Sedation Lecture 10

Front 1

6 advantages of IV sedations?

Back 1

PRMMET

1) Predictable
2) Rapid reversal possible depending on the drugs used
3) Morbidity low
4) Mortality equivalent to or better than GA
5) Economical (more economical than GA)
6) Titration of sedation level possible

Front 2

3 disadvantages of IV sedation and 1 that is thought to be a disadvantage, but not true?

Back 2

RAT
1) Rapid onset, accentuated drug action may lead to problems faster with magnified onset
2) Advanced training required
3) Technically demanding

Not really a disadvantage: Though to be difficult and unsafe in kids - but it's actually just eye-hand coordination skill and technical staff can do it well

Front 3

1) What is the definition of agent bioavailability?
2) Compare the bioavailabilities/elimination/outcomes of PO, IM, and IV
3) Drug elimination is identical, regardless of route, once what two things are completed?

Back 3

1) Portion of the administered drug that reaches the systemic circulation in active form
2) PO - highly variable absorption and highly unpredictable outcome due to first pass hepatic metabolism and gastric degradation

IM - less varied rate of absorption, varied rate of elimination

IV - 100% bioavailability, titration possible to desired effect, highly precise

3) Absorption, distribution

Front 4

What 3 categories of drugs do you consider using for IV sedation, and why?

Back 4

1) Opioids: Meperidine, Fentanyl - use for analgesia, and synergistic effect on sedation
2) Benzodiazepines: Midazolam, Diazepam - use for sedation, amnesia, and anxiolysis
3) Antihistamines: Diphenhydramine, Promethazine - use to support effects of opioids and benzodiazepines (synergism)

Front 5

1) Meperidine - drug type? Metabolite? Duration? Unique pharmacodynamic effects? IV increments?
2) Fentanyl - drug type? Metabolite? Duration? Pharmacodynamic unique effect? IV increment?
3) Midazolam - drug type? Metabolite? Onset? Duration? Unique effects? IV increment?
4) Diazepam - drug type? Active metabolite? Onset? Duration? Unique effects? IV increment?
5) Diphenhydramine - drug type? Active metabolite? Duration? Pharmacodynamics? IV increment?
6) Promethazine - drug type? Active metabolites? Duration? Pharmacodynamics? Unique effects? IV increment?

Back 5

1) Opioids. Normeperidine. 3-5 hrs. Anticholinergic, negative ionotrope, histamine release. 1-2 mg/kg
2) Opioid. Unknown. 1-2 hrs. Skeletal muscle rigidity. 0.01 mg/kg.
3) Benzo. None. 30 seconds. 20-60 mins. 1-2 mg
4) Benzo. Yes. 60 seconds. 30-60 minutes. Thrombophlebitis. 2.5-5 mg
5) Antihistamine. No. 4-6 hrs. Muscarinic and histaminic blockade. 1.25 mg/kg
6) Antihistamine. No. 4-6 hrs. Muscarinic, histaminic, dopaminergic, alpha-adrenergic blockade. Unique effects = agitation, delirium, hypotension. 1.25 mg/kg (antihistamines have the same dosages)

Front 6

1) 2 choices for the "point" of the IV - advantages and disadvantages?
2) EMLA - 2 forms it's available in? Which is better? How many sites should you prepare? How long should you put it in place?
3) What is a possible site for IV placement in the hand, and what's the advantage/disadvantage?
4) What are the 3 main things to keep in mind when you're taping a peripheral IV catheter?
5) T or F: IV sedation is highly effective, safe, and predictable for the provision of comprehensive dental treatment to children
6) Can tx be completed in one appointment with IV sedation?
7) Are parents usually pleased with the outcome?

Back 6

1) A) "Butterfly" winged needle - rigid and sharp, pt mvmt will cause needle to perforate vein wall. Not recommended for peds. B) In-dwelling angiocatheter - technically more difficult to place, catheter is soft and flexible and won't perforate vein wall. Child's hand/arm stabilization not as critical.
2) Cream > patches. Prepare 2 sites in case you miss. Place at least 60 minutes, preferably 90 minutes preop.
3) Dorsum of the hand - veins are readily visible but mobile.
4) Hand stability essential, arm board/position of comfort, transparent tape in event of extravasation
5) T
6) Yes
7) Yes

Front 7

1) Dr. Stone's protocol involves atropine, midazolam, ketamine, and toradol. What is each used for?
2) Drug used the most by anesthesiologists?
3) 2 impacts of office-based anesthesia by third party providers?

Back 7

1) Atropine - dries secretions. Ketamine knocks them out, midazolam helps with hallucinations. Toradol is analgesic.
2) Midazolam
3) Abandonment of other parenteral sedation modalities offered to parents, and abandonment of hospital privileges (43% of users retained privileges and performed an average 5 cases/month)

Front 8

1) 4 steps in hospital staff appointment?
2) What are the things you have to consider with equipment, instruments, and supplies?
3) Permanently stored equipment?
4) Creature comfort equipment?

