• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/100

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

100 Cards in this Set

  • Front
  • Back
1) 4 criteria for patient selection for dental sedation?
2) 8 risk factors associated with sedation complications?
1) GUAPo - GA not a financial option, Unsuccessful with nitrous before, ASA 1 Poor behavior rating (uncooperative or pre-cooperative). HEALTHY KID WHO DOESN'T COOPERATIVE, NITROUS FAILED, CAN'T AFFORD GA
3) MA, DAD RID of kid if these sedation complications go to crap:

1) Medications currently taking
2) Age
3) Depth of sedation achieved
4) Airway obstruction/compromise
5) Drugs (dosages and routes)
6) Rescue training skill of practitioner
7) Improper observation and monitoring
8) Disease present/severity of co-existing disease
1) What are the primary sedation concerns in a kid vs. adult?
2) What needs to be reviewed, generally speaking?
3) What historically needs to be reviewed about the kid?
1) In kid, airway patency + respiratory function (LUNGS). In adult, cardio stability and function (HEART)
2) Family dynamics + config, Kid's med hx/developmental assessment, physical assessment, behavior/temperament, and parent's expectations
3) Diseases, allergies, meds (type, route, dose, timing, frequency), previous hospitalizations, previous sedation/GA and complications, family hx of disease
1) How do you assess a child's social and psychological behavior?
2) How do you assess their cognitive ability?
3) 4 developmental issues that can affect a child?
1) Previous experiences (parental report), interactive ability (body language, facial expression, eye contact), verbalization and vocalization, degree of fear and/or anxiety.
2) STALC - social/emotional skills (coping strategies), temperament (disposition, usual mood), attention span, language (expressive and receptive), comprehension,
3) Learning disability, developmental delay, behavioral disorder, sensory issues
1) __% of children <12 yo had used at least one medication in the last wek, __% take multiple meds
2) What % take common rx meds, and what are they? What % regularly take one or more meds daily?
3) What are the common OTC meds?
4) Name 3 non-stimulant ADHD drugs
5) What are the most common conditions that cause kids to need medication?
6) What are the 4 psychotropic drug categories? How do they work? What is the most common side effect, and what can occur?
1) 56%, 28%
2) 21% Amoxicillin, albuterol, vitamins with fluoride. 40%
3) Acetaminophen, multivitamins, Ibuprofen, Cough/cold
4) ADHD is SIK - Strattera, Intuniv, Kapvay
5) Asthma/allergies, behavioral (ADHD, depression, antipsychotic)
6) Sedative-anxiolytics, antidepressants, antipyschotics, antimanic. Inhibit doapmine NT activity, neuronal reuptake of NE and serotonin. Sedation most common side effect, paradoxical responses can occur
SEDATIVE ANXIOLYTICS: What are the common types?

1) What are the biggest problems with using these?
2) What can they enhance?
3) Why do you only use them for a short time period?
4) Why should you be cautious with use of reversal agents in case of overdose?
Benzos, antihistamines, herbs

1) Tolerance and dependence
2) CNS depressants
3) Long term use leads to tolerance and increasing dosage over time
4) You can induce withdrawal
1) What are most popular, between tricyclics, SSRIs, and MAOIs?
2) What are the bad side effects of tricyclics?
3) What two things do tricyclics interact with?
4) SSRIs avoid the annoying autonomic side effects of TCAs, but what are its bad side effects?
5) What do SSRIs interact with?
6) Most anti-depressants, except ____, can elevate epi and produce cardiac excitation
1) SSRIs - tricyclics are less popular and MAOIs are uncommon
2) With TCAs, Our Arses Constipate - Orthostatic hypotension, Anticholinergic (xerostomia/constipation), cardiac arrhythmias (monitoring with periodic ECG is important)
3) TCAs + Meperidine = SEIZURES
TCAs + epinephrine in LA agents = CARDIAC EXCITATION
4) HINa MAD - headache, insomnia, nausea, manic behavior, agitation, diarrhea
5) Potentiate sedative effect of benzos
SSRIs + BENZOS = DEEPER SEDATION
6) SSRIs
1) Do MAOis influence epinephrine metabolism?
2) How do most antidepressants affect epinephrine? Which present the greatest concern?
3) Sedative agents + antidepressants =
1) No
2) Elevate epi and produce cardiac excitation (except SSRIs). TCAs are the greatest concern
3) DEEPER sedation (enhanced effect)
ANTIPSYCHOTICS

