively larger tongue and epiglottis
- larger head:body ratio
- less developed mandible
- potential for significant lymphoid tissue obstruction of: nasopharynx, oropharynx, and laryngopharynx.
pg 267 handbook
5
Q
The extent of treatment under sedation is ultimately determined by what?
A
By the amount of local anesthesia allowed by weight
pg 267 handbook
6
Q
Patient selection is important when considering sedation. Name a few selection criteria. (8)
A
- traditional techniques unsuccessful in managing behavior
- ASA 1 or well-controlled ASA 2
- below age of reason (pre- or un-cooperative)
- extent of treatment (which is ultimately determined by amount of LA allowed by weight)
- needle phobia
- excessively fearful older child
- older child with poor experiences/coping abilities
- distance traveled even for patients w/o behavior problems.
pg 267 handbook
7
Q
When looking at history prior to sedation, why is birth history important?
A
Premature birth is a huge risk factor.
If pt is a premie, it means their respiratory system is even less developed than a normally birthed child. Therefore, reduced surfactant and less patent alveoli, which leads to less surface area for qualitative gas exchange.
Premies also have poor qualitative AND quantitative gas exchange.
With premies, there is an increased incidence of early life intubation, altered neural reflex pathways, increased gag reflex and potentially greater risk for laryngospasms.
There are also increased incidences of hospitalizations and ventilator usage.
pg 268 handbook
8
Q
Besides birth history being a large component of assessing a pediatric patient for sedation, what other medical hx do we look for?
A
- allergies/asthma/croup
- -atopic triad: asthma, eczema, food allergy (having these three may suggest IGE hyper-responder) - current meds including OTC
- -including depressants and herbal supplements - diseases
- -CV, CNS, pulm, liver, kidney, pregnancy status - malignant hyperthermia risk
- sleep apnea
- -snoring suggests tonsil/airway problem - previous sedations/GA/hospitalizations
- family hx of dz
pg 268 handbook
9
Q
What is the atopic triad and why is this important?
A
Atopic triad is when a patient has asthma, atopic dermatitis (eczema), and food allergies.
Having this triad may suggest IgE hypersensitivity.
pg 268 handbook
10
Q
What are some vital signs/stats we need for pediatric pt undergoing oral sedation?
A
HR (think RRR-regular rate and rhythm), RR, BP, age, weight, and height
11
Q
When doing a physical assessment for a patient prior to oral sedation, what do we look for?
A
- general physical condition
- -gait, wheelchair, coordination - vital signs
- -HR, RR, BP - vital stats
- -age, weight, height - airway
- -tonsils, neck, nose, tongue - mouth breather/nasal speech
- C-spine precautions
- -DS and Arnold-Chiari malformations - midfacial hypoplasia
- -may be suggestive of existing airway co-morbidities - risk assessment
- -ASA status - obesity
- -per CDC, use percentile for ages 2-19 years - communication ability
pg 268 handbook
12
Q
What are the dietary precautions given to patients prior to sedation?
A
- No solids/non-human milk/infant formula up to 8 hours prior.
- No breast milk up to 4hrs prior
- No clear liquids up to 2hrs prior to procedure for children over 6 months of age
ASA fasting guidelines:
minimum fasting of 2hrs of clear liquids, 4hrs of breast milk, and 6hrs of formula, non-human milk, and light meal.
pg 269 handbook
13
Q
Reasons to cancel/defer oral sedation appointment
A
- active/recent URI
- nasal discharge
- NPO violation
- fever/cough
- recent head trauma
- recent change of note in medical hx requiring consult
* 7. parent change of mind
pg 269-270 handbook
14
Q
What is the dosage for lidocaine (xylocaine)?
A
4.4mg/kg with or w/o VC
comes in 2% and 1%
pg 270 handbook
15
Q
what is the dosage for articaine (septocaine)?
A
5mg/kg
comes in 4%
handbook says 4-5mg/kg but manufacturer’s instruction says 7mg/kg.
**should not be used on children under 4yo
pg 270 handbook
16
Q
With LA overdose, what do you expect to see in a lidocaine vs septocaine overdose?
