Guidelines - Deep Sedation / GA

Resident’s Name: Joanne Lewis Date: December 11, 2009

Guideline on Use of Anesthesia Care Providers in the Administration of In-office Deep Sedation/General Anesthesia to the Pediatric Patient

Background

- Many pediatric dentists would like to provide deep sedation/general anesthesia outside of the traditional surgical setting.

- Utilizing deep sedation/general anesthesia in the dental office offers benefits for the patient and the dental team.

- It is well documented that treating the patient in an appropriate outpatient facility is a safe and viable approach.

Recommendations

- In-office deep sedation/general anesthesia requires at least 3 people – the anesthesia care provider, the treating dentist, and an assistant.

- It is the responsibility of the treating dentist to verify the credentials of the anesthesia care provider.

- The operating dentist and clinical staff need to maintain current expertise in basic life support. An individual experienced in recovery care must be in attendance until the patient exhibits stable vital signs for discharge. The staff of the treating dentist must be well versed in emergency protocols.

- The facilities in which the dentist practices must meet the guidelines and appropriate state codes for administration of the highest possible level of sedation/anesthesia.

- Minimal monitoring equipment for deep sedation includes a blood pressure monitor, pulse oximeter, precordial stethoscope, capnograph, and electrocardiograph. In addition, for general anesthesia, a temperature monitor and pediatric defibrillator are needed.

- Documentation requirements vary from state to state; however, at a minimum, vital signs, drugs used, and recovery period need to be documented.

- High-risk patients should be treated in a facility properly equipped to provide for their care.

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.

Guideline on the Use of Antibiotic Therapy of the Pediatric Dental Patients

Guideline on the Use of Antibiotic Therapy of the Pediatric Dental Patients

AAPD Reference Manual V31, No. 6, 2009-10

Intro: Widespread use of antibiotics has resulted in resistance of common bacteria to antibiotics therefore necessitating conservative use of such antibiotics.

Wound Healing: Host factors such as age, systemic disease, malnutrition,and type of wound (clean, potentially contaminated, or dirty) all determine the need for antibiotics. Facial lacerations may require topical antibiotics. Intraoral lacerations contaminated by extrinsic bacteria, open fractures,and joint injuries are at increased risk of infection and thus require antibiotics. If antibiotics are needed, it should be given as soon as possible for the best result in the most effective route whether IV, IM, or oral. Antibiotics should be given for a minimum of 5 days beyond the time of significant improvement.

Special conditions:
Dental origin: If a child presents with acute symptoms of pulpitis, then treatment should be rendered, and usually antibiotics are not indicated. In this situation, the child should have no systemic signs of infection like a fever or facial swelling.

Facial swelling of dental origin: Antibiotics are indicated when there is evidence of facial swelling, and treatment is required immediately.

Dental trauma: Local application of antibiotics to the root of an avulsed tooth with an open apex with less than 60 Minutes of drying time. Systemic antibiotics are indicated with avulsions, usually tetracycline in older individuals and penicillin in younger patients.

Pediatric periodontal disease: Antibiotics are usually indicated due to inadequate immune response to protect against the growth of periodontal pathogens. Culture and susceptibility tests of isolate is helpfule .

Viral disease: Only use antibiotics if one suspects a secondary bacterial infection.

Oral Contraceptive use: Use caution when prescribing antibiotics on patients taking oral contraceptives as the antibiotics decrease the effectiveness of oral contraceptives. Tetracycline and penicillin like medications as well as Rifampicin all decrease plasma levels of ethinyl estradiol , causing ovulation.