Sedation Lecture 4

Front 1

1) What is the definition of pharmacokinetics?
2) What is the definition of pharmacodynamics?
3) What are the 4 components of pharmacokinetics?

Back 1

1) What the body does to the drug
2) What the drug does to the body
3) ADME - absorption, distribution, metabolism, excretion

Front 2

PHARMACOKINETICS:

1) What is absorption and bioavailability?
2) What is distribution? What are the factors that affect distribution? How does distribution in kids differ from adults?
3) What is metabolism?
4) Elimination is?
5) IV route bypasses what?

Back 2

1) Diffusion of mucosa into plasma. Bioavailability is the resulting plasma concentration
2) Plasma to tissue. Blood-brain barrier, plasma protein binding, fat. Kids have a lower volume of distribution so they need a higher dosage.
3) Break down of drug to metabolites
4) Clearance
5) Absorption and distribution

Front 3

According to the Becker article,

1) What is % bioavailability?
2) What does the PO route require? What % bioavailability do you get from it?
3) What does SL (topical) route require? What % bioavailability?
4) What routes give you 100% bioavailability?
5) Map out the route of a drug through PO route. How does this affect dosage compared to IM or IV?
6) Does SL have first pass metabolism?

Back 3

1) The amount of drug absorbed into systemic circulation
2) Liposolubility (tissue diffusion), first pass hepatic metabolism by CP450 enzymes, bioavailability is 40-60%
3) Liposolubility and metabolism of unknown amount swallowed, 80%
4) IV, IM, SC routes
5) PO goes through gut mucosa, capillaries, to liver and vena cavae. You need to give a higher dose PO because it goes through first-pass metabolism and IM/IV doesn't.
6) No, goes straight into capillaries => liver

Front 4

First pass hepatic effect

Back 4

After a drug is swallowed, it is absorbed by the digestive system and enters the hepatic portal system. It is carried through the portal vein into the liver before it reaches the rest of the body. The liver metabolizes many drugs, sometimes to such an extent that only a small amount of active drug emerges from the liver to the rest of the circulatory system. This first pass through the liver thus greatly reduces the bioavailability of the drug. Alternative routes of administration like suppository, intravenous, intramuscular, inhalational aerosol, transdermal and sublingual avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation.

Front 5

1) Rate and amount of drug distribution depends on what 3 things?
2) Sedative drugs with good lipid solubility are distributed in proportion to _______. Which organs are distributed to first?
3) What limits the amount of free drug in the blood stream? What factor affects this?
4) Competition for the same protein binding sites does what to the free drug availability?
5) What influences the potency and effectiveness of a drug?

Back 5

1) Degree of tissue perfusion (blood supply) and drug affinity for that tissue, nature of capillary bed (ie CNS capillaries have the blood-brain barrier, a tight endothelial junction)
2) Degree of tissue perfusion. Brain-> kidney/liver -> muscle -> fat/bone
3) Plasma protein binding. Acidity affects it - lower pH releases drug from binding, so increase risk of toxicity
4) Increases free drug availability
5) The amount of free drug

Front 6

1) Where does metabolism generally take place?
2) What are the metabolites of codeine and Valium like?
3) How do drugs that undergo hepatic metabolism affect drug availability?
4) How does CP450 enzyme inhibition affect drug elimination and drug action?
5) Does Rifampin inhibit or induce CP450 enzymes?
6) Does Cimetidine and Clarithromycin inhibit or induce?

Back 6

1) Gut mucosa and liver by cytochrome P450
2) They have active metabolites, so they have a longer duration of action. Codeine's active metabolite is morphine! Codeine, hydrocodone, and oxycodone are converted to their principal active metaoblites by CYP2D6
3) They are usually substrates for the same enzyme so they can INHIBIT or INDUCE enzyme action. If they inhibit the enzyme, they increase availability. If they induce it, they decrease availability.
4) Reduces drug elimination, prolongs drug action
5) Induces, so shortens sedation
6) Inhibits, so prolongs sedation

Front 7

Drug elimination:

1) What is half-life? How many half-lives does it take to completely eliminate a drug?
2) How does the elimination rate of a PO drug compare to IV?
3) T or F: half life determines the drug duration of action.
4) Once drug is metabolized, it is secreted through..?

Back 7

1) Time required to reduce plasma concentration by 50%. 4 half-lives.
2) Once it's distributed, elimination rate is the same as an IV drug.
3) F - drugs vary with their threshold concentration to achieve effect
4) The kidney

Front 8

Definition of:
1) Drug efficacy
2) Drug potency - is it realed to efficacy or toxicity?
3) Drug safety (therapeutic index)
4) t or F: All adverse reactions are dose related, and allergic reactions and toxic reactions are similar
5) How is ketamine's efficacy and potency?
6) What is the potency of benzos like?
7) What is the efficacy and potency of chloral hydrate like?
8) Is a wider therapeutic index good or bad?