A
lidocaine overdose causes CNS and CV effects, whereas septocaine overdose causes CNS, CV, and immune effects.
pg 270 handbook
17
Q
What does a vasoconstrictor do in LA?
A
epi (one type of VC used in LA) prolongs action of the anesthetic by constricting bv.
It also prevents rapid systemic uptake of LA.
**can lead to increased potential for post-tx soft tissue trauma from biting or scratching.
pg 270 handbook
18
Q
What are some effects of LA overdose?
A
CNS excitement followed by depression
- seizures
- disorientation
- LOC
CVS depressed
- decreased myocardial contractility
- decreased cardiac output
- CVS collapse
pg 270 handbook
19
Q
For a minimal level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
A
- cognitive fxn MAY be impaired but physiological fxn is not affected
- monitor by observation only with no need for specified personnel.
pg 271 handbook
pg 305 guidelines
20
Q
For a moderate level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
A
- cognitive fxn is depressed but pt responds to light tactile stimulation; physiological function is patent with self-correcting airway and ventilation/CV fxn is adequate.
- Must monitor O2 sat, HR, BP, RR, capnography recommended, and (EKG and defib should be available)
There must be a specific person responsible for monitoring other than operator that may do other tasks.
pg 271 handbook
pg 305 guidelines
21
Q
For a deep level of sedation,
- what are the effects on cognitive function and physiological function?
- what are the requirements for monitoring and personnel?
A
- cognitive fxn is depressed and pt cannot be easily aroused; physiologically, there is potential for loss of airway reflexes and CV may be affected
- Must monitor O2 sat, HR, BP, and RR EKG, capnography rec’d. Must have a specific person responsible SOLELY for monitoring
pg 271 handbook
pg 305 guidelines
22
Q
T or F. In moderate sedation, patient cannot be easily aroused but responds purposefully after repeated verbal or painful stimulation.
A
FALSE.
In DEEP sedation, patient cannot be easily aroused but responds purposefully after repeated verbal or painful stimulation.
In minimal and moderate sedation, patient is independently and continuously maintaining airway and responding to verbal commands along with light tactile stimulation. They also have intact cough, swallowing, and gag reflex with minimal effects on CVS and resp system.
pg 271 handbook
pg 305 guidelines
23
Q
What is the fatal trio in emergencies?
A
hypovolemia, hypoxia, and hypercapnia.
Hypovolemia–make sure pts are NPO but not overly NPO
hypoxia–important to recognize respiratory obstruction/distress immediately and if persists, can lead to hypercapnia, which can make pt more prone to cardiac arrhythmia.
pg 272 handbook
24
Q
What are the different sedation routes?
A
inhalation, oral, IN, IM, submucosal, IV
pg 272-273 handbook
25
What are some advantages of inhalation sedation route (nitrous)?
delivery system has a minimal 25% O2 fail safe feature, scavenger system, titratable
pg 272 handbook
26
What are some advantages/disadvantages of oral sedation?
Advantages--most accepted by children as there are no needles involved
Disadvantages--non-titratable, taste can be nasty so can cause aspiration (require partial patient cooperation), onset/recovery may be prolonged/variable absorption, and cannot add more meds after initial dose.
pg 272 handbook
27
Characteristics of nitrous oxide.
1. CNS depressant--minimal CV/resp effect
2. anxiolytic--minimal analgesia
3. chronic exposure/abuse can lead to peripheral neuropathies
pg 273 handbook
28
What are some relative contraindications for nitrous?
1. wheezing (mod-severe asthma)
2. nasopharyngeal obstruction
3. TB
4. CF
5. SCD (due to lowered O2 tension in blood)
6. acute OM
7. methionine synthetase deficiency
--nitrous irreversibly inhibits this enzyme, thereby raising homocysteine levels which is associated with vascular events and prolonged recovery.
high homocysteine levels occur when vitamin deficient such as B6 or B12. Homocysteine helps to process amino acids.
