Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment

Resident: Roberts

Date: 1/19/2011

Article title: Fasting State and Episodes of Vomiting in Children Receiving Nitrous Oxide for Dental Treatment

Author: Kupietzky, Ari

Journal: Pediatric Dentistry

Volume: 30 Number: 5

Year: 2007

Discussion

The pre-procedural fasting (PF) guidelines by the AAPD for use of Nitrous Oxide state that PF is not required for patients undergoing Nitrous Oxide administration (NOA. Conversely they also state that the practitioner may recommend that only a light meal be consumed in the 2 hours prior to the NOA. No controlled study is referenced supporting the recommendations. PF advocates may argue that the foremost adverse reaction associated with NOA is vomiting; thus if a child has eaten prior to the appointment he or she should not be treated. Dentist who argue that fasting is not a concern with NOA might reason that the incidence of vomiting is extremely low and since the patient remains conscious they continue to maintain their protective reflexes intact - unlike deeply sedated patients. They may also reason that unfed children tend to be cranky and combative thus requiring higher levels of nitrous oxide for optimal sedation which then has a greater chance of inducing nausea and vomiting. Another paradox might be that patients who receive NOA on an empty stomach might be more susceptible to nausea and vomiting. One study suggested that nausea and vomiting are a result of hypoxia and over-sedation.

Method and materials

One hundred and thirteen children (64 male, 49 female), ranging in age from 24 to 160 months and a mean weight of 23 kg, participated in this study. Patients were assigned to two operative appointments. One fasting( 6 hours prior for solids 2 hours for clear liquids), and the other not fasting. During the study patients were titrated up-to no higher than 50% nitrous oxide. No appointment lasted longer than 35 minutes.

Results

Vomiting occurred in one subject immediately after cessation of treatment. The 8 yr. old ( did not specify gender) had consumed a heavy lunch following by a late afternoon snack of chocolate pudding 1 hour prior to treatment. Less than 0.5% of the total treatments (1% of the patients), fasting or non fasting, ended in an event of emesis.

Conclusion

Dentist using Nitrous Oxide for minimal sedation purposes should be aware that an episode of emesis is possible. In the event that a patient has nausea, Nitrous oxide should be turned off and oxygen should be restored to 100% delivery until the patient begins to feel normal. If vomiting does occur, the patients head should be turned to the side allowing the vomitus to pool in the cheek until it can be expectorated or suctioned away. According the author, many other studies cited no significant association between non fasting patients and an increased incidence in emesis during an appointment. We as pediatric dentist should consider carefully the risks and benefits involved with completing the procedure at hand and make our decisions accordingly.

Children Sedated for Dental Care: A Pilot Study of the 24-Hour

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Children Sedated for Dental Care: A Pilot Study of the 24-Hour Postsedation Period
Author(s): David Martinez, DDS Stephen Wilson, DMD, PhD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. vol 28 No 3 260-264
Major topic: Evaluating children 24 hours post sedation
Minor topic(s): Difference in sedation between chloral hydrate/meperidine/hydroxyzine and midazolam
Main Purpose: Investigate postseadtion events during the first 24 hours after discharge from the treatment facility.

Overview of method of research:
Prospective pilot study. 30 healthy ASA 1 children ranging in age from 2-5 were selected and scheduled for dental sedation. The children were worked up pre operatively with a thorough eval of med/social.dental hx, review of systems, vitals, dental needs, behavior, tonsil size, and sedative regime. 14 Children received a triple combo of chloral hydrate/meperidine/hydroxyzine ranging in dose from 20 to 30 mg/kg, 1 to 2 mg/kg, 1 to 2 mg.kg, respectively. 16 children received midazolam with does ranging from .05 to .75 mg. After the dental procedure was completed and the child was discharged, an investigated called the parents of the patients at the 24 mark. A 20 item questionnaire , including questions about amount of napping, discomfort, food intake, changes in diurnal rhythms, etc was asked to the parents. Responses were entered into an excel spreadsheet and analyzed using SPSS Statistical Package, version 13.

Findings:
It has been suggested that children are often discharge early from treatment facilities following sedations. This may result in an adverse event that may not be detected by non-medical caregivers. This pilot study aimed to quantify any issues arising 24 hours post sedation.
All of the 30 case questionnaires were used in the study. Differences were noted between the triple group compared to the midazolam group with respect to sleeping on the way home, or shortly after getting home. This may be significant because of the parents inability to monitor a sleeping child in car seat while driving, the child may be in a car seat with their head flexed, airway may become compromised.
No difference was found between the groups with regards to eating habits, bathroom habits, vomiting, or post op pain.

Key points/Summary:
There is a chance that an adverse reaction could occur after the child is discharged from the treatment facility. The proper discharge criteria must be met or exceeded to decrease these chances.

Assessment of Article: Good, insightful article that is relevant for us. Limitations include small number of cases, no notes about depth of sedation, pre/post op behavior, age, weight, or what was completed. Overall very well done. More research needed.

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.