Back 8

1) Effectiveness (how great the drug works when you get it to where it needs to go)
2) Amount required to create the effect - not related to efficacy or toxicity (how much you need to get to where you need to go)
3) Range between effective (ED) and toxic dose (TD)
4) F - allergic reactions are not dose related at all, can react to just a little bit. With toxic reactions, it's all about the quantity of drug given
5) Ketamine has high efficacy and potency (don't need a lot to get sedated, works great once you reach the right dose)
6) Not potent (need a lot to get the effect)
7) Very effective, but not potent (need a big dose of the drug to get you to the effect, but once it's there, it works very well)
8) Good - you're farther away from the toxic dose

Front 9

1) What is TI (therapuetic index) equal to?
2) Name some wide therapeutic index drugs
3) Name some narrow therapeutic index drugs

Back 9

1) LD50/ED50 (where 50% of subject die/where 50% of subjects get desired response)
2) Penicillin Ain't Illin Anyone, Bro - Penicillin, Acetaminophen, Ibuprofen, Antihistamines, Benzodiazepines*
3) However, Lidocaine Causes Everyone's Death - Hydrocodone, Lidocaine, Codeine, Epinephrine, Demerol

Front 10

Sedative Side Effects:

1) What are Type A effects?
2) Type B?
3) Idiosyncratic?
4) Paradoxical?
5) What is potentiation?

Back 10

1) Major adverse events causing change in vital signs (respiratory depression, bradycardia)
2) Mild adverse event - hives, hiccups, diplopia, nausea
3) Rare adverse outcome, not expected
4) Opposite of desired effect (euphoria vs. dysphoria)
5) Synergistic effect when combining drugs with similar action (1+1 = 3)

Front 11

What is:

1) Procedural sedation? What is the dosage like?
2) Lifestyle sedation?
3) What is the third type of sedation
4) How do you perform procedural sedation for someone with chronic sedation?

Back 11

1) Acute application of agents to overcome situational anxiety/fear or induced pain/stimulation, and to immobilize during treatment. Requires higher doses, risk for toxicity
2) Chronic application of agents to manage everyday living, requires lower doses that can lead to habit and tolerance
3) Recreational use
4) Always make sure they're on their current chronic m medication (don't adjust anyone else's meds), dose with lower dose but keep in mind that they might have a good tolerance

Front 12

1) What are the 4 factors that should lead you to select a sedative agent?
2) Some factors of the pt that it might depend on?
3) What is the reversal agents for narcotics? Benzos?
4) What agents don't have reversal agents?
5) Picking the right sedative agent depends on the operator's?

Back 12

1) The Perfect Restful Sleep - Therapeutic index high, Potential to deliver sedation beyond intended level is low, Reversal agent, Somnloence/respiratory depression risk is minimal
2) Age/emotional maturity, cognitive development, temperament and attachment characteristics, coping and communicative skills, level of displayed behavior, current meds, health history, physical (risk assesment), past experience
3) Narcon. Flumazenil.
4) Chloral hydrate, local anesthetics
5) SEED - Skills/training, experience and preference, estimated length of sedation and desired goal of sedation

Front 13

1) What are the depths of sedation and what drugs do you use to accomplish them?

Back 13

1) Awake => minimal sedation (N2O + single benzo or antihistamine) => moderate sedation (Low dose combined hypnotics, opiates) => deep sedation (high dose combos) => GA

Front 14

Level of sedation, analgesia, and amnesia for: Barbiturates

Back 14

Great sedation, no analgesia, no amnesia (great for sedation only)

Front 15

Level of sedation, analgesia, and amnesia for:
Benzodiazepines

Back 15

Great sedation, no analgesia, great amnesia (great sedation and amnesia only)

Front 16

Level of sedation, analgesia, and amnesia for:
Opioids

Back 16

Good sedation, great analgesia, no amnesia (sedation and analgesia only)

Front 17

Level of sedation, analgesia, and amnesia for:
Ketamine

Back 17

Great sedation, great analgesia, good amnesia (only one pretty good for all 3)

Front 18

Level of sedation, analgesia, and amnesia for:
Propofol

Back 18

Great sedation, no analgesia, ok amnesia

Michael Jackson got great sleep but no pain relief, and he kind of forgot about it.

Front 19

Level of sedation, analgesia, and amnesia for:
Chloral Hydrate

Back 19

Good sedation, no analgesia or amnesia (sedation only)

Front 20

Level of sedation, analgesia, and amnesia for:
Nitrous oxide

Back 20

Good sedation and analgesia, okay amnesia (has all three)

Front 21

1) What is the most popular route of sedation in postdoc education? Approach? Drug?
2) What drugs have decreased in use over the decades?
3) What 3 trends occurred over the last decade?
4) What is THE most popular drug?

Back 21

1) Oral (98%), combined drugs (79%) with nitrous (89%), diazepam/midazolam (88%)
2) Chloral hydrate (down 24%), meperidine (down 16%)
3) Increased lighter sedation experience, increased number of sedation performed (57%), increased emergency preparedness training
4) Oral midazolam

Front 22

Top 5 reasons for why dentists choose to do PS? What is the top region in the US for using PS?