8. first tri pregnancy
pg 273 handbook
29
What are some side effects of nitrous?
sweating, nausea, GI discomfort, vomiting, inhibition of airway reflexes
pg 274 handbook
30
What are some common medications used in OCS?
chloral hydrate (sedative/hypnotic)
BDZP (sedative/hypnotic)--diazepam, midazolam
antihistamines--hydroxyzine
narcotics--meperidine
pg 274 handbook
31
what is the brand name of diazepam?
Valium; it is a sedative/hypnotic; a BDZP
pg 274 handbook
32
Brand name of midazolam?
Versed; sedative/hypnotic; a BDZP
pg 274 handbook
33
brand name of meperidine?
demerol; narcotic
pg 275 handbook
34
Effects of chloral hydrate
1. CNS depression (minimal CV or respiratory effect)
- -similar to nitrous
2. mucosal and GI irritant
pg 274 handbook
35
Where is chloral hydrate metabolized and into what? What organ excretes it?
metabolized to trichlorethanol in the liver and excreted by kidney
pg 274 handbook
36
what is the onset, peak, working time, and duration of chloral hydrate?
onset: 30-60min
peak: 60min
working time: 60mins
duration: 5hrs
pg 274 handbook
37
Dosage of chloral hydrate and reversal agent
Dosage: 10-50mg/kg with 1g max dose (as sole agent)
NO REVERSAL AGENT
pg 274 handbook
38
Effects of diazepam/Valium
1. CNS depression (minimal CV or resp effect)
- -similar to nitrous and chloral hydrate
2. amnesia
3. ataxia
4. acts in cortex, limbic system, thalamus, hypothalamus
- -Functions of the cerebral cortex involves processing information as well as language
- -limbic system includes amygdala, hippocampus, and olfactory cortex. The limbic system serves a variety of fundamental cognitive and emotional functions. The hippocampi, which lay on the inside edge of the temporal lobes, is essential to memory formation.The amygdala communicates closely with the hippocampus, which helps explain why we remember things that are more emotionally important. The limbic system communicates with our autonomic nervous system (which regulates things like heartbeat and blood pressure), endocrine system, and the viscera (or “gut”).
- -The amygdala also communicates closely with the hypothalamus, the area of the brain that is responsible for regulating temperature, appetite, and several other basic processes required for life.
https://www.verywellhealth.com/the-limbic-system-2488579
pg 274 handbook
39
what is the onset, peak, working time, and half-life of diazepam/Valium?
onset: 45-60mins
peak: 60mins
1/2 life: 20-40 hours
pg 274 handbook
40
Dosage of Valium/diazepam and reversal agent.
| Any contraindications for usage of diazepam?
dosage: 0.25mg-0.3mg/kg
max dose: <10mg total
reversal agent: flumazenil (0.01mg/kg up to 1mg total and takes 1-2min onset)
contraindications: narrow angle glaucoma
- -Some benzodiazepines have pupil-dilating effects. Dilated pupils = increased intraocular pressure
- - As muscle relaxant, it widens opening behind eye which increases pressure inside the eye which is a term for glaucoma.
pg 274 handbook
41
Effects of midazolam/Versed
1. CNS depression (minimal CV or resp effect)
- -similar to nitrous, chloral hydrate, and diazepam
2. anterograde amnesia
- -Anterograde amnesia is a loss of the ability to create new memories after the event that caused amnesia, leading to a partial or complete inability to recall the recent past, while long-term memories from before the event remain intact. This is in contrast to retrograde amnesia, where memories created prior to the event are lost while new memories can still be created.
3. 3-4x potency of diazepam
pg 274 handbook
42
what is the onset and working time of midazolam/Versed?
onset: 15mins
working time: 30-40mins
pg 274 handbook
43
Dosage of Versed/midazolam and reversal agent.
| Any contraindications for usage of midazolam?
dosage: 0.5-0.75mg/kg orally with 15mg max total; and 0.2-0.3mg/kg IN
reversal agent: flumazenil (0.01mg/kg up to 1mg total and takes 1-2min onset)
**no contraindications noted**
pg 274 handbook
44
Effects of hydroxyzine
1. CNS depression
2. anxiolytic
3. bronchodilator
4. analgesia
5. dry mouth
pg 274 handbook
45
what is the onset and duration of hydroxyzine?
onset: 15-30mins
duration: 2-4hours
**often combined with chloral hydrate, meperidine, or midazolam
pg 275 handbook
46
Dosage of hydroxyzine and reversal agent.
