Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnositc and Therapeutic Procedures

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Important Definitions

Minimal sedation: (anxiolysis) pt responds normally to verbal commands; ventilatory and cardiovascular fxn unaffected.

This can be done by the practitioner alone.

Moderate sedation: (conscious sedation) pt responds purposefully to verbal commands either alone or accompanied with light tactile stimulation. Interactive state for older patients, and age appropriate behaviors for younger patients (expect crying). No intervention needed to control airway. CV function is usually maintained. Practitioners must protect pt airways and if the pt’s reflexes don’t protect the airway, consider it a deep sedation.

additional support personal must be present.

recovery must be monitored in a facility until discharge criteria has been met. young children should be able to stay awake for at least 20min in a quiet environment.

Deep sedation: pt is not easily aroused, but respond purposefully after repeated verbal or painful stimulation. Ability to maintain ventilatory function may be impaired. CV function is usually maintained. Complete or partial loss of protective airway reflexes may be lost.

the state and risks may be indistinguishable from general anesthesia.

trained person is required to administer and monitor. must have electrocardiograph and defibrillator. vascular access is required.

recovery is same as for moderate sedation

Goals:

guard pt safety and welfare

minimize physical discomfort and pain

control anxiety, minimize psychological trauma, amnesia

control behavior/movement

return patient to safe state

Always use the lowest dose of drug with the highest therapeutic index for the procedure.

Combining drugs is ok, but the use of 3 or more is associated with increase in adverse reactions

Candidates:

ASA class 1 or 2 for minimal, moderate or deep sedation.

ASA classes 3 or 4 require special consideration and consultation with anesthesiologist is recommended

Prescription medications intended to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.

Responsible person:

Obviously sedated patients must be accompanied, but it’s best to have 2 adults present.

Facilities

must have immediate personnel and equipment to manage emergency and rescue situations

most adverse rxns are compromised airway, depressed respirations, even hypotension and cardiopulmonary arrest: must be able to treat these complication in a sedation facility.

Back-up

protocol for back-up emergency services must be identified. ready EMS notification will work, but availability of EMS services doesn’t replace the practitioner’s responsibility to provide initial rescue in managing life-threatening complicaions.

On-site monitoring and rescue equipment

emergency cart must be accessible. use appendix C and D for drugs and equipment lists.

Documentation before sedation

Informed consent

Instructions: written and verbal

Considerations for post-op observation

24-hour telephone access for patients

Dietary Precautions

for elective sedation use general anesthesia fasting guidelines as listed in Table 1.

for emergency sedation: must balance benefit vs. risks of aspiration

Use of Immobilization Devices

papoose must not obstruct airway or restrict chest. a hand or foot should always be exposed.

Documentation at time of sedation

Health evaluation must be done: there is a list of all items that should be included. Very similar to our current H&P (minus Does the patient have lice?)

herbal medicines and strongly affect cytochrome P450 systems and result in prolonged drug effect and altered blood drug concentrations

Documentation during treatment

time based record

time-out to start

include durgs and dosages as well as inspired oxygen and vitals

Documentation after treatment

use generally recognized scales to determine when patient is ready for release.

use recognized discharge criteria

be careful when using anecdotes that resedation does not occur.

Preparation: SOAPME

Suction

Oxygen

Airway

Pharmacy

Monitors

equiment or drugs

If you are going to aim for a particular level of sedation you must be prepared to handle the next deeper level or sedation.

Special considerations:

LA: must not overdose. Also max dosages can affect sedation levels. aspirate frequently to avoid intravascular injections.

New pulse oximeters are better than old ones

Capnography can be very helpful to monitor respiratory activity

LMA (laryngeal mask airway) is an new airway device that you should seek training in.

Intraosseous injection: another adjunct that may be useful

N2O

considered minimal sedation at levels under 50% when used alone.

when used in higher concentration than 50% moderate sedation can be achieved

some guidelines for usage are outlined.