Back 8

1) Application, appointment, delineation of privileges, maintenance
2) Storage/inventory concerns (We have to buy all disposable items), electrical and safety concerns (all our things should have inspection tags). Partial patient fees returned to service for new and replacement cost
3) Dental handpiece cart (uses compressed nitrogen gas from a central supply or self-contained unit with compressor), portable x-ray unit, developer, cavitron, curing light, storage cart for disposable supplies
4) Dental handpieces, operator stools, headlamps, back-ups in case of breakdown

Front 9

1) 5 criteria for GA patient selection?
2) 3 things that ambulatory GA changes?
3) 5 things required for ambulatory surgery?
4) 6 aspects of informed consent/witness?

Back 9

1) Medicall compromised, <2 y/o or pre-cooperative, complex/extensive therapy, distance traveled or difficult compliance, third party payment
2) "Managed care" puts an end to routine in-patient care (for MD convenience) and excessive laboratory testing, some patients require pre-op admission (sickle cell anemia for hydration, chemo patients), some pts need post-op admission for IV fluids or apnea monitoring
3) HILPP - History + physical within one month (updated by MD anesthesiologist), Insurance preauthorization (state regulations and qualifications), Lab tests (no routine screening), Pre-op anesthesia note, Parental informed consent
4) Risks with and without tx, alternative tx, concerns (incisors, silver crowns, attempt to save what we can but plan for the worst and hope for the best), pain control/eating/timeline/waiting, Questions? Who can be a signed witness?

Front 10

1) 4 things that you can use to supplement informed consent

Back 10

1) Apply pt ID stickers on all forms
2) Phone consent
3) Language translator (Shands Hospital) using conference call system
4) Time-out procedure in OR

Front 11

3 things that need to be assessed pre-operatively for GA

Back 11

1) Child must be NPO - solids up to 6 hrs, clear liquids permitted up to 2 hrs.
2) Child is cleared for surgery, if free from acute systemic disease, especially URI and recent asthmatic attack (use pre-op nebulizer as a precaution).
3) Updated H&P and valid consent

Front 12

1) What pre-op sedatives do you administer on an extremely cooperative child?
2) Normal child?
3) Uncooperative child?
4) When do you separate child from parents to take them to the OR? What do OR personnel have to wear? Are parents welcome?
5) Who are the OR personnel in the room?
6) Who must be present at "time-out" and induction?

Back 12

1) IV NS placed first
2) PO midazolam
3) IM ketamine (Ketalar)
4) Child separated from parents after pre-op medication takes effect. OR personnel required to wear scrubs, head and shoe covers. Parents not welcome
5) Anesthesiology (attending and resident), Surgery attending and resident, Nursing (OR, PACU), support staff (scrub tech, anesthesia tech)
6) Anesthesiology and surgery

Front 13

1) What's placed first when you're prepping a patient?
2) 6 physiological monitors you need for GA
3) What are the stats you need to monitor?
4) What are 2 things you need to monitor about inhalation agents?
5) Two tools you need?
6) How is the child induced?
7) IV access is established immediately for drug delivery of what 2 drugs?

Back 13

1) Vital signs monitors placed first
2) TEP, BPC - Temperature probe, ECG leads, Precordial steth, Blood pressure cuff, Pulse ox, Capnograph
3) THE RBC - Temperature, Hemoglobin O2 saturation, End tidal CO2, RR and PR, Blood pressure, Cardiac rate and rhythm
4) Volume and concentration
5) Ventilation and suction
6) "Masked down" with a combination of sevoflurane (standard for us) and nitrous oxide
7) Succinylcholine, atropine

Front 14

Malignant hyperthermia:

1) What is the first sign? What is it preceded by?
2) What in the med history can alert you to a possibility of it happening?
3) Trigger agents?
4) Incidence?
5) Treatment? How does the drug work?

Back 14

1) Unchecked rise in temperature, preceded by masseter contraction, tachycardia
2) Positive family history
3) Halogenated hydrocarbons, succinylcholine, N2O? but not LA
4) 1:200,000
5) Dantrolene - decrease calcium release from sarcoplasmic reticulum (removes contraction of muscles)

Front 15

1) What do you give to maintain fluid, and what is the rate?
2) This IV is also a vehicle for what agents?
3) What is the 4:2:1 rule for IV fluid maintenance?