0.5mg-1mg/kg orally
no reversal agent
pg 274 handbook
47
effects of meperidine/Demerol
1. CNS, CV, respiratory depression
- -differs from ALL the other meds
2. sedation
3. analgesia
4. lowers seizure threshold
side effects: dizziness, xerostomia, sweating, N/V, seizures, resp depression
--Versed can cause resp depression with higher doses as well
pg 275 handbook
48
Where is meperidine/Demerol metabolized? What organ excretes it?
metabolized by liver, excreted by kidney
pg 275 handbook
49
what is the onset, peak, working time, and duration of meperidine/Demerol?
onset: 30min
peak: 1-2hrs
duration: 2-4hrs
pg 275 handbook
50
Dosage of Demerol and reversal agent.
| Any contraindications for usage of meperidine?
dosage: 1-2mg/kg oral; 50mg max PO/SM/IM
No reversal agent
Contraindications: pts with hx of asthma (may shift production in respiratory tree from PG to LT, which are bronchial irritants)
exercise caution in pts with pulmonary complications, head trauma, seizures, hepatic/renal dz, airway obstruction.
**concomitant LA dose consideration is VERY important!!**
pg 275 handbook
51
If during OCS you hear your pt starting to snore, what should you do?
reposition the head
pg 276 handbook
52
If during OCS your pt starts to vomit, what should you do?
turn pt to the side and suction
pg 276 handbook
53
What does the pulse oximeter measure?
oxygen saturation of the blood
pg 276 handbook
54
What does capnograph measure?
end tidal CO2
pg 276 handbook
55
What are some ways to monitor respiratory system during OCS?
1. mirror fogging
2. chest movement (look for rate change from baseline)
3. listen for respiratory sounds through stethoscope
4. watch O2 sat on pulse ox
5. patient color, reservoir bag movement
6. capnograph for moderate to deep sedation
- -one key question to ask to see if in mild or moderate/deep sedation and to assess need for capnograph is: Is appropriate bi-directional verbal communication possible?
pg 276 handbook
pg 306 guidelines
56
What are the discharge criteria for OCS?
1. vital signs and airway stable
2. no nausea/fever
3. oriented to surroundings, recognizes guardian
4. can walk/talk/support head
5. hydrated
6. guardian available and post-tx instructions given in writing
7. documentation of recovery status is critical!!!
pg 277 handbook
57
What must an OCS operating facility have?
1. full face mask with positive pressure O2
2. emergency kit
3. high speed suction
4. pre-tracheal stethoscope
5. sphygmomanometer (auto/manual)
6. pulse oximeter
7. other as required by state law
pg 278 handbook
58
What are the potential emergencies associated with sedation?
- respiratory rate depression or arrest
- upper airway obstruction including laryngospasm
- allergic reaction/overdose
- bradycardia and/or hypotension
- hypoglycemia
- vomiting
- seizures
pg 279 handbook
1. apnea
2. airway obstruction
3. laryngospasm
4. pulmonary aspiration
5. desaturation
pg 300 guidelines
59
What is SOAPME?
S- size appropriate suction catheters
O- adequate oxygen supply and functioning flowmeter
A- size appropriate airway equipment such as BMV, OPA, LMA, NPA, facemasks, endotracheal tubes
P- pharmacy to include basic life-supporting drugs for emergency
M- monitors (functioning and appropriate for one level deeper than intended sedation)
E- special equipment such as defibrillator/AED
pg 279 handbook
pg 305 guidelines
60
What are some signs to look for during OCS to suggest respiratory rate depression?