Back 22

1) Better experience for pts
2) Nitrous not always effective
3) Parents request it
4) Helps control bad behavior
5) Improves quality of treatment

South

Front 23

Top 5 reasons why dentist do NOT do PS?

Back 23

1) Don't want liability
2) Prefer OR
3) Nitrous does the trick
4) Able to manage difficult patients without PS
5) Not worth the hassle

Front 24

Why is there such a wide range and combination of agents used?

Back 24

1) No one agent yields a superior outcome
2) Selection determined by desired level of sedation or acceptable level of liability
3) Lack of uniformity among training programs
4) Community standard of practice

Front 25

What are the different routes of administration?

Back 25

1) Inhalational
2) Enteral (goes through GI tract): Oral (PO) and rectal (PR)
3) Parenteral: Intravascular (IV), intramuscular (IM), subcutaneous (SC), submucosal (SM), transmucosal (TM - and within this is sublingual SL and intranasal IN)

Front 26

What are the transmucosal routes of administraion, and why are they classified as parenteral?

Back 26

Sublingual (SL) and intranasal (IN) - they would be considered enteral, but they are considered parenteral because of rapidness of achieving blood levels

Front 27

What are the 5 disadvantages of oral route administration? What is the failure rate?

Back 27

The Oral's Unpredictable, Tastes Bad

1) not Titratable to desired effect, redosing is not advised
2) slow Onset and recovery
3) Unpredictable - level can be anticipated, but never predicted (accept 30% failure rate)
4) poor Taste and GI disturbance
5) low Bioavailability due to first pass hepatic metabolism and variation in intestinal absorption (GI pH, motility, contents)

Front 28

Common oral agents for pediatric conscious sedation, and their manufacturing names?

1) Chloral hydrate
2) Phenergan
3) Demerol
4) Versed
5) Atarax
6) Valium

Back 28

Certain Pharmaceuticals Make My Head Drowsy

1) Chloral hydrate (opioid)
2) Promethazine (antihis)
3) Meperidine (opioid)
4) Midazolam (benzo)
5) Hydroxyzine (antihis)
6) Diazepam (benzo)

Front 29

1) What are the most commonly used single agents, and what kind of sedation do they achieve alone?
2) What are the most common combinations of agents, and what kind of sedation do they achieve alone?

Back 29

1) Diazepam (Valium) , midazolam (Versed), hydroxyzine (Atarax/Vistaril) - MINIMAL SEDATION
2) Ch + H (chloral hydrate + hydroxyzine), Ch + D + H (chloral hydrate + demerol/meperidine + hydroxyzine) , Demerol + Phenergan (Meperidine + Promethazine), - moderate sedation

Front 30

1) 5 advantages of oral benzodiazepines?
2) Name the 4 properties of benzos
3) Name common oral benzos used for PS
4) What is the sequence of effects with increasing serum levels (receptor site occupancy)?
5) What causes sedation with oral benzos (what is the mechanism of action)?

Back 30

1) WARMS - Wide therapeutic index (safety/efficacy not easily affected by dosage), Acceptable properties (anxiolytic, amnesic, anticonvulsant, muscle relaxant), Reversal agent (Flumazenil), Minimal adverse reactions, Short to intermediate onset of action,
2) MAAA - muscle relaxant, anxiolytic, amnesic, anticonvulsant
3) Diazepam (Valium), midazolam (Versed), triazolam (Halcion - don't really use in pediatrics)
4) Anxiolysis -> anterograde amnesia -> sedation
5) Interact with GABA receptors, increase their inhibitory action

Front 31

TRIAZOLAM:

1) Drug type? Product name?
2) What is the dose?
3) How do you administer? Bioavailability with sublingual?
4) Onset time?
5) Half-life time?
6) How does it affect children?
7) What scandal is this causing?

Back 31

1) Benzo. Halcion
2) 0.125 mg (child)
3) Oral or sublingual (crush and sprinkle under tongue - 28% better bioavailability because avoids hepatic first pass effect)
4) 30-60 minutes
5) 2 hours
6) SUCKS! Don't really use in pedo
7) Docs, "Oral titration" - booster (incremental doses) lead to overdose. Plasma levels of 3 doses of 0.25 mg Halcion given at 30 minute intervals)

Front 32

DIAZEPAM:

1) Drug type? Product name?
2) 6 properies of valium?
3) What drugs potentiate sedation and may cause you to lower the dose?
4) What drugs inhibit sedation and may cause you to up the dose?
5) What is the solution?
6) What is the dosage?
7) Chemistry: what pH is it active in? Inactive? What form is it in when it's inactive?

Back 32

1) Benzo, Valium
2) DDIMPS - Drug interactions (erythromycin, graepfruit juice increase sedation, affect CP450 enzymes), Delayed onset (30-60 minutes), Inexpensive, Muscle relaxant (spastic cerebral palsy), Prolonged recovery due to active metabolites which are also sedatives (Desmethyldiazepam, Temazepam and Oxazepam aka Serax), Safe and effective
3) Influenced by CP450 enzymes, interact with erythromycin, clarithromycin and grapefruit juice, the azoles, cimetidine, verapamil/diltiazem (inhibit metabolism) which increase sedation
4) Anti-seizure drugs - CPR - carbamazepine (tegretol), phenytoin (dilantin), rifampin (rifadin)
5) 5 mg/5 mL
6) 0.2-0.5 mg/kg (1 mg per year of age)
7) >5, 3.5 - open-ring form.

