Concious Sedation

The presentation features the techniques to obtain a submissive stage in children for better patient compliance during a dental treatment.

1. CONSCIOUS SEDATION Submitted by: Swati Markandey Ashish Arya Department of Pedodontics Govt. College of Dentistry, indore

2. CONTENTS Introduction Behaviour management Definition Levels of sedation Objectives Indications Contraindications Conscious sedation in children Prerequisite Patient assessment and preparation Sedation techniques Nitrous oxide and oxygen sedation

3. INTRODUCTION To perform the highest quality dental care in pediatric patients, the practitioner may need to use pharmacologic means to obtain a quiet, cooperative patient.

4. BEHAVIOR MANAGEMENT Definition: It is defined as means by which the dental health team effectively and efficiently performs dental treatment and thereby instils a positive dental attitude. (Wright,1975)

5. DEFINITION A minimally depressed level of consciousness, that retains the patient’s ability to maintain an airway independently & respond appropriately to physical stimulation & verbal commands. (AMERICAN DENTAL ASSOCIATION,1993)

6. LEVELS OF SEDATION Sedation/analgesia is defined by a continuum of “levels” ranging from minimally impaired consciousness to unconsciousness. The following terminology refers to the different levels of sedation intended by the practitioner Remember: Levels of sedation are considered to be on a continuum because a sedated child can go in and out of an intended level quite rapidly.

7. Minimal Sedation ( Anxiolysis ) A drug-induced state during which Patients respond normally to verbal commands. Cognitive function & coordination may be impaired. Ventilatory and cardiovascular functions are unaffected. N ote: This level is rarely adequate for an infant or young child undergoing sedation for a procedure .

8. MODERATE SEDATION A drug-induced depression of consciousness during which Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Airway is patent, & spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

9. DISSOCIATIVE SEDATION ( Ketamine ) A cataleptic state occurs with both profound analgesia and amnesia while maintaining protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. NOTE: Due to Ketamine’s markedly different clinical effect, it does not officially fit ASA sedation continuum. However it is generally recognized to produce a level of sedation between moderate and deep sedation.

10. DEEP SEDATION A drug induced depression of consciousness during which Patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimulation. The ability to independently maintain ventilatory function, may be impaired. Patients may require assistance in maintaining a patent airway. Cardiovascular function is usually maintained. A state of deep sedation may be accompanied by partial or complete loss of protective airway reflexes.

11. GENERAL ANESTHESIA A drug-induced loss of consciousness during which patients are not arousable , even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired .

12. Conscious sedation General anaesthesia Patient is cooperative , but anxious and fearful Patient is uncooperative Generally no extensive investigations are required At least basic investigations are must. No premedication is required Premedication is required Patient is conscious and contact is maintained Patient is unconscious. Airway is maintained Ventilation is required NPO not required NPO strict Recuperation period is 1-2 minutes Time consuming procedure

13. objectives Benett (1978) has stated the objectives to be: The patient’s mood should be altered. Child’s pain threshold should be increased. Amnesia should occur. Patient should be cooperative. Patient should be conscious, respond to verbal stimuli. All protective reflexes are intact. Vital signs stable and normal.

14. INDICATIONS Dental anxiety and phobia Prolonged or traumatic dental procedures Medical conditions potentially aggravated by stress Medical conditions affecting the patient’s ability to cooperate Patient lacking cooperation because of lack of psychological or emotional maturity Special needs

15. CONTRAINDICATIONS Chronic obstructive pulmonary disease (COPD), epilepsy, & bleeding disorders. Uncooperative or unwilling patients. Unaccompanied patients.. Prolonged surgery. Lack of equipment or inadequate personnel.

