Thursday, February 22, 2018

Sedation in pediatric dentistry: a practical assessment procedure


Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Michael Hatton                                                                        Date: 2/22/2018

Article Title: Sedation in pediatric dentistry: a practical assessment procedure
Author(s): Paul Moore, Eugene Mickey, J.A. Hargreaves, Howard Needleman
Journal: JADA
Date: October 1984
Major Topic: Sedation
Type of Article: Assessment presentation and RCT study
Main Purpose: Describe an assessment developed for sedation in pediatric dentistry and use in a RCT study
Key Points/Summary: The purpose of this article was to describe an assessment model for evaluating sedation in pediatric dental patients.

Purpose:  Evaluate the safety and efficacy of a particular agent and develop an assessment tool that could be used by clinicians to assess their own sedation regimens

Methods:  Assessment is limited to the preoperative period in which procedures are most uniform rating the behaviors as satisfactory or unsatisfactory. 60 pts (healthy pats age 2-5 needing tx requiring LA) who were considered uncooperative for routine dental care and who were to receive outpatient premed were recruited for study. Pts assigned to random grps A-D.  Each child was monitored by a single research assistant and rated 6 times b/f operative tx: (A)sedation behavior in quiet room, (B) sedation behavior on arrival to operatory, (C)airway patency b/f N2O, (D) sedation behavior in operatory after 3 min N2O, (E) airway patency after 3 mins N2O, (F) response to LA injection. The dentist who performed the operative provided behavior Frankl rating.

Key Points:
-Sedation behaviors of 20mg/kg group were nearly identical to placebo. 40mg/kg grp tended to have more negative behaviors. 60mg/kg group was statistically superior to the placebo.
-The risks involved in sedated children are related to a variety of factors.
-Toxic reactions are related to dose and must be considered when considered when selecting premedication treatment.
-Loss of consciousness can be seen at lower does than those that produce respiratory and cardio depression. -Monitoring of consciousness, by checking response to command and protective reflexes, is an important requirement for the sedation of children.
-The practitioner should be prepared to control any adverse drug effects. It is essential that the respiratory and cardio functions be continuously monitored at all times and if need be maintained in the case of emergency.

Conclusions: Children receiving the placebo tx behaved favorably for at least 46% of the ratings; the 20 mg/kg and 40 mg/kg chloral hydrate groups showed little or no improvement when compared with the placebo group; the group receiving 60 mg/kg chloral hydrate had as much as a 33% improvement in behavior as compared with placebo and with the addition of 40% N2O/60% O2 to 60 mg/kg chloral hydrate premedication, four of 15 children (27%) were unable to maintain a patent airway when intentionally obstructed.


Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 25 year follow-up survey


Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 25 year follow-up survey

Department of Pediatric Dentistry
Lutheran Medical Center

Wayne Dobbins                                                                                                                   Date: 2/22/18
Article Title: Project USAP 2000 – Use of Sedative Agents by Pediatric Dentists: a 25 year follow-up survey  
Author(s): Wilson S, Houpt M 
Journal: Pediatric Dentistry
Date: 2016
Major Topic: Sedation
Type of Article:  Survey Research
Main Purpose: Survey of the members of the American Academy of Pediatric Dentistry on their usage of sedative agents.
Summary:

A Survey:
A 31 question survey, (similar surveys sent in 1985, 1991, 1995, and 2000), was emailed to members of the AAPD, with a response rate of 44% - a total of 1,642 responses. Of the respondents, the majority were board certified, 58%. The questions covered geographic location of the practitioner, types of training programs attended and lengths of time in practice, use of nitrous oxide and other sedative agents, ages of patients seen and special needs status, reasons for changes in the use of sedation over the past five years, use of restraints during sedation, methods for monitoring patients during treatment, typical doses and effects of drugs used, and the prevalence of any undesirable side effects.

Key Findings:
Nitrous oxide was used for over 50 % of patients. Protective stabilization during sedation was used by 72 % of respondents, a decline from previous surveys. The vast majority of providers preferred oral sedation to non-oral administration methods – 93%. Benzodiazepines and nitrous oxide were the most frequently used sedatives.

Changes from Previous Surveys:
Fewer percentages of respondents were from university-based programs, and more respondents were from combined hospital/university programs; and the respondents from the university programs were less likely to perform sedations. Practitioners in the West and Southeast are most likely to perform sedations; a slow decrease trend over time is noted in the Midwest. The Northeast remains quite stable, with fewer sedations overall. Practitioners who practiced five years or less, or who practiced for 20 years or more, were performing larger percentages of sedation.

A trend for higher percentages of patients in practices receiving nitrous oxide continued from the 2000 survey. The percentage of respondents indicating that they did not use other sedative agents, with or without nitrous oxide, continued to increase compared to previous surveys; concurrently, those sedating larger percentages of patients with sedatives and nitrous oxide also continued to increase.
                                                                             
Benzodiazepines remain most popular but are closely followed with combinations involving chloral hydrate and Demerol. While the respondents’ selection of dosages of drugs was predominantly consistent with published values, there were several individuals who selected doses or dosages that were disconcerting (e.g., eight individuals indicated their dosage range of hydroxyzine was between 21 to 30 mg/kg). It is likely that these responses were miss-clicks entered when responding to the survey question or misunderstanding of the question.