Front 33

1) In a study by Pisalchaiyong, how did oral diazepam do vs. midazolam in autistic children?
2) Onset of action for midazolam? Diazepam?
3) Duration of action?

Back 33

1) Midazolam was more effective during periods of increased oral stimulation. His personal preference is valium (diazepam) for older kids, midazolam for younger
2) Midazolam - 20-30 minutes. Diazepam: 30-60 minutes
3) Midazolam - 30-45 minutes. Diazepam: 60 minutes

Front 34

What are the 5 advantages of Midazolam (Versed) over Diazepam?

Back 34

WARRP

1) Water soluble (less irritating IM/IV)
2) Amnesia is stronger
3) Rapid onset because higher lipid solubility
4) Rapid recovery (half-life is 2-3 hours)
5) Potency is 2x that of diazepam

Front 35

How did 0.2 mg/kg midazolam IN do vs. 3.7 mg/kg hydroxyzine PO in 2 year olds when it came to the Stanford-Binet Memory for Objects Test (which had better amnesia?)

Back 35

Midazolam had way better anterograde amnesia than hydroxyzine. 29% of subjects under Midazolam recalled objects, 71% recalled with hydroxyzine

Front 36

MIDAZOLAM:

1) What are the physiological complications of Midazolam?
1a) What are the unique properties that allow a change in operational philosophy?
2) 4 characteristics of Midazolam's paradoxical response?
3) How does Midazolam affect quiet, sleeping, crying, and struggling compared to Chloral hydrate + hydroxyzine or Chloral hydrate + demerol + hydroxyzine?

Back 36

1) HARD NaP - Hiccups, Ataxia (loss of head control - injury, loss of airway), Respiratory depression (hypercarbia, stridor, apnea - more common with IM/IN routes), Diplopia, Nightmares/hallucinations (57% in 1-10 yo after 1 week FU), Paradoxical reaction (2%, dysphoria, whining, agitation, higher incidence in ADHD)
1a) TREQS
- Turnaround time faster
- Reversal agent improves safety
- Efficient emergency dental service
- Quadrant restorative therapy
- Shorter appointments
2) DOUR - Dysphoria + agitation, onset is 45 mins after admin and can last several hours, Uncontrolled screaming and thrashing not responsive to console attempts (classic sign), Reversed by flumazenil
3) Produces more quiet and less sleep behavior. Equal crying and struggling

Front 37

**MIDAZOLAM, ORAL ROUTE **

1) What is the dosage for oral midazolam?
2) Onset time?
4) Duration of action?
5) How long does recovery take?
6) Half-life?
7) Bioavailability?
8) Oral syrup - sol'n? Max dose?
9) 1 tsp = __ mL

Back 37

1) 0.5-0.75 mg/kg, 20 mg max dose (4-7 x parenteral dose, which is 0.05-0.1 mg/kg)
2) 20-30 minutes
4) 30-45 minutes
5) 60-90 minutes
6) 2-3 hours
7) Low (36%) - cytochrome P450 enzymes in GI mucosa cells and liver process it.
8) 2 mg/mL, max dose is 20 mg = 10 mL (2 tsp)
9) 5 mL

Front 38

Midazolam - Injection form
1) We use injection form for what route? What concentration should you use?
2) How is it packaged? What is our dept using?
3) What is the pH?
4) What is the best vehicle to mask it?
5) What is your max amount of teaspoons you should do?

Back 38

1) Nasal. 5 mg/mL to minimize volume to be swallowed, mask bitter taste with flavoring agents
2) 1 mg/mL and 5 mg/mL in 1, 2, 5 and 10 mL vials. Our dept uses 50 mg in 10 mL vial (5 mg/mL) - reserve for IN!
3) 3.5 - crappy acidic taste
4) Probably Ibuprofen
5) 2 tsps (10 mL)

Front 39

Midazolam Ibuprofen Vehicle:

1) What are the types?
2) What are the properties?
3) Dosage?

Back 39

1) Children's Advil, children's motrin
2) NAA: NSAID - inhibits prostaglandin synthetase, Antipyretic, Analgesic acting at peripheral nerve cells
3) 10 mg/kg q 6-8 hours

Front 40

Midazolam supplemental vehicles:

1) What can you add for additional duration/less post-op agitation?
2) What 3 things can you add for improved analgesia?

Back 40

1) Hydroxyzine, 1-2 mg/kg
2) Acetaminophen elixir (15 mg/kg), Ibuprofen (10 mg/kg), Meperidine syrup (1 mg/kg)

Front 41

1. What are the recommended dosages of oral midazolam + hydroxyzine?
2. Midazolam + Hydroxyzine Vehicle Properties?
3. So adding hydroxyzine to midazolam has what benefits?

