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25 Cards in this Set

  • Front
  • Back
1) Sedation vs. General Anesthesia: what is the gold standard for pediatric care and why?
2) According to College of Diplomates, __% of dentists say that children are less cooperative now, with more __ and __ exhibited. Why?
3) What kind of behavior modification techniques are parents accepting less? More?
4) Things you need to take into account for tx option acceptance?
5) What kind of shift are we seeing in clinical styles?
6) When does GA become more cost effective than enteral sedation?
1) GA - 100% successful and safe, airway is protected
2) 88%, crying, struggling. Less discipline and limits set, parents have unrealistic expectations of dentist, parents don't assume responsibility
3) Less: voice control, HOME, physical restraints. MORE: Drugs (nitrous, sedation, GA), parents in the operatory (more trust)
4) Minimize choices, esthetics, convenience, schedule, cost
5) Management styles => less assertive modes (older people - discipline-oriented, younger dentists - deferment style)
6) GA more cost effective if you'll need more than 3 sedation appts
4 goals of pediatric dental sedation and why?
Quiet Down Patient's Weirdness

1) Quality dental care - quality of restorations under GA better for all parameters, higher need for re-tx in sedation, success of restorations higher in sedation pts with positive behavior)

2) Disruptive behavior minimized - success rate is 60-70% regardless of definition, drug modality used, practice location/type

3) Positive psychological response to tx - however, studies show no difference in child's future dental behavior or anxiety comparing PS to GA or PS to controls

4) Welfare and safety - no cases of mortality since 1985 when AAPD guidelines were employed as standard of care
How do you prepare your staff and you to defend your office's sedation procedures?
1) Hold staff meetings to discuss report, review guidelines/QA/ER plans and identify spokes-person for office
2) Explain that office strictly follows the AAPD sedation guidelines to ensure the safety of their patients
3) Defend the office safety record
4) Provide the experience and training of the dentist and staff
1) Cote's review of adverse sedation events found that successful outcomes were associated with what 2 things?
2) Unsuccessful outcomes most likely due to what 3 things?
3) Chicka et al found that what is more important in producing adverse events - drug choice or drug dosage?
4) Chicka et al found that ______ is a significant factor in adverse events, _____ were more at risk, ______ was not recorded in 1/3 of cases, and ___ overdose is a contributing factor
1) Pulse oximeter use and appropriate monitoring
2) Inadequately trained personnel lacking appropriate skill in monitoring and intervention, drugs being administered by non-medical personnel and drugs administered at home, medications with long half-lives (chloral hydrate, promethazine)
3) Dosage
4) Lack of monitoring, younger patients, weight, local anesthetic
1) 4 root causes for adverse sedation events?
2) What is the dose response effect for increasing dose?
3) What are the main risks of opiates?
4) What are the main risks of hypnotics?
5) Without monitoring, respiratory complication lead to what 2 things?
6) Monitoring emphasizes on what?
1) LIMP - Lack of monitoring, Insufficient rescue intervention (don't recognize, diagnose, coordinate, effectively manage), Medications (respiratory depression), Physical (respiratory obstruction),
2) Increased dose => increased sedation depth => increased risk
3) Respiratory depression, mucosal irritation
4) Airway obstruction, respiratory arrest, mucosal irritation, dysrhythmia
5) Hypoxemia, cardiac arrest
6) Maintenance of airway patency
1) Dionne et al found that the oral route is the (riskiest, safest) and (most predictable/least predictable). Why?
2) What are the 5 depths of sedation?
3) What best determines achieved depth?
1) Safest, least predictable. Safest because of natural protective physiology (vomiting, first-pass elimination, muted anaphylactic response), least predictable because of poor/variable absorption => low bioavailability
2) Awake, minimal, moderate, deep, general
3) Patient responsiveness
What is the definition of minimal sedation? What was the old term?
Patients respond normally to verbal commands, cognitive function and coordination may be mildly impaired but ventilatory and cardiovascular functions are unaffected (anxiolysis)
What is the definition of moderate sedation? What is NOT acceptable as the only purposeful response for this level of sedation? What is the old term?
Patient respond PURPOSEFULLY to verbal commands, either alone or accompanied by light tactile stimulation

- Older patients: Implies interactive state if prompted by provider

- Younger patients: Indicated by age appropriate response + behaviors - e.g. crying

Reflex withdrawal (although a normal response to painful stimulus) is NOT acceptable as only purposeful response

No interventions needed for patent airway, cardiovascular function is usually

Old term = "conscious sedation"
What is the definition of deep sedation?
Patients cannot be easily aroused, may respond purposefully following repeated verbal or painful stimulation. Reflex withdrawal from a painful stimulus may occur, but NOT considered higher functioning and purposeful response.