```
nasal flaring
platysma flaring
grunting
rocking horse/see-saw respiratory patterns
use of intercostal muscles for breathing
```
pg 279 handbook
61
If during OCS, pt gets allergic reaction/overdose, what med do you give?
if only one organ system involved--give diphenhydramine
if more than one organ system involved (ex. respiratory + dermatologic)--give epinephrine
pg 279 handbook
62
Steps to manage airway obstruction
```
in order of what to do first and if it does not succeed, go to second:
reposition airway-->
jaw thrust-->
insert oral airway-->
call for help-->
insert nasal trumpet-->
insert supraglottic device (LMA or other)-->
tracheal intubation-->
surgical airway
```
pg 280 handbook
63
T or F. Children with developmental disabilities have been shown to have a THREEFOLD increased incidence of desaturation compared with children without developmental disabilities.
true.
pg 300 guidelines
64
steps to manage laryngospasm during OCS.
in order of what to do first and if it does not succeed, go to second:
positive pressure ventilation-->
deepen sedation (ex propofol)-->
call for help-->
give muscle relaxant (succinylcholine + atropine)-->
tracheal intubation-->
surgical airway
pg 301 guidelines
65
steps to manage apnea during OCS.
```
in order of what to do first and if it does not succeed, go to second:
bag/mask ventilation-->
reposition airway-->
jaw thrust-->
insert oral airway-->
call for help-->
insert nasal trumpet-->
insert supraglottic device (LMA or other)-->
tracheal intubation-->
surgical airway
```
**notice that it's the SAME EXACT steps as management of airway obstruction except first step of this one is to bag/mask ventilate**
pg 301 guidelines
66
What age group are particularly vulnerable to the effects of sedating medications on
1. respiratory drive
2. airway patency
3. protective reflexes?
children younger than 6 years and particularly younger than 6 months.
pg 300 guidelines
67
Studies have shown that it is common for children to pass from the intended level of sedation to a deeper, unintended level of sedation.
Therefore, it is critical that practitioners of sedation must have skills to rescue the patient from a deeper level than that intended for the procedure.
1. Both statements are true.
2. First is false; second is true.
3. First is true; second is false.
4. Both are false.
1. Both statements are true.
pg 300 guidelines
68
T or F. Once practitioner has called EMS, it is no longer their responsibility to care for patient.
False.
Practitioner is responsible for life-support measures while awaiting EMS arrival via whatever is needed, such as:
-open the airway
-suction secretions
-provide continuous positive airway pressure (CPAP)
-successful bag-valve-mask ventilation
-insert oral airway, nasopharyngeal airway, or laryngeal mask airway
-intubate
pg 300 guidelines
69
What are the goals of sedation in the pediatric patient for diagnostic and therapeutic procedures?
1. guard the patient's safety and welfare
2. minimize physical discomfort and pain
3. control anxiety, minimize psychological trauma, and maximize potential for amnesia
4. modify behavior and/or movement to allow for safe completion of procedure
5. return pt to a state in which discharge from supervision is safe.
pg 301 guidelines
70
Which antihistamine has a black box warning and why?
Promethazine due to fatal respiratory depression in children younger than 2 years.
pg 301-302 guidelines
71
What type of patients would not be good candidates for moderate or deep sedation?
ASA III/IV, moderate to severe tonsillar hypertrophy, anatomic airway abnormalities, SHCN pts
pg 302 guidelines
72
What are the most common serious complications of sedation?
- compromised airway
- depressed respirations resulting in...
1. airway obstruction
2. hypoventilation
3. laryngospasm
4. hypoxemia
5. apnea
- rare complications include seizures, vomiting, and allergic reactions.
pg 302 guidelines
73
How do herbal medications such as St. John's Wort, gingko biloba, ginger, ginseng, and garlic alter drug pharmacokinetics?
these herbal medicines inhibit the cytochrome P450 system, thereby prolonging drug effect and alter (increase/decrease) certain blood drug concentrations (midazolam, cyclosporine, tacrolimus).
pg 303 guidelines
74
What drugs' blood concentration is altered by herbal meds?
midazolam
cyclosporine
tacrolimus
**it can increase/decrease the drug's blood concentration and potentially prolong the drug effect.
pg 303 guidelines
75
What herbal medicines alter drug pharmacokinetics? And in what way?