Back 41

1. 0.3 mg/kg midazolam + 3.7 mg/kg hydroxyzine, or 0.5 mg/kg midazolam + 2.0 mg/kg hydroxyzine


BAAAPS

1) Bronchodilator
2) Antihistamine (decreases edema, inflammation)
3) Anticholinergic (drying)
4) Antiemetic
5) Potentiates CNS depression
6) Sedative

3. Improved duration, less post-op agitation, decreased crying and movement behavior for first 30 minutes

Front 42

Hydroxyzine Suspension:

1) Dosage?
2) Half-life?
3) Onset?
4) Duration?
5) Two types of suspensions and how they're packaged?
6) What did a study find about the additive effect of Hydroxyzine PO if 20 mg is given 24 hrs pre-op, in addition to 3.7 mg/kg PO given at appointment with N2O?

Back 42

1) 2-3.7 mg/kg as single agent with nitrous
2) 3-20 hours
3) 30-40 minutes
4) 2-4 hours
5) Vistaril capsules = 50 mg, 25 mg. Atarax: 10 mg/5mL. . high volume to reach dose!

6) No benefit with the additional Hydroxyzine

Front 43

Additive Effect of Hydroxyzine with Oral Midazolam (Shapira) gave 0.5 mg/kg MDZ alone, 20 minutes prior, and compare dit with 0.3 mg/kg MDZ plus 3.7 mg/kg hydroxyzine 30 minutes prior to procedure. What did they find?

Back 43

Crying movement behavior was less during the first 30 minutes for the combined regimen - the combination approach is best.

Front 44

OTC DIPHENHYDRAMINE:

1) Dosage?
2) Types?

Back 44

1) 1-2 mg/kg
2) Benadryl tablets (25, 50 mg), syrup 12.5 mg/5mL, elixir 25 mg/5 mL. Diphen tablets (25 mg)

Front 45

CONVERSIONS:

1) 1 kg = ___ lbs
2) 1 lb = ____ kg
3) 1 teaspoon = ___ mL
4) 1 tablespoon = ___ mL
5) 1 grain = ____ mg
6) 1 mg = ____ mcg

Back 45

1) 2.2
2) 0.45
3) 5
4) 15
5) 60
6) 1000

Front 46

1) What is the benzodiazepene antagonist name?
2) How is it packaged?
3) Initial dosage? Max dose?
4) Follow up dosage?
6) Shelf life?
7) IV administration - incidence of injection pain is ___%
8) IV administration - Onset of action?
9) IV administration - plasma half-life?
10) SM administration: where do you administer?
11) Onset of action?

Back 46

1) Flumazenil (brand name: Romazicon)
2) 0.1 mg/mL in 5 and 10 mL vials
3) 0.01 mg/kg initial, up to max dose of 0.2 mg
4) 1-2 minutes
6) 1 year (short)
7) 6%
8) 1-2 minutes
9) 1-1.5 hrs
10) In maxillary tuberosity away from LA site
11) 5 minutes

Front 47

FLUMAZENIL:
1) How does the blood level achieved compare between IV and SM routes?
2) How does it affect the tissue at SM injection site?
3) In the study by Unkel, how do the IL, SM, and IV routes compare in reversing midazolam-induced oxygen desaturation
4) What is the method for administering Flumazenil to a 20 kg (6 yo) child?
5) How do you support the child through recovery?
6) Duration of action?

Back 47

1) Similar
2) Tissue biopsy is normal
3) Comparable
4) Initial dose = 0.2 mg => 2 mL in 3 ML syringe given SM or SL. Wait 3-5 mins for desired effect, follow up dose 0.1 mg -> 1 mL SM or SL. This is the max dose
5) Airway support and oxygen supplementation, observe for 2 hours, place pulse ox on and observe for RAH - resedation, hypoventilation, anxiety
6) 20-30 minutes (less than midazolam, so have to be concerned about re-sedation)

Front 48

1) What are the ways you can administer medication?
2) According to Primosch and Bender, is oral administration compliance a good predictor of sedation outcome?
3) What are the 3 oral syringe types?
4) Syringe etiquette?
5) What are some complications of syringing medication in?
6) According to Primosch and Bender, what are the factors common to IN route selection?
7) Management techniques common to IN route?

Back 48

1) Dropper, syringe, dosing spoon, dosing cup (25 mL, graduated)
2) No
3) 5 mL self-righting tip cap, 10 mL with slip-tip cap, curved tip irrigating
4) Slightly recline child, use slowly, inject by side of tongue or alongside of your finger
5) Aspiration, laryngospasm, conjunctivitis
6) Younger age, shorter procedures, emergency appointment, exts, no prior sedation experience
7) Increase papoose board, decrease nitrous oxide/oxygen inhalation

Front 49

Midazolam Oral vs. Nasal Routes - Johnson et al:

1) How did crying and overall behavior compare in patients who received oral midazolam vs. IN?
2) How did the success of oral compare to nasal?
3) Which method did clinically significant desaturations occur more with?