16. Conscious sedation in children Children receive sedation more frequently than adults To meet the necessary goals sedation/analgesia must be deeper than adults Child can easily slip from one sedation level to another Anatomical and physiological differences exist between children and adults

17. ANATOMIC & PHYSIOLOGICAL DIFFERENCES IN CHILDREN Differences in basal metabolic rate Difference in respiratory rate Airway management Reduced tolerance to respiratory obstruction. Cardiovascular parameters are different

18. PREREQUISITES FOR CONSCIOUS SEDATION Knowledge of the agents to be used Consent No lack of equipment Planned rationale for use of sedation

19. PATIENT ASSESSMENT & PREPARATION Obtaining patient history & information. Age, weight, height Health history Systems review Airway evaluation ASA Physical Status Classification Instructions to parents preop & postop . Adequate documentation of the sedation experience with monitoring of vital signs.

20. PREPARATION FOR SEDATION PROCEDURES SUCTION FUNCTIONING SUCTION APPARATUS OXYGEN ADEQUATE OXYGEN SUPPLY & FLOWMETERS TO ALLOW ITS DELIVERY AIRWAY APPROPRIATE AIRWAY (ENDOTRACHEAL TUBES, FACE MASK) PHARMACY ALL BASIC DRUDS NEEDED TO SUPPORT LIFE DURING AN EMERGENCY MONITORS FUNCTIONING PULSE OXIMETER EQUIPMENT SPECIAL EQUIPMENT OR DRUGS FOR A PARTICULAR CASE (E.G. DEFIBRILLATOR) ( AAP/ AAPD GUIDELINES , 2006 ) The acronym “SOAPME” offers a routine for preparing for sedation .

21. SEDATION TECHNIQUES Inhalation sedation Oral sedation Intramuscular sedation Intravenous sedation Rectal sedation Submucosal sedation

22. INHALATION Name of agent Dose Indications and benefits Limitations and risks Nitrous oxide Used for mild to moderate levels of anxiety Rapid onset, early elimination and recovery Duration of action can be controlled Agent has weak potency Not used in children with severe behaviour problems Cannot be used in claustrophobic patients, respiratory tract infections Desflurane Inhaled concentration should be 6-8% Rapid induction of anaesthesia and rapid emergence Produces direct skeletal muscle relaxation No hepatotoxicity and no nephrotoxicity Irritating to airway in awake patients Result in transient tachycardia Concentration dependent increase in respiratory rate and decrease in tidal volume Sevoflurane Inhaled concentration should be 2-4% Non irritating to airway Does not produce tachycardia No heapatotoxicity Hypotension and decrease in cardiac output Concentration dependent increase in respiratory rate and decrease in tidal volume Renal injuries and renal impairment have been reported

23. ORAL Name of agent Dose Indications and benefits Limitations and risks Hydroxyzine 1-2mg/kg Mild sedative along with antiemetic and anticholinergic action Potentiate narcotic and CNS depressant Better used in combination with other drugs Adverse reaction in form of extreme drowsiness and dry mouth , hypersensitivity Promethazine 0.5-1.1mg/kg With sedative and antihistaminic properties Potentiate other CNS depressant Better used in combination with other drugs For mild level of anxiety only To be used with caution in children with history of asthma and sleep apnoea Should be avoided in seizure prone patients Diazepam 0.2-0.5mg/kg To a maximum dose of 10mg Safe agent for mild to moderate anxiety particularly in children with cerebral palsy, mental retardation Children less than 6 years of age Not effective in severe anxiety when used alone Common adverse reaction in form of ataxia and prolonged CNS effect Meperidine 1-2.2mg/kg Best used in combination with other agent Poor oral absorption Should be used with extreme caution in patients with hepatic/ renal diseases or history of seizures

24. INTrAMUSCULAR Name of agent Dose Indications and benefits Limitations and risks Ketamine 10 and 50mg/ml Dissociative anaesthesia Midazolam 1 and 5 mg/ml Possesses hypnotic, anticonvulsant, muscle relaxant properties as well as being antegrade amnesic and anxiolytic Little data for effective dose in paediatric context Used mainly for short procedure