Pediatric conditions associated with compromised airway: Part 1 – congenital


Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Albert Yamoah, DDS                                                                                                         Date: 02/22/2018
Article Title: Pediatric conditions associated with compromised airway: Part 1 – congenital
Author(s): Waage, N. S., Baker, S. and Sedano, H. O.
Journal: Pediatric Dentistry
Date: 2009
Major Topic: Respiratory complications are collectively the leading cause of pediatric anesthetic-related morbidity and mortality. Review congenital conditions with potentially difficult airway
Purpose: To discuss congenital conditions with potentially difficult airway management and propose treatment considerations to prevent adverse events in these patients. To emphasize the importance of patient evaluation prior to sedation and general anesthesia
Type of Article: Literature review discussing congenital conditions that have potentially difficult airway management
Anatomic and physiologic variation between the pediatric and adult patient:
·       Oxygen consumption of child and adult is 6ml/kg/min and 3ml/kg/min, respectively
·       Pediatric patients have a high minute ventilation (MV) to functional residual capacity (FRC)
o    5:1 in children compared to 1.5:1 in adults
·       Children under 10 years old have narrowest part of airway below vocal cords near cricoid cartilage
·       Glottis is at level of C4 in children and C5 in adults.
·       Combination of large tongue and high glottis
o    More difficult to establish a line of vision between the mouth and the larynx
·       Pediatric respiratory systems require higher levels of O2 consumption, higher ventilation and limited reserve
o    High CO + High O2 demand + limited O2 reserve
o    Too little O2 leads to dysrhythmias and cardiac arrest
·       Children depend on increase in HR for CO
o    Left ventricle’s compensatory capacity for increased SV not developed until early adolescence

 

Congenital Conditions Associated With a Compromised Airway:
·       Robin sequence: cleft palate, micrognathia, glossoptsosis, downward displacement of tongue.Cyanotic attacks, respiratory difficulty, little support of tongue musculature.
·       Treacher Collins Syndrome: Mandibular condyle and coronoid process may have sever hypoplasia, malformation, or even aplasia. Sleep apnea common, clefting in 35%. Upper airway obstruction common
·       Crouzon: Maxillary hypoplasia, mandibular prognathism, high arch, v-shaped palate. Cleft lip and or palate. Chronic tonsillar herniation.
·       Apert Syndrome (acrocephalosyndactyly): Craniosynostosis, midface malformations and symmetric syndactyly. Midface retruded and hypoplastic. Cleft palate, reduction of nasopharynx, respiratory complications, cartilagenous trachea and tracheal ring abnormalities.
·       Goldenhar Sndrome (Hemifacial Microsomia): most complex clinical manifestations of the aculoauriculovertebral spectrum. Maxillary, temporal and malar bones are reduced in size and flattened. Aplasia or hypoplasia of the mandibular ramus and condyle. After these patients undergo TMJ surgery airway management is difficult. TEFare common. Hypoplastic tongues, cleft lip and palate and VPI.
·       Down Syndrome: mandibular prognathism, midface hypoplasia. Open mouth, protruding tongue, enlarged tongue, tonsils and adenoids. Tracheal intubation may lead to subglottic stenosis.
·       Klippel-Feil Anomaly: Cervical vertebral fusion, short neck, limitation of head movement. Spina bifida, spnialcanal stenosis, scoliosis, atlanto-occipital fusion, cleft vertebrae and hemivertebrae.
·       Beckwith-Wiedemann Syndrome: Exopthalmos, macroglossia and gigantism. Alveolar hypoventilation at birth leading to cor pulmonale or right sided heart failure. Primary cause of airway obstruction is large protuberant tongue.
·       Cherubism: Expansion of the posterior mandible, fullness of face. Gingival enlargement preventing jaw closure. Airway obstruction has be a significant cause of morbidity when tongue is displaced.
·       Congenital hypothyroidism (Cretinism): Obesity, lethargy, swelling of face, bradycardia and hypothermia. Fluid accumulation.
·       Cri du Chat Syndrome: severe physical and cognitive growth retardation, feeding problems, microcephaly, micrognathia and facial asymmetry. Bifid uvula, dental malocclusion, short neck, scoliosis, hemivertebrae.
·       Von Recklinghausen Disease: Neurofibromas found in organs. Neoplasms in the scalp, cheek, neck and oral cavity. Tongue lesions can cause gross tongue enlargement. VPI also noted.
·       Hurler Syndrome: Lips enlarged and mouth open till age 3. Hyperplastic adenoids and constricted nasopharynx. Upper airway obstruction from epiglottic, tonsillar and tracheal thickening. Ramus is reduced and limited movement of the TMJ
·       Hunter Syndrome: Airway obstruction due to macroglossia, pharyngeal deformation, short immobile neck, mucous nasal discharge, anatomical deformation and narrowing trachea.
·       Pompe’s Disease: Most patients rely on artificial ventilation due to multisystem organ dysfunction. Swallowing is difficult with a protruded tongue. Laryngeal nerve paralysis and feeding difficulties may lead to aspiration.
·       Osteogenesis Imperfecta: Due to bone fractures patients should be repositioned carefully.
·       Moebius Syndrome: Limitation of eye movement, facial expression, feeding and swallowing difficulties, choking predisposition, drooling, cleft palate and speech difficulties. Upper midfacial protrusion, hypoplasticmandible and tongue.
·       Saethre-Chotzen Syndrome: High arch palate, malocclusion, supplemental teeth and cleft palate.
·       Rubenstein-Taybi Syndrome: High arched palate, micrognathia, bifid uvula, palatal clefting, bifid tongue, macroglossia and natal teeth.
·       De Lange: Small nose with inverted nostrils depressed nasal bridge, high arch palate, short muscular neck and micrognathia.

Conclusion:
·       Many of these syndromes pose a profound effect of airway management during sedation, induction and maintenance of GA.
·       A controlled inpatient setting is most appropriate.
·       Caution should be used for oral sedation with out IV access and advanced monitoring.
·       Moderate sedation is risky and should be avoided.
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