Back 49

1) Patients who had oral had improved crying and behavior early in appt
2) Effective or very effective significantly more often than intranasal sedations
3) Occurred in both - so monitor effectively

Front 50

What are the advantages of the nasal route of midazolam?

Back 50

Crying Babies Rapidly Turn Compliant & Docile, Everyone!

Cmax is equivalent between IV and IN routes
Bioavailability is higher (avoids first pass metabolism)
Rapid onset = 10 minutes
Taste avoided
Compliance not required
Dietary precautions are relaxed
Emergency Extractions possiblre

Front 51

1) Do you have to strictly adhere to fasting requirements when you administer midazolam IN?
2) How do drops compare to spray?
3) What is the mechanism of absorption with the nasal route?
4) What is the only location in the body that provides a direct link to the CNS?

Back 51

1) No
2) Spray with atomizer = better tolerance (less burning and bitter taste), spray is more effective due to greater CSF and plasma uptake
3) Sprayed into nasal mucosa => absorbed rapidly through cribiform plate into the CNS by 3 routes (olfactory neurons, surrounding capillary beds, CSF)
4) Nasal mucosa

Front 52

1) Use of an atomizer: how big is a particle size? How should you spray it? How much of a dose should you give per naris? How much dead space is in the system?

Back 52

1) 30 u, spray in short sprays, 1/2 dose per naris, 0.1 mL dead space in the system

Front 53

1) Dallman et al: How does 0.2 mg/kg intranasal midazolam compare to 62.5 mg/kg chloral hydrate with 12.5 mg promethazine?
2) What are 2 exceptions to a fixed dosage regimen?
3) What is the maximum recommended dosage for midazolam orally and nasally?

Back 53

1) Pts with IN midazolam slept less and recovered quicker. It's as safe and effective.
2) Younger patients need a higher dosage due to lower volume of distribution, obese patients require lower dosage (if weight > weight based on age, then dose based on age, not weight)
3) 20 mg PO, 10 mg IN

Front 54

CHLORAL HYDRATE:

1) What kind of drug is it?
2) What is it rapidly metabolized into, and then what is it converted into in the liver?
3) Half-life?
4) What does its chemical structure resemble? Why is this bad?
5) What are the 4 advantages of using chloral hydrate?
6) What is the best age range for use?
7) Disadvantages?

Back 54

1) Hypnotic
2) Trichloroethanol, trichloroacetic acid (cardiotoxic metabolite)
3) 4-14 hrs
4) Halothane. Myocardium may be sensitized to adrenergic amines
5) Hydrate Likes Wide Babes - Hypnotic (produces sleep), Long hx of use/safety, Wide therapeutic range, Ages 2-5
6) Ages 2-5
7) BAD PRAMS
Bitter taste
Airway obstruction can be caused by somnolence/hyptonocity of glossal mucles
Delayed onset and prolonged recovery
Paradoxical reaction (agitation, disinhibition, dysphoria)
Reversal agent not available
Arousal frequency related to intensity of stimulation
Mucosal/gastric irritation causes vomiting

Front 55

1) Is chloral hydrate approved by the FDA?
2) Concentration?
3) Dosage?
4) Dose range?

Back 55

1) NO
2) 100 mg/mL
3) 30-50 mg/kg
4) 500-1500 mg

Front 56

CHLORAL HYDRATE + Hydroxyzine:

1) Chloral hydrate: concentration? Dosage? Dose range?
2) Hydroxyzine in combo: Concentration? Dosage? Dose range?
3) In Hasty et al's study comparing CH @ 50 mg/kg with 25 mg hydroxyzine and meperidine at 1.5 mg/kg vs. CH @ 50 mg/kg with 25 mg hydroxyzine, what did they find?

Back 56

1) 100 mg/mL, 30-50 mg/mL, 500-1500 mg
2) 5 mg/mL, 1-2 mg/kg, 25-50 mg
3) The addition of meperedine resulted in more quiet behavior

Front 57

OPIOIDS (NARCOTICS)

1) List the 5 opioid agents?
2) 4 properties?
3) Narcan: how is it packaged, how much do you give and how often? Max?
4) For a 15 kg child, how much would you give?

Back 57

1) My Favorites Are Morphine + Codeine: Meperidine, Fentanyl, Alphaprodine, Morphine, Codeine
2) SANA: Sedative, Analgesic, Narcan, Antispasmodic
3) 0.4 mg/mL in 10 mL vial, give 0.1 mg/kg q 2-3 minutes up to 2 mg (5 mL) total
4) 15 kg x 0.1 mg/kg = 1.5 mg (4 mL) in 10 mL syringe

Front 58

MEPERIDINE:

1) AKA?
2) Bad effects?
3) What MRD do you have to reduce and why?
4) How is it packaged?
5) Dosage?
6) Max dose?
7) Often combined with?