25. INTRAVENOUS Name of agent Dose Indications and benefits Limitations and risks Propofol 2mg/kg bolus iv for induction 9mg/kg for maintenance Suited for outpatient surgeries as incidence of postoperative nausea and vomiting is low Respiratory depression

26. NITROUS OXIDE & OXYGEN SEDATION DESIRABLE CHARACTERSTICS OF N 2 O/O 2 SEDATION: Analgesic Properties (Pain Control) Amnestic properties Anxiolytic properties (sedative effects) Onset of Action Recovery Elimination Acceptance

27. PHARMACOKINETICS It quickly agent crosses the pulmonary membrane & enters the blood stream. It is an insoluble drug & remains unchanged in blood & does not combine with any blood elements. Since N 2 O does not break down, so peak clinical effects may be seen within 3-5 minutes. There is no biotransformation & 99% of gas is rapidly eliminated by the lungs.

28. PHARMACODYNAMIcS It produces nonspecific CNS depression. At concentrations 30-50%, N 2 O will produce a relaxed & dissociated patient who is easily susceptible to suggestion. Moderate sedation is achieved when N 2 O concentration is 50% . At concentrations greater than 60%, patients may experience discoordination, ataxia, giddiness, and increased sleepiness. Concentrations greater than 50% are not to be used in dental practice. The gas is non-irritating to the respiratory tract .

29. Nitrous oxide is a good analgesic , even 20% produces analgesia equivalent to that produced by conventional doses of morphine. A mixture of 70% N 2 O+25-30% O 2 +0.2-2% another potent anesthetic is employed for most surgical procedure.

30. ARMAMENTARIUM The Central Storage System The nitrous oxide tanks are always marked blue for identification, and the oxygen tanks are green. Nitrous Oxide-Oxygen Machine Breathing Apparatus Nasal hood Safety Features

31. Schematic diagram to show components of a N 2 O/O 2 delivery & scavenging system

32. A-Poorly fitting mask with leakage under nares . B-Well -fitting mask.

33. Bag is filled with 100% oxygen and delivered to the patient for 2/3 minutes at an appropriate flow rate of 5-6 L /minute. Once the proper flow rate is achieved, the N 2 O can be introduced by slowly increasing the concentration at increments of 10% to 20% to achieve the desired level. SENSATIONS- Felt are floating, giddy feeling with tingling of digits. The eyes will take on a distant gaze with sagging eyelids. TECHNIQUE

34. TECHNIQUE When this state is reached, the local anaesthetic may be given. Once this is completed, the concentration can be reduced to 30% nitrous oxide and 70% oxygen or lower. The patient can now be maintained and monitored & procedure carried out. Recovery can be achieved quickly by reverse titration. Once the sedation is reversed, the patient should be allowed to breathe 100% oxygen for 3-5 minutes. The patient should be allowed to sit. Even though psychomotor effects return to normal within 5 to 15 minutes, it is not advisable to allow teenage patients to drive themselves.

35. STAGES OF ANESTHESIA Plane 1:Moderate sedation and Analgesia Achieved with concentration of 5-25% N 2 O Plane 2: Dissociation sedation and analgesia Concentration of 25-45% N 2 O Plane 3: Total anaesthesia Achieved with 45-65% concentration Lightest plane Somnolent state Deepest plane Plane4

36. ADVERSE EFFECTS AND TOXICITY Nausea and vomiting Middle ear pressure can increase pain in patients with acute otitis media. Neurotoxicity, renal/liver toxicity. The greatest concern regarding toxicity centres on exposure of dental personnel to high ambient air levels of the gas during its use for patient sedation (i.e. longer than 3 hours per week Diffusion hypoxia

37. REFERENCES DENTISTRY FOR THE CHILD & ADOLESCENT; 9 th edition; R E McDonald, D R Avery, J A Dean . TEXTBOOK OF PEDODONTICS; 2 nd edition; Shobha Tandon

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