Conscious sedation

Conscious sedation

1. conscious sedation PRESENTED BY: ROSHNI MAURYA 1 ST YEAR PGT

2. INTRODUCTION In the past decade, the use of sedatives and analgesics to relieve pain and anxiety associated with invasive diagnostic and therapeutic/painful procedures on pediatric patients in non-traditional settings (i.e., Emergency Department, Radiology, EEG lab, etc.) has substantially increased. Further complicating matters, there is very little existing conformity in providers’ choice of technique, medication(s) and depth of sedation/anesthesia to accomplish the same procedure. Consequently, adhering to a systematic approach of appropriate assessment, monitoring, and rescue skills has become critically important in promoting safe and effective procedural sedation and analgesia.

3. Purpose : To f amiliarize with principles and standards underlying safe and effective pediatric moderate sedation, review optimal presedation patient evaluation, review commonly used sedative/analgesic drugs, review potential patient complications, provide resources to improve patient safety and outcomes.

4. Procedural Sedation in Children Children receive sedation more frequently than adults (largely due to diagnostic procedures that require controlled/no movement). To meet necessary goals, sedation/analgesia usually must be deeper than given to adults. Due to physiologic differences, children are at higher risk for respiratory depression and life-threatening hypoxia. Technically, providers with the intent to practice “moderate sedation” may be closer to the definition of “general anesthesia” because children can easily slip from one level to another.

5. Procedural Sedation/Analgesia Continuum

6. Procedural Sedation/Analgesia Continuum Some general information regarding the definition and categorization of procedural 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 Minimum moderate dissociative deep general anesthesia 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. Continuum – Minimal Sedation Minimal Sedation (Anxiolysis) = a drug-induced state during which children respond normally to verbal commands. Although cognitive function and 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. Continuum – Moderate Sedation Moderate Sedation (formerly Conscious Sedation) = a drug-induced depression of consciousness during which sedatives or combinations of sedatives and analgesic medications are often used and may be titrated to effect. Children respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

9. Continuum – Dissociative Sedation Dissociative Sedation = ( Ketamine ) A trancelike, cataleptic state occurs with both profound analgesia and amnesia while maintaining protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Child’s eyes remain open with nystagmic gaze; may exhibit random tonic movements of extremities. Causes hyperactive airway reflexes, with a risk of Laryngospasm. Does not blunt protective airway reflexes to the same degree as other sedatives (e.g., opioids, benzodiazepines ). Consciousness Unconsciousness Moderate Sedation Deep Sedation General Anesthesia Minimal Sedation Dissociative

10. Continuum – Deep Sedation Deep Sedation = a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

11. Continuum – General Anesthesia General Anesthesia (GA) = 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. Preparation

13. Goals of Effective Sedation Guard the patient’s safety & welfare Minimize physical discomfort & pain Control anxiety, minimize psychological trauma, and maximize the potential for amnesia Control behavior and/or movement to allow the safe completion of the procedure Return the patient to a state in which safe discharge from medical supervision (as determined by recognized criteria) is possible

14. Strike a Balance Strike a Balance MAXIMIZE benefits while minimizing the associated risks RISK BENEFIT Hypoventilation Apnea Airway obstruction Laryngospasm Cardiac depression Death Minimize pain & discomfort Control movement Minimize psychological trauma/anxiety Maximize amnesia

15. Before We Begin… Each sedation should be tailored to the individual child considering the following factors : Select the lowest drug dose with the highest therapeutic index for the procedure - consider if agent(s) can be reversed Consider whether the procedure could be accomplished without sedation by engaging alternative modalities Alternatively, do not undertreat the child when sedation/analgesia is appropriate & necessary

16. Implications No matter the level of sedation you intend to produce, you should be able to rescue patients one level of sedation “deeper” than that which was intended. – Joint Commission For example: Y ou must be prepared/skilled to manage and rescue a “moderately sedated” child who slips into an unintentional state of “deep sedation.” This highlights the fact that different levels of sedation require different levels of expertise in airway & physiological function management of the patient.

17. Principles for Safe & Effective Sedation/Analgesia

18. Foundation for Safe Sedation Patient evaluation Competency Monitoring Rescue Skills

19. Guiding Principles – Supervision & Training The following action items are necessary to ensure safe sedation 1 Supervision & Training Children should not receive sedative or anxiolytic medications without supervision by medical personnel appropriately trained & skilled in both airway management and cardiopulmonary resuscitation. Do not prescribe (or encourage) any sedating medications to be administered by the parent before arriving at the hospital. Formulate a reasonable plan of sedation/analgesia. Understand the pharmacokinetics/dynamics and interactions of sedating medications.