```
St. John's Wort
Ginkgo
Ginger
Ginseng
Garlic
```
They alter by way of inhibiting cytochrome P450, which results in prolonged drug effects and altered blood drug concentrations of med such as MIDAZOLAM, CYCLOSPORINE, and TACROLIMUS.
**the four Gs and a wort**
pg 303 guidelines
76
What is cyt P450 and why is it important?
Cytochromes P450 (CYPs) are a superfamily of enzymes containing heme as a cofactor that function as monooxygenases. In mammals, these proteins oxidize steroids, fatty acids, and xenobiotics, and are important for the clearance of various compounds, as well as for hormone synthesis and breakdown.
source: Wikipedia
77
How does kava affect the effects of sedatives?
Kava may increase the effects of sedatives by potentiating g-aminobutyric acid inhibitory neurotransmission and may increase acetaminophen-induced liver toxicity.
pg 303-304 guidelines
78
How does valerian root affect the effects of sedatives?
Valerian may itself produce sedation that apparently is mediated through the modulation of g-aminobutyric acid neurotransmission and receptor function.
pg 304 guidelines
79
Besides herbal meds that inhibit P450, are there meds that can inhibit it too?
Yes. Such as erythromycin and cimetidine.
pg 304 guidelines
80
What are the meds that inhibit P450 talked about in the guidelines?
herbal meds--the four Gs and the wort, along with erythromycin and cimetidine.
they may alter the blood concentration and effects of meds such as MIDAZOLAM, cyclosporine, and tacrolimus.
pg 303-304 guidelines
81
In Feb 2013, the US FDA issued a warning regarding the use of codeine for post-op pain management in children undergoing tonsillectomy, particularly those with OSA. Why?
The safety issue is that some children have duplicated cytochromes that allow greater than expected conversion of the prodrug codeine to morphine, thus resulting in potential overdose. Therefore, codeine should be avoided for post-op analgesia.
pg 304 guidelines
82
T or F. If using opioids in children with severe OSA, titrate at lower doses because they have experienced repeated episodes of desaturation, which has likely altered their kappa receptors, causing them to experience analgesia at 1/3 to 1/2 the opioid levels of a child w/o OSA.
FALSE.
Although almost all is true, it's an alteration in the MU receptor, not kappa.
pg 304 guidelines
83
Nitrous oxide can cause pernicious anemia and megaloblastic anemia in susceptible patients by inhibiting which enzyme?
Methionine Synthase
84
Where is nitrous oxide metabolized?
N2O is not metabolized significantly by the body
85
Which of the following are true about nitrous oxide:
1. depletes ozone layer
2. increases cardiac output
3. causes peripheral vasoconstriction
4. supports combustion
1,2,4
86
In a full E-cylinder, what is the PSI and volume of nitrous oxide?
a. 2000 and 660
b. 840 and 1600
c. 2000 and 625
d. 745 and 1600
D.
87
In an E-cylinder, what is the best way to assess the remaining volume of nitrous oxide left?
a. look at the PSI gauge as it correlates with remaining volume
b. weighing the cylinder before and after use
c. impossible to assess
C.
88
In an E-cylinder, at what volume will the PSI of nitrous oxide start to decrease?
a. 1500L
b. 750L
c. 425L
d. 100L
C.
89
When procaine undergoes metabolic breakdown, the major metabolic product is what?
a. pseudocholinesterase
b. 2-chloroprocaine
c. succinylcholine
d. para-aminobenzoic acid (PABA)
D.
90
Biotransformation of amides takes place in which organ?
Liver
91
Which portion of the nerve do local anesthetics work on?
a. neuron
b. dendrites
c. myelinated sheath
d. nerve membrane
D.
92
What is one important way that local anesthetic drugs differ from all other drugs used in dentistry?
a. high potential of overdose
b. route of administration
c. rate of uptake into bloodstream
d. blood levels must be sufficient to exert effect
C.