Back 58

1) Demerol
2) GHORR - Gastric upset and emesis, Histamine release from mast cells (precaution in asthmatics without medical consult), Orthostatic hypotension, Respiratory depression, Reduce MRD for LA as narcotics reduce plasma protein binding of LA (decrease seizure threshold)
3) Reduce MRD for LA because narcotics reduce plasma protein binding of LA (decrease the seizure threshold)
4) 50 mg/ 5 mL
5) 1-2 mg/kg
6) 50 mg
7) Phenergan (decrease vomiting)

Front 59

PROMETHAZINE

1) Aka?
2) Properties?
3) Bad effects?
4) Dosage and route?
5) Not to be given to who?
6) How its it packaged?

Back 59

1) Phenergan
2) BLAASE - bronchodilator, lowers seizure threshold, antihistamine, anticholinergic, sedative (minimal when used alone), extrapyramidal response (jerky limb movements)
3) Lowers seizure threshold, extrapyramidal responses (jerky limb movements)
4) 1-2 mg/kg PO
5) Under 2 y/o
6) Elixir: 5 mg/5 mL, syrup plain is 6.25 mg/5 mL, syrup fortis is 25 mg/5mL

Front 60

ORAL MEPERIDINE COMBOS:

1) What are the usual combos and dosages?
2) When do the effects begin? Duration of action?
3) Has usage of combos increased or decreased in recent years?
4) What are the 3 actions?
5) When do you choose to use a combo clinically?
6) What is the efficacy when you take it orally?
7) What are the bad side effects?

Back 60

1) M 2 mg/kg + P 1 mg/kg; M 1-2 mg/kg + Midazolam 0.5-0.75 mg/kg, M 2 mg/kg + CH 30 mg/kg + H 2 mg/kg (TRIPLE COCKTAIL)
2) 45-60 minutes. Duration of action is 2-3 hours
3) Decreased
4) Anti-anxiety, analgesia, sedation
5) Long appts, moderate to severely apprehensive pts, when you want moderate to deep sedation
6) Variable
7) RUN High Risk Vomiting - Respiratory depression, Unconsciousness, Nausea, Hypotension, Risk of lidocaine toxicity, Vomiting

Front 61

1) What is the original triple cocktail? Dosages?
2) How does the triple cocktail compare to midazolam in Chowdhury's study?
3) How does CH+M+H compare to CH+H or M alone, behaviorwise in Wilson et al's study?
4) What does minute volume depend on? How do Meperidine and Chloral hydrate affect it? So this combo causes what alarming potential?
5) What is the combination oral regimen for meperidine and midazolam?
6) According to Nathan and Vargas, how does the addition of meperidine to midazolam affect things? How did other studies compare?

Back 61

1) Meperidine (2 mg/kg), Chloral hydrate (30 mg/kg), Hydroxyzine (2 mg/kg)
2) CH+H+M had significantly higher success rates (89% vs. Midazolam's 70%)
3) Significantly higher quiet and sleeping behavior
4) Minute volume = RR x tidal volume. Meperidine decreases RR, chloral hydrate decreases tidal volume. Combo increases potential for respiratory depression
5) 1 mg/kg meperidine + 0.5 mg/kg midazolam
6) Adding meperidine enhances EFFECTIVENESS and DURATION of midazolam, makes 2-4 year olds easier to manage (but kids can become oversedated). Musial found no difference

Front 62

SUBMUCOSAL ROUTE:
1) How do you administer?
2) This is an alternative site to ___ route for reversal agents

Back 62

1) Infiltrate in mucobuccal fold @ the maxillary tuberosity (high vascularity results in rapid absorption) - do it at site away from LA
2) Sublingual

Front 63

MEPERIDINE (Demerol) - parenteral route

1) What is the downside of administering through the parenteral route?
2) What is meperidine often combined with in this case? What is the ratio?
3) What did Cathers et al find regarding effectiveness 1.1 mg/kg meperidine SM vs 2 mg/kg PO routes?
4) What did Song and Webb find with behavior comparing 2.2 mg/kg ORAL meperidine + 0.5 mg/kg promethazine + N2O vs. 0.5 mg/kg SUBMUCOSAL meperidine plus 0.5 mgkg promethazine + N2O?

Back 63

1) Erythematous wheals, urticaria, pruritis at injection site due to histamine release from mast cells
2) Promethazine (injection form is MEPERGAN), 1:1 ratio
3) No significant difference in effectiveness
4) No significant difference in behavior

Front 64

SUBMUCOSAL MIDAZOLAM:

1) What did Myers et al find when they augmented 50 mg/kg chloral hydrate PO with 0.2 mg/kg midazolam SM behaviorwise?
2) What are the 3 benefits of adding midazolam in this study?

Back 64

1) Improved behavior in 2-5 yo when given at beginning of procedure 45 minutes after CH and away from LA site
2) Augments ineffective sedation, avoids oral titration, avoids early polypharmacy

Front 65

INTRAMUSCULAR ROUTE:

1) What are the 2 advantages?
2) What are the muscle sites? (What is the preferred and why?)
3) Armamentarium?