20. Guiding Principles – Staffing Staffing Ensure that an adequate number or trained/credentialed/competent staff are present for procedure and monitoring (minimum of two experienced providers). Specifically assign a staff member whose main responsibility it is to constantly monitor the child’s cardiorespiratory status during & after the procedure, and assist in supportive or resuscitation measures (as required). Ensure a properly equipped & staffed recovery area (note: parents/caregivers should not be considered as part of the staff).

21. Guiding Principles – Evaluation Evaluation Conduct a focused airway evaluation (potential complications include: large tonsils, anatomic airway abnormalities, loose teeth, etc.). Conduct a thorough presedation evaluation for underlying conditions that would increase the risk ( wheezing etc.). Screen for medications the child takes at home and/or allergies the child may have. Ensure appropriate fasting (balance the risk/benefit of shortened fasting in emergent situations).

22. Guiding Principles – Equipment & Disposition Equipment Have access to all appropriate medications and reversal agents. Use age/size-appropriate and functioning equipment for airway management & venous access. Disposition Ensure patient is recovered to baseline status before discharge. Appropriately manage pain. Provide appropriate discharge instructions to parent/caregiver.

23. Personnel & Training Primary Practitioner: Be qualified and institutionally credentialed to administer drugs to predictably achieve and maintain the desired level of sedation Recognize and manage complications of one level deeper than intended sedation Be trained/capable of providing (at minimum) bag mask ventilation and, ultimately, endotracheal intubation Understand pharmacology of sedating medications, as well as role of reversal agents for opioids and benzodiazepines Maintain advanced pediatric airway skills

24. Support personnel: At least 1 person dedicated to constantly monitor appropriate physiologic parameters and assist in any supportive or resuscitation measures Be trained in, and capable of providing, pediatric basic life support Know how to use resuscitation equipment & supplies in the event of an emergency THIS PERSON SHOULD HAVE NO OTHER SIGNIFICANT RESPONSIBILITIES

25. Sedation/Analgesia Specifics

26. Sedation Considerations Consider each of these factors when planning for sedation Procedural issues: What type -- therapeutic (painful) vs. diagnostic (non-painful)? What is the child’s health status, age/development level & personality type? How stressful/anxiety-producing is the procedure (e.g., sexual abuse evaluation)? Is immobility/behavior control required? What position will the child be in during the procedure? How much time will it take to complete the procedure? How quickly can rescue resources be available? Medication issues: What is the mechanism of action? How is the sedating/analgesic agent metabolized? What is the duration of action? (avoid dose stacking) Potential adverse reactions/monitoring issues: Need for appropriate reversal agent Medication side effects/allergic reactions Oxygen desaturation Laryngospasm Hypotension

27. Equipment & Supplies To ensure systematic & thorough preparation for every sedation, the AAP 1 recommends S O A P M E S uction – age/size-appropriate suct ion catheters and suction apparatus ( Yankauer -type) O xygen – adequate O 2 supply, working flow/delivery devices A irway – age/size-appropriate airway equipment (e.g., ET tubes, LMAs, oral and nasal airways, laryngoscope blades, stylets , bag mask) P harmacy – all basic life-saving drugs, including reversal agents ( Naloxone , Flumazenil) M onitors – pulse oximeter , BP monitor, ECG, stethoscope, thermometer, cardiac monitor, end-tidal carbon dioxide (EtCO 2 ) monitor/detector E quipment – special equipment/drugs for particular child (e.g., defibrillator, respiratory box, IV access equipment) should be readily available MOST IMPORTANT PERSONNEL SKILLED IN ADVANCED LIFE SUPPORT!

28. Presedation Evaluation Evaluate every child in need of procedural sedation prior to sedation & perform universal procedures (i.e., “time out”) immediately prior to sedation. Age, weight, height Health history Allergies and previous allergic or adverse drug reactions Medication history, herbal or illicit drugs (dosage, time, route, and site) Relevant diseases, physical abnormalities, and pregnancy status Relevant hospitalizations Prior sedations & surgeries, and any complications (esp. airway issues) Relevant family history NPO status Systems review Vital signs (BP, heart rate, respiratory rate, temperature, SpO 2 ) Pulmonary, Cardiac, Renal, GI, Hematological, CNS, Endocrine Physical exam with focused airway evaluation (include: body habitus , head/ neck, teeth/mouth, and jaw) Physical status Review of objective diagnostic data (e.g. labs, ECG, x-ray, etc.) Level of child’s anxiety, pain, consciousness Name and telephone number of the child's primary physician

29. Airway Evaluation Class View = patient seated with mouth open as wide as possible I Soft palate, fauces , uvula, tonsillar pillars II Soft palate, fauces , full uvula III Soft palate only IV Hard palate only MALLAMPATI AIRWAY CLASSIFICATION Mallampati classification system is a standard airway evaluation used as a method to predict difficult intubation. Assess ability to open mouth and protrude tongue Check for loose teeth Assume that it may be necessary to establish an artificial airway during any sedation. Anticipate any/all obstacles before the real time occurrence. Class III & IV = potential difficult intubation (consider anesthesia consult)