Ability to independently maintain ventilatory function may be impaired

Pts may require assistance in maintaining a patent airway (can't independently move head or maintain)

Cardiovascular function usually maintained
1) Enteral routes of administration?
2) Parenteral routes of administration?
3) Education requirements based on depth of sedation required?
4) According to CODA< we need __ N2O cases as primary operator, __ patient encounters of sedation with anything other than nitrous, and of those encounters, we must be primary operators in __
5) What DOESN'T CODA address?
6) Future options for sedation education
1) Oral (PO), rectal (PR) - anything absorbed through mucosal lining
2) IV, IM, IN, SC, SM anything injected. Submucosal and intranasal are also absorbed through mucous (enteral definition), but since they're absorbed so rapidly, they're defined as parenteral
3) Minimal - 16 hrs didactic, demos. Moderate - 24 hrs didactic, 10 case exp (3 live pts in groups of 5 participants max), Deep - 60 hrs didactic, 20 live pts per participant
4) 20 nitrous, 50 sed, primary operator in 25
5) Type of clinical cases (age, depth, route), only number, and extent of formal training (no method of eval or determination of competency)
6) Bimodal practice with minimal sedation or GA, office-based anesthesia which needs increased supply of DAs, cooperation of insurance carries and BOD, removal of dual role (dentist/anesthesiologist), increase training with IV route, improved performance in rescue skills, standardization of sedation protocols + experiences in training programs
AAPD sedation guidelines:

5 things required for equipment?
May Need Functional, Positive Equipment

1) Monitors + all equipment should accomodate kids of all ages and sizes
2) N2O must be capable of 100% O2, no less than 25%, otherwise need an in-line analyzer (need one if you go above 50% nitrous)
2) Functional suction
3) Positive pressure O2 (>90% concentration) at 10 L/min flow (15 L/min with anesthesia bag) for min of 12 hr (650 L, "E" CYLINDER)
4) Emergency kit + drugs available to resuscitate non-breathing patient
AAPD sedation guidelines:

5 things to take into considerate for patient selection?
CARMA

1) Clear, patent airway (minimal obstruction by tonsils)
2) Adherence to dietary restrictions
3) Responsible parents - accompany patient and stay at facility
4) Minimal risk - healthy ASA I, II
5) Absence of acute systemic illness
AAPD Sedation Guidelines:

9 things that should be on the pre-op record
Can Patients Die Here? NAW! Because Records Protect Patients

1) Calculation of max LA dose
2) Physical + risk assessment
3) Dietary restrictions compliance
4) Health history review (current and past, ESPECIALLY allergies, asthma, prematurity, snoring/sleep apnea, meds)
5) Name, age, weight
6) Baseline pulse ox reading + BP
7) Rationale for sedation/patient selection
8) Physician's name, phone number - consult?
9) Parental informed consent
AAPD Sedation Guidelines:

6 things required for intra-op record
Detailed, Precise Records Covered During Sedation

1) Drugs (including LA, N2O - time, route, dose)
2) Periodic vital signs (recorded at appropriate intervals - rules not given, so rule of thumb is deep sedation 5 min, moderate 10 min, minimal none at all)
3) Responsiveness of patient
4) Complications/morbidity
5) Duration of procedure
6) Status of patient upon discharge
AAPD Sedation Guidelines:

3 levels of responsiveness?
1: Uninterrupted interactive ability, totally awake, eyes always open

2: Minimally depressed consciousness, responds to verbal commands, eyes closed temporarily

3: Moderately depressed consciousness, asleep, responds to physical stimulation, requires airway maneuver occasionally
AAPD Sedation Guidelines:

6 monitoring requirements?
PARC in DC

1) Pretracheal steth (intraoperatively)
2) Adverse occurrences recorded/reported
3) Record (permanent) compelted
4) Continuous monitoring with pulse ox during sedative state
5) Drugs (ALL) must be administered in office
6) Continuous observation by qualified personnel
1) How many personnel are needed for minimal sedation, moderate sedation, deep sedation, and GA?
2) What monitoring do you need for minimal sedation, moderate sedation, deep sedation, and GA?
3) What monitoring info do you need for each?
4) Frequency recorded?
1) 2 for min/mod, 3 for deep/GA
2) Min - only clinical observation. Mod - BPC, PO, PC/capno. Deep - add ECG. GA - add temp.
3) Min - skin color/resp effort. Mod - HR, RR, BP, SaO2. Deep - Add ETCO2, ECG. GA - Add temp
4) Minimal - continual. Mod - q15 minutes. Deep and GA - q5 minutes.
AAPD Sedation Guidelines:

7 discharge criteria?
SHARP CATE

1) Sit
2) Hydration adequate
3) Ambulatory with minimal assistance
4) Responsible adult available
5) *Presedation level of responsiveness achieved*
6) Cardiovascular function satisfactory and stable
7) Airway patency uncompromised and satisfactory
8) Talk
9) Easily arousable and protective reflexes intact
1) What supersedes what - national guidelines or state law?
2) How many states require a permit? What district is least regulated? What states are highly regulated? What is the most common renewal interval?
3) How many states regulate by parenteral route only? How many states require CE specifically relevant to sedation practices?
4) Do all states follow ADA guidelines?
5) What % of states require certification in ACLS?
6) Conclusions: State boards have (increased/decreased) regulation of oral sedation over the past 10 years. What are some complications?
1) State law always supersedes national guidelines
2) 41 (and they require a fee. West, Mid Atlantic and South Central, biennial
3) 7, 71%
4) NO
5) 66%
6) Increased - state regulations are constantly changing, hard to maintain up-to-date info for trending, existing rules + requirements vary widely, need to develop more unified approach to governing sedation
1) Definitions of sedation levels in Florida are based on?
2) T or F: a single oral agent with N2O is exempt from Florida sedation permit law
3) What are the 3 different types of anesthesia permits you can have in Florida? What are the requirements for each?
1) Depth
2) T
3)
a) GA/deep - 1 yr anesthesia training OR oral surgeon/DA + ACLS + facility/staff requirements

b) Parenteral conscious sedation - 60 hrs didactic + 20 pts treated, covers pediatric conscious sedation. + PALS/ACLS + must sedate only 1 pt at a time per permit holder

c) Pediatric conscious sedation: 60 hrs didactic + 20 pts treated, pts <18 years or special needs, PALS/ACLS, office inspection
1) What does permit issuance in Florida require? What does re-issuance require?
2) Is permit issued for the individual or for a specified facility?
3) What are the 3 requirements for the op room?
4) What does the recovery room require?
5) What equip needs to be readily available to both rooms?
6) What emergency equipment do you need to have with conscious sedation
7) How many hours of CE do you need in FL each biennium?
1) $300 fee ($200 renewal every 2 years), certificate of formal training by approved institution (60 hrs didac. 20 hrs pt), facility inspection to demonstrate compliance to req. Re-issue: training in type of anesthesia + clinical admin to 20 pts within 2 years prior to app
2) Specified facility
3) Right size + design to permit emergency equip, chair or table for emergency tx (including CPR board of chair good for CPR), suction + BACKUP suction equipment, also including tonsil suction tips
4) Suction + backup, positive pressure oxygen, sufficient light, good size + design, dentist must be able to see it at all times
5) PABST'S Pulse Ox - Positive pressure oxygen and backup system w/ full face mask for pedo, Airways for pedo, BP cuff and stethoscope, Suction and backup suction (including tonsil suction tips), Thermometer, Scale, Pulse ox,
6) IV set-up with hardware + fluids, syringes, tourniquet, tape, AED (defib equipment)
7) 4
1) T or F: In Florida, you can use a single enteral sedative administered in dosage UNSUPERVISED for tx of anxiety
2) Does minimal sedation involve oral titration method?
3) Do you need a conscious sedation permit to provide minimal sedation (anxiolysis)
4) If you use nitrous + single dose of enteral sedative or single dose narcotic analgesic, and don't exceed the manufacturer's MRD of enteral agent, do you need a sedation permit?
5) Can you do multiple sedations at a time?
6) If you bring in a pediatric anesthesiologist, can they bring in their own equipment do bring your office up to DEEP sedation standards? What do they need to bring?
7) Administration of GA requires how many individuals?
8) A dentist can comply with ECG and PCO2 equipment being mobile if they do what? How long is this good for?
1) T
2) NO
3) No
4) No, as long as you don't exceed the MRD
5) No, cannot induce a pt until the other is fully recovered
6) Yes! LECC SAD - Laryngoscope/McGill/ET Tubes/Stylet, ECG, Capno, Cricothyrotomy Set. Succinylcholine, Adenosine, Dantrolene when used with volatile gases
7) 3 - operating dentist, person assisting, person monitoring the patient
8) Have it inspected by a licensed health care risk manager. Good for 12 months
Proper administration of drugs according to the state board?
1) Drugs must be administered in the dental office
2) Patient must be observed by a qualified office staff member
3) Continuous monitoring with pulse ox must be initiated with early signs of conscious sedation and continued until pt is alert
ADMINISTRATION OF A SEDATIVE AGENT IS AN IRREMEDIABLE TASK THAT CANNOT BE DELEGATED BY A DENTIST TO A DENTAL STAFF MEMBER
What requires an adverse occurrence report and how do you file it properly?
Incident requiring hospitalization or ER tx, written notification to Board within 48 hrs and complete written report filed within 30 days
16 emergency drugs you need to have?
A LEAN VANAA CABANA

- Atropine
- Lidocaine
- Epi
- Antihistamine
- Narcotic and benzodiazepine antagonists
- Vasopressor
- Antihypoglycemic
- Nitroglycerine
- Antiemetic
- Anticonvulsant
- Corticosteroid
- Anticholinergic
- Bronchodilator
- Antihypertensive
- Nitroglycerin again?!
- Amiodarone