Back 65

1) Faster + more dependable absorption than oral route, doesn't require patient compliance
2) Vascus lateralis (preferred site) - largest muscle group in kids, can tolerate large injected volume (1-2 mL, absence of important nerves and blood vessels), ventrogluteal, dorsogluteal, deltoid
3) 22-25 ga, 5/8 - 1 inch needle

Front 66

KETAMINE:

1) AKA?
2) Used primarily for what kind of sedation?
3) What does it produce when you administer a subanesthetic dose?
4) Recommended sedation dose?
5) Onset? (IM)
6) Duration of action (IM)
7) Recovery time?
8) What are the 2 good properties?
9) Disadvantages?

Back 66

1) Ketalar
2) Deep
3) State resembling sedation
4) 1-2 mg/kg
5) 5-10 minutes
6) 10-25 minutes
7) 2 hrs
8) Dissociative anesthesia - CSRN (catelpsy trance-like state)/skeletal muscle rigidity/rotatory nystagmus/non-responsive and can't communicate). Potent analgesic (low dose enhances effects of opioids)
9) New Nightmares Haunt Petrified, Horrified Children- , No reversal agent, Nightmares in older children and adults, Hypersalivation, Psychic reactions (agitated delirium, unpleasant recovery), Hypersalivation (leading to airway obstruction and laryngospasm), Classified as dissociative anesthetic (interpreted as deep sedation/general anesthesia)

Front 67

KETAMINE:

What are the three negative side effects you can overcome with ketamine, and how?

Back 67

1) Hypersalivation: lower by adding anticholinergic (atropine, scopolamine). Glycophyrrolate (Robinal) - 0.005-0.008 mg/kg IM
2) Hallucations: add benzo (Midazolam, 0.1-0.15 mg/kg IM)
3) Emergence reactions: psychological prep

Front 68

KETAMINE: Advantages?

1) How does it affect vital signs?
2) Other physiological response that makes this beneficial for treating patients with a certain condition
3) Does it maintain the airway?
4) How does it affect protective reflexes?
5) Contraindications?

Back 68

BAPI - bronchodilator (good for pts with asthma), Airway patency maintained as muscle tone increased, Porotective reflexes preserved, increased HR, CO, BP

1) Increases all - HR, CO, BP
2) Bronchodilator, so recommended for patients with asthma
3) Yes, patency is maintained as muscle tone is increased
4) Preserves, but there is some diminishment in their effectiveness
5) don't CHASE someone with ketamine if they have CVA (history), High BP/intracranial/intraocular pressure, Arteriosclerotic heart disease, Severe psychiatric disorders, Epilepsy

Front 69

ORAL KETAMINE PROTOCOL:

1) Dosage?
2) What drugs can you add?
3) Dose related vomiting = ____%?
4) Onset?
5) Duration of action?
6) Bioavailability is ___%

Back 69

1) 3-6 mg/kg
2) 0.03 atropine to decrease hypersalivation, 0.5 mg/kg midazolam to reduce psychedelic reactions
3) 6-33% (add flavoring agent to mask bitter taste)
4) 20-30 minutes
5) 60 minutes
6) 17% - POOR!

Front 70

IV PROPOFOL:

1) AKA?
2) What is its effect?
3) Used for induction and maintenance of what kind of sedation?
4) Long or short acting IV infusion agent?
5) What combo was administered to Michael Jackson? ;)
6) What kind of permit do you need to use ketamine or propofol in Florida?

Back 70

1) Diprivan, "milk of amnesia"
2) Hypnotic (not analgesic like opioids)
3) General anesthesia
4) Short acting (minutes)
5) IV propofol + benzos + diluted with lidocaine
6) General anesthesia permit

Front 71

Heard et. al study:

1) What is the DOC for most anesthesiologists for moderate pediatric dental sedation?
2) Oral Tranmucosal Fentanyl Citrate (OTFC) is ___ x more potent that morphine, often combined with ____. Absorption is __% in buccal mucosa and __% in oral. Onset of action is ___ minutes. What kind of sedation does it provide?
3) Sufentanil Citrate (Sufenta) is ___x more potent than fentanyl and can cause significant _________
4) What kind of sedation do you get if you use fentanyl or sufentanil?

Back 71

1) Midazolam
2) 100, midazolam, 25% in buccal mucosa, 75% oral. 15. Moderate.
3) 10, respiratory depression
4) Moderate

Front 72

Dexmedetomidine:

1) AKA?
2) What kind of route for procedural sedation?
3) Dose?
4) Negative side effects and what you can give to counteract?
5) What kind of state is produced?

Back 72

1) Precedex
2) IV route
3) 2 mcg/kg/hr infusion after initial bolus
4) Bradycardia, sinus arrhythmias (16%) - give atropine or anticholinergic to counteract the effect
5) Motionless state (good for MRIs)

Front 73

Why is it so hard to find evidence for support best sedation practices?

Back 73

1) Small # subjects
2) Varying age groups + behaviors
3) Lack of randomized subject assignment + control group
4) Varying/poorly categorized pre-op behavior
5) Lack of quantifiable criteria for success
6) Lack of interexamines reliability and blindedness
7) Confounding variables not controlled
8) Variation in drugs, dosges, routes
9) Variation in waiting time prior to onset of procedure
10) Degree of physical stimulation, extent of invasive procedure