30. ASA Physical Status Classification In 1941, the ASA developed a classification for a patient's physical status before sedation/surgery to alert the medical team to the patient's overall health. STATUS DISEASE STATE EXAMPLES I Healthy, normal child II Child with mild systemic disease Controlled asthma, controlled diabetes III * Child with severe systemic disease Active wheezing, diabetes mellitus w/ complications, heart disease that limits activity IV * Child with severe systemic disease that is a constant threat to life Status asthmaticus , severe BPD, sepsis V * Child who is moribund and not expected to survive without the procedure Cerebral trauma, pulmonary embolus, septic shock *Anesthesia consultant is usually required

31. ASA/AAP NPO Guidelines INGESTED TIME Clear Liquids (water, fruit juices w/o pulp, carbonated beverages, clear tea, black coffee) 2 hours Breast milk 4 hours Infant formula 6 hours Nonhuman milk (similar to solids) 6 hours Solids (light meal; if includes fatty/fried food, consider longer faster period) 6 hours NPO Guidelines for Elective* Sedation *In emergency situations, carefully weigh the need for immediacy with the increased risk of pulmonary aspiration. Use the lightest effective sedation possible.

32. Documentation – Before & During Before Sedation Presedation health evaluation (include initial aldrete score) Confirm staff privileges & universal procedures (i.e., “time out”) Drug calculations (include reversal agents and local anesthetics) Informed consent (risks vs. benefits, alternatives to planned sedation) Instructions to family: Objectives of sedation Anticipated changes in behavior (during & after) Why/when to expect longer observation time (drugs with long half- lifes ; severe underlying condition; neonates/preemies, etc.) Special transport instructions for children going home in car seat (child’s head positioning) 24-hour emergency phone # During Sedation On a time-based flowsheet : Drug name(s) & drug calculations Route Site Time Dosage (titrated to desired effect) During administration, record: Inspired concentrations of O 2 & duration of sedating/analgesic agents Level of consciousness Heart rate, respiratory rate, SpO 2 Adverse events and corrective intervention/treatment given Document at least once every 5 minutes until child reaches predetermined discharge criteria

33. Documentation - After During the recovery & discharge phase, document the following: Time and condition of child upon discharge Level of consciousness SpO 2 on room air Modified Aldrete Score 11 (also known as the Postanesthesia Recovery Score) Child meets all predetermined discharge criteria

34. Monitoring - During During sedation, continuously monitor: SpO 2 Heart rate Respiratory rate Head position/airway patency Blood pressure (forego if interferes with sedation) Level of sedation (e.g., Modified Ramsey Scale 12 ) ECG monitoring (esp. child with significant CV disease or dysrhythmias ) Ensure all monitors & alarms are working & routinely safety-checked

35. Monitoring - Transport If the child is transported while sedated, don’t forget to: Have credentialed/competent/skilled personnel accompany Monitor all vital signs Monitor level of consciousness Monitor SpO 2 Bring necessary O 2 supplies (tank, tubing, face mask, bag mask, oral airway, etc.) Bring necessary emergency drugs (including reversal agents) Bring cardiac monitor (esp. child with significant CV disease or dysarrhythmias )

36. Monitoring - After During recovery: Continuously observe and monitor ,heart rate,and level of consciousness until the child is fully alert Monitor other required vital signs at specific intervals until the child meets appropriate discharge criteria Ensure adequate pain management as effects of sedation/analgesia begin to wear off Observe for longer periods of time if child: Received any reversal agents (duration of sedating agents may exceed duration of antagonist) Received sedating agents with a long half-life (e.g., chloral hydrate ) that may delay return to baseline or pose risk of resedation

37. Discharge Criteria Every hospital must develop discharge criteria based on objective measures suitable to their patient population. Consider, at minimum, the following measures : Return to pre-sedation (age/developmentally-appropriate) activity/ambulation & cognitive level Child is easily arousable, alert and oriented Protective airway reflexes are intact Stable vital signs, pain level, O 2 and respiratory effort (e.g. Modified Aldrete Score ≥ 9) If reversal agent is given, allow sufficient time (up to 2 hours) after last dose to observe for risk of resedation Child/caregiver is able to understand written instructions (include emergency contact #) Child has safe transportation home with responsible adult (for infants going home in a car seat, adjust head position to ensure a patent airway if infant falls asleep)

38. PRE ANESTHETIC MEDICATION Refers to the use of drugs before anesthesia to make it more pleasant & safe.

39. AIMS & OBJECTIVES Relief of anxiety , apprehension preoperatively , to facilitate smooth induction Amnesia for pre & postoperative events. Supplement analgesic action of anesthetics. Decrease secretions, vagal stimulation caused by anesthetics Anti –emetic effect extending to postoperative period. Decrease acidity , volume of gastric juice so less damaging if aspirated.