Back 15

1) Normal saline solution, rate of 3-4 mL/kg/hr (follow 4:2:1 rule)
2) Non-inhalation (remifentanil, propofol (Diprivan - continuous infusion)
3) 4 ml/kg/hr for first 10 kg weight (1-10 kg), 2 ml/kg/hr for next 10 kg (10-20 kg), 1 ml/kg/hr for every 1 kg after 20 kg

Front 16

1) How do you place an ET tube?
2) Do we prefer a nasal or oral intubation? Why?
3) 3 ways you can prep the patient for nasal intubation?
4) 3 contraindications for using a nasal tube, AKA situations where you would want to use an oral tube?
5) How do you stabilize an oral tube? How do you maneuver a throat pack around it?
6) Proper eye protection?
7) Proper head placement?
8) How do you secure the ET tube? What do you place after?

Back 16

1) Place with McGill forceps and straight (Miller) or curved (MacIntosh) blade laryngoscope
2) We like nasal RAE, because it improves visibility, permits occlusion check, allows for full-arch isolation
3) Nasal spray, soften tube in warm sterile water, lubricate tube with surgilube or xylocaine jelly
4) Repaired CL/P, bleeding disorder, nasal obstruction
5) Tape to one side. Remove throat pack before moving tube to other side, then repack throat
6) Tape eyes closed after eye ointment is placed
7) Head placed in sniffing position by a shoulder roll and stabilized with a donut
8) Secure ET tube with tape to the head, place body drape

Front 17

1) 3 reasons why we place a moist throat pack?
2) What will an excessive throat pack do? What arch do we do first?
3) What kind of intraoral radiographs are taken? What processor is on site as a backup?
4) You need proper set-up and positions for?
5) Is the OR environment for GA clean or sterile?
6) Who does the protective gowns, masks, and gloves to protect?

Back 17

1) Protect airway, prevent gas leak-back (since we use a non-cuffed tube, we will get leakback) enhance positive pressure ventilation
2) Force tongue forward and interfere with intraoral access. Do mandibular arch first, because placement will cause tongue to swell during procedure.
3) 6 film digital intraoral films are taken for diagnostic purposes and tx is determined. Perio-pro daylight processor on site as a backup
4) Maximize speed and efficiency of delivery
5) Clean only - NOT sterile
6) Dental personnel

Front 18

1) How do you isolate? (What clamps do you use)
2) What arch do you do first?
3) When should you perform extractions?
4) What kind of sutures should you use, and what other things should you use after ext?
5) If anesthesia complications occur, what 3 things should you do?

Back 18

1) Molt mouth prop, full arch dental dams with winged #8A clamps or wingless clamps
2) Mandibular arch
3) Middle of the case, if it will not interfere with isolation and composite polymerization
4) Resorbable sutures (3-0 chromic gut) and gelfoam or surgicel
5) Remove rubber dam/throat pack, head and body drape, be prepared to assist with suction

Front 19

1) Dosage for acetaminophen suppositories
2) What is the dosage for acetaminophen IV?
3) What is critical to efficacy?
4) 30 minutes before case completion, what should you do?
5) 10 minutes before case completion, what should you do?
6) At case completion, what do you do?

Back 19

1) 15 mg/kg
2) 15 mg/kg over 15 min infusion
3) Advanced planning - always be thinking one-step ahead, active communication with DA
4) Pre-op and call for next pt
5) Warning to anesthesiologist
6) Remove throat pack and patient drapes. Clean face

Front 20

1) 7) When and how do you transport the patient to the recovery room?
2) Where is the patient monitored and when are they usually discharged? What do you discuss with the parent, and what info do you obtain?
3) When does the IV stay in? What is a concern?
4) What do you document in the dental chart?
5) What do you document in the medical chart?
6) 5 post-op orders?

Back 20

1) After PACU slot is confirmed. Feet first, anesthesiologist at head (airway)
2) Monitored in recovery room, usually discharged within 1-2 hours. Discuss outcome and post-op instructions with parent, get contact phone # for a FU appointment
3) If child can't swallow or if they're vomiting - keep the IV in until we're sure that they can hold fluids. Dehydration and fever are a concern
4) Tx, charges, notes
5) Post-op notes, orders, post-op and discharge instructions
6) Acetaminophen 15 mg/kg qid PRN pain, liquid diet and advance to soft diet when tolerated, hemorrhage control - apply pressure gauze pack over bleeding site for 5 minutes. Bed rest. Notify if temperature >101 F, Vomiting >3 times, pain not controlled with acetaminophen PO

Front 21

1) 5 post-op complications?
2) What do you do if they vomit >3 times?
3) 4 antiemetic medications and dosages?

Back 21

1) Vomiting, fever (>101 degrees F), sore throat, bleeding (swallowed blood causes vomiting), edema and swollen lips
2) Stop all intake for 2-3 hours, resume slowly with fluids and "light" soft food
3) Phenergan (25 mg), Compazine (25 mg), Tigan (200 mg), Reglan IV (droperidol)