40. DRUG DOSAGE ROUTES OF ADMINISTRATION FEATURES opioids morphine (10 mg) pethidine( 50-100 mg) im allay anxiety, apprehension of procedure , produce pre & post operative analgesia, smoothen induction, reduce dose of anesthetic agent sedative anti anxiety drugs diazepam (5-10mg) lorazepam (2mg) oral im produce tranquility, smooth induction anti cholinergics atropine(0.6mg) im iv to reduce sal .& bronchial secretions neuroleptics chlorpromazine(25 mg) im allay anxiety , smoothen induction , have antiemetic effect h2 blockers ranitidine (150mg) oral reduces ph of gastric juices may reduce its volume anti emetics metaclopramide (10-20 mg) im reduces post operative vomiting

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

42. NITROUS OXIDE SEDATION Nitrous oxide/oxygen inhalation sedation is the most commonly used technique in dentistry.

43. Equipment Continuous flow design with flow meters Safe delivery of O 2 and N 2 O (fail safe mechanism) Pin-indexed yoke system Efficient scavenger

44. Nasal Mask Selection of an appropriately sized nasal hood should be made. A flow rate of 5 to 6 L/min generally is acceptable to most patients(AAPD,2009)

45. Thorough inspection of equipment Place the mask over nose Bag is filled with 100% oxygen and delivered to patient for 2 – 3 mins Slowly introduce nitrous oxide Encourage the patient to breathe through nose Explain the sensation to be felt- floating, giddy, tingling of digits Adjust the concentration to 30% nitrous oxide and 70% oxygen Carry out the procedure with continuous monitoring After completion of procedure give 100% oxygen for 5 mins

46. Advantages Ability to titrate & to reverse Rapid onset & recovery Patient can be discharged alone Disadvantages Patient acceptance is not universal Cost of the equipment Not always effective C/I Nasopharyngeal obstruction COPD Pregnancy

47. Potential Problems Diffusion hypoxia Vomiting Toxicity inhibit vitamin B 12 dependent enzymes ( Pernicious anemia ) Reproductive Abnormalities

48. Commonly Used Agents

49. DRUG ROUTE DOSAGE ADVANTAGES DIS – ADVANTAGES PROPERTIES Hydroxyzine Oral IM 0.6 mg/kg 1.1 mg/kg Rapidly absorbed from GIT Dry mouth, drowsiness, hypersensitivity Clinical effect seen in 15-30 min Half life of 3 hours Promethazine Oral IM 0.5 mg/kg 1.1 mg/kg Sedative and antihistaminic properties,well absorbed after oral ingestion Dry mouth, Blurred vision,thickening of bronchial secretions,hypo -tension Onset – 15 to 16 mins Metabolized in liver Potentiates CNS depressant Diphenhy – dramine Oral IM, IV 1.0 – 1.5 mg/kg Absorbed GIT, eliminated in 24 hours Disturbed coordination, epigastric distress Maximum effect in 1 hour Metabolized in liver Mild sedative Diazepam Oral Rectal IV 0.2-0.5 mg/kg 0.25 mg/kg Sedative and Anxiolytic, rapidly absorbed from GTI Ataxia,respiratory depression in high doses, Hypotension Lipid soluble and water hours insoluble Half life is 20-50 Has three metabolites Strong anticonvulsant

50. Midazolam Oral IM 0.25-1mg/kg 1-0.15mg/kg High water solubility, sedation in 3-5 min and recovery in 2 hrs ,no rebound effect ,rapid absorption from GIT Apnea, prolonged CNS effects, rebound effect Packed at 3.3 PH, changes to 7.4 on entering blood. Highest lipid solubility Very less half life Chloral hydrate Oral, Rectal 25 – 50 mg/kg Commonly used fro children due to its well known effects Irritating to gastric mucosa, drowsiness Onset: 15-30 mins Half life is 8-10 hrs Fentanyl IM, IV 0.002-0.004 Mg/kg Potent analgesic,rapid onset Respiratory depression Metabolized in liver Excreted in urine Onset: 7-15 min Ketamine IM,IV 1.5 mg/kg Potent analgesic, rapid onset: 1 min in IV and 5 min I IM Gastric distress ,apnea , CVS disorders, Hallucinations Safety not yet established Fast onset and short duration of action

51. CONCLUSION Dental Chair Anesthesia is steadily gaining popularity challenging, new, unexplored but promising territory Balancing of ‘Pros & Cons’ for: conscious sedation, relative analgesia or GA Setting up the services is as such not easy, cheap, or frivolous and simple Must be done by trained qualified anesthesiologists Proper homework, preparation and execution are absolutely essential.

52. THANK U!