1) How do antipsychotics work?
2) What kind of drugs are used to tx the delusional impairments/agitation/delirium/dementia/depression/nausea?
3) Extrapyramidal side effects of antipsychotics?
4) What should you avoid using in conjunction with antipyschotics?
1) Antagonize dopamine receptors within the limbic region
2) Neuroleptics
3) TAP - Tardive dyskinesia (tics, facial grimaces, blinking), Akathisia (restlessness, desire to walk around - not agitation), Parkinsonism (tremors)
4) Antihistamines, antiemetics (they enhance the above side effects)
ANTIMANICS:

1) What is mania?
2) What are characteristics of mania?
3) Common drug?
4) Anticonvulsants used can enhance the effects of ________
5) What is the note of caution with using anticonvulsants?
1) Opposite of depression, but many patients fluctuate between periods of depression and mania (bipolar)
2) Agitation, talkativeness, attention deficit, excessive motor activity
3) Lithium (has few side effects), anticonvulsants (ie Depakene, carbamazepine)
4) Benzodiazepenes
5) Pts can develop a tolerance to sedative effect of anticonvulsants and can be overdosed in an attempt to overcome this tolerance
1) What 2 drugs used for tx psychological disorders enhance the sedative effect of benzodiazepenes?
2) Best DOC for a patient with seizures?
1) Antidepressants, anticonvulsants
2) Benzos
1) What needs to be reviewed physically to determine the correct ASA category for a kid?
2) Describe ASA 1, 2, 3. If in doubt, get a...
3) 7 indicators of respiratory concern?
4) What is the #1 in history of respiratory concern?
1) WARV - weight in kg, age in years/months, ROS (emphasis on respiratory function/airway patency), vitals (BP, HR, RR, HbO2 saturation)
2) 1- No organic, physiologic, biochemical, psychiatric disturbances. 2 - mild/moderate systemic abnormality. 3 - severe systemic abnormality. Consult
3) POTFASE - Premature/low birth weight (bronchopulmonary dysplasia/diaphragmatic hernia/hyaline membrane disease), Obesity, Tracheal defects, Frequent URI, Allergies/asthma/CF, Snoring/sleep apnea, Enlarged tonsils/adenoids
4) Asthma
ASTHMA:

1) ___% in under 18 years old
2) ____% increase in children under 5
3) _______ ER visits (most common cause of pediatric ER admission)
4) ______ missed school days
1) 8.5%
2) 160%
3) 2 million
4) 14 million
ASTHMA:

1) Dentofacial manifestations?
2) Drugs used to prevent acute attacks?
3) Drugs used to manage acute attacks?
4) What two questions should you ask when reviewing hx of asthma?
5) How long should you wait before sedating a pt who had a hospitalization bc of asthma, and why?
6) The increased airway resistance and difficulty in expiration is due to what three things?
7) Triggering agents?
1) DOC - Dental caries increased (secondary to medication effect of decreased salivary flow), Oral candidiasis (second to steroid inhaler, located on SOFT PALATE), Chronic gingivitis (secondary to mouth breathing and elevated aminopeptidase/myleoperoxidase in crevicular fluid)
2) Inhaled steroid (Triamcinolone), inhaled long-acting-beta-agonist (Solmeteral)
3) Metered-dose-beta-agonist inhaler (Albuterol - Ventolin, Proventil), or liquid nebulization (Metaproternol)
4) Frequency of attacks? Any hospitalizations?
5) 6-8 weeks because they'll be more prone to laryngospasm and coughing
6) Bronchial smooth muscle patterns, inflammation of bronchial mucosa, mucous hypersecretion
7) ASIA - Allergens, Stress/exercise, Infectious agents (RSV, URI), Anxiety
ASTHMA:

1) What are the 5 types of asthma?
2) What is the most common form on asthma, what is it triggered by, who is it mostly seen in, and it's associated with what hx?
3) What is the second most common asthma? It's seldom associated with what hx? How do pts respond to skin testing and what are their IgE levels like? Generally seen in who? Onset appears to be associated with what causes?
4) Drug induced asthma: Triggered by ingestion of drugs or ____. What is a main trigger here? Sensitivity to this trigger is seen in 30% of asthmatics with?
5) In infection induced asthma, infectious agents like viruses and bacteria cause what in bronchi? Tx of infection improves what? How often to healthy, school-age children develop a viral respiratory infections? How many infections can you expect a year?
1) Extrinsic (allergic (type 1 hypersens), atopic (type 4 hypersens)), Intrinsic (idiosyncratic, nonallergic, nonatopic), Drug-induced, Exercise-induced, Infection-induced
2) Extrinsic (35%), inhaled seasonal allergens/dust/dirt, young children and adults, family hx of allergies
3) Intrinsic (30%), seldom ass. with family hx of allergies or known cause, pts respond normally to skin testing/normal IgE levels, middle aged adults, onset w/ endogenous causes (stress, GI acid reflux, vagal responses)
4) Food. ASPIRIN - causes bronchoconstriction in 10% of pts with asthma, sensitivity to aspirin seen in 30% of asthmatics with pansinusitis and nasal polyps
5) Inflammatory response in bronchi, tx of infection improves control of pulmonary constriction. Q4-6 weeks (expect 8-12 infections/year)
1) Asthma severity classifications BEFORE therapy and their symptoms?
2) Asthma severity classifications AFTER therapy?
1) Mild intermittent (<2x/week, brief, PRN rescue inhalers only). Mild persistent (<2x/week, <1x/day, may affect acitivity). Moderate persistent (daily use of rescue beta2 agonist, may affect activity, >2x/week), Severe persistent (continual, frequent, limits physical activity)
2) Mild (spasmodic/seasonal, symptoms 1-2x/month). Moderate (Symptoms >2x/week, nocturnal symptoms 4-5x/month, can persist several days). Severe (every day/night, ER or med visits 3x/month, activity limited)
CHRONIC ASTHMA:

3 categories of "controller" inhaled medications used for chronic asthma
1) INHALED BRONCHODILATORS - LONG-acting beta-2 adrenergic agonists (Solmeterol)

2) INHALED ANTI-INFLAMMATORY AGENTS - corticosteroids (fluticasone), NSAIDS (Cromalyn sodium)

3) COMBINED inhaled dry powder bronchodilator and corticosteroid in one inhaler - Solmeterol + Fluticasone (Advair Diskus)
CHRONIC ASTHMA INHALED MEDS:

1) What is the first choice for prophylactic use in chronic asthma, why, how does it work, and what SHOULDN'T you use it for? What are some examples?
2) How do NSAIDs work? Who are they most efficient in ? How often can you administer them? Who are they not effective in?
3) LONG acting Beta2-adrenergic agonists: name? When do you use them? What's the best approach to limit side effects?
1) Corticosteroids - has better overall control of asthma, less likelihood of sudden severe attack. It reduces the inflammatory response. Long term use rarely => systemic side effects (growth retardation) if dosing is followed. DON'T use for relief of acute asthma attack due to slow onset of action. Beclomethasone (Qvar), Budesonide (Pulmicort), Fluticasone (Flovent), Triamcinolone (Azmacort)
2) Cromalyn Sodium - stabilize mast cell membranes, decreasing airway hyper-responsiveness. Most efficient in atopic pts, exercise induced asthma. Give prophylactically prior to exercise or contact with known allergin. Not effect in acute asthma
3) Solmeterol - moderate to severe persistent asthma where inhaled corticosteroids alone have failed. Combine with inhaled corticos to limit side effects.
CHRONIC ASTHMA ORAL MEDS:

1) What are the oral meds, how do they work? Why would you use them?
2) Outdated meds? When should you contact a physician?
1) Leukotriene modifiers (Montelukast (Singulair), Zofirlukast) - block leukotriene receptors (the inflammatory mediators), creates a bronchodilator effects, Alternative tx to inhaled corticosteroids for mild persistent asthma
2) AMC - Anticholinergics (Ipratropium bromide), Methylxanthines (theophylline), Corticosteroids (Prednisone) - contact physician to supplement if 4 brief courses (1-3 days) in past year, or 1 prolonged course (>10-14 days) in past year
CHRONIC ASTHMA SUBCUTANEOUS MEDS:

What are they, what's a downside, when do you use them and for what type of asthma?
Anti-IgE monoclonal antibody (Omalizumab - Xolair) - expensive, last choice when other agents fail. Refractory asthma
ACUTE ASTHMA "RESCUE" MEDICATIONS:

1) How do they act?
2) Drug names?
3) Why are these preferred for the relief of acute asthma? How do they work?
4) Onset of action?
1) Inhaled SHORT-acting beta2-adrenergic agonists
2) Albuterol, Metaproternol
3) Greatest and fastest bronchodilation. Activate beta2 receptors on airway smooth muscle cells to produce bronchodilation
4) <5 minutes
Asthma Inhalation devices:

1) What are the two types of inhalers and what are their advantages/disadvantages?
2) Other devices?
3) How do you select which device you should give?
4) Admin intervals for chronic intervals?
5) Admin intervals for acute asthma?
1) Metered dose (requires hand-lung coordination), dry powder (doesn't require hand-lung coordinatino)
2) Spacer containing valved holding chamber, nebulizer that produces fine mist for kids 3-5 y/o who can't tolerate inhalers
3) Based on technique competency
4) 1 puff q 12 hours
5) 2-3 puffs over 2 min x 2
3 reasons why kids with asthma are often considered for sedation?
1) Over-indulged by parents + have behavioral issues, poor oral hygiene and diet
2) Require management that reudces stress/anxiety so you don't induce an acute attack
3) Higher caries susceptility (beta2 agonists decrease salivary flow by 35%, associated with increased lactobacilli, have low pH)
What is the pre-op preparation for sedating an asthma patient who uses PRN inhaled beta agonists?
1) Daily admin for 3-5 days prior (inhaled steroid Triamcinolone - they RARELY cause adrenal suppression) or inhaled beta-agonist (Salmeteral)

2) Remind pt to bring bronchodilator (rescue inhaler) to appointment

3) Update current hx, perform thorough auscultation of lungs

4) Defer sedation for 4-6 weeks if coughing, have recent URI/ER admission
What is the pre-op prep for sedating an asthma patient who uses CHRONIC oral or inhaled meds?
1) Consult about addition of oral steroids
2) Consider GA instead of sedation
3) If they've been hospitalized within last 6 weeks because of recent exacerbation, don't do elective tx
4) If URI, postpone tx for 6 weeks if coughing, even if no wheezing BECAUSE 11x increase in respiratory complications!!
Asthma sedation protocol:

1) What 3 things should you avoid?
2) What should you reduce?
3) What should you use?
4) What anesthetic should you use with caution? What should you consider using?
5) What should you minimize during operative?
6) Use minimal sedation with what drug?
1) Known trigger factors, NARCOTICS (release histamine), ASPIRIN containing meds, deep sedation (airway more reactive => higher risk of laryngospasm/bronchospasm)
2) Stress/anxiety
3) N2O/O2 (for supplemental O2, doesn't exacerbate condition)
4) LA with vasoconstrictor (bisulfite may set off allergy, may add to CV effects of beta-agonists resulting in palpitations, increased BP, arrhythmias). Consider 3% plain LA sol'n
5) Water spray irritation on airway
6) Midazolam
1) Signs and symptoms of an acute asthmatic attack?
2) Behavior of someone having an attack?
1) Coughing, SOB, tachypnea, nasal flaring, bronchospasm (wheezing), retraction of chest muscles (chest tightening)
2) Sit up in chair, increased anxiety, agitation, confusion
How do you manage an escalating acute asthma attack?
SAOG DB

1) Semi-erect position
2) Albuterol inhaler 2-3 puffs q 2 min x 2 or nebulizer
3) Oxygen at 5-8 L/min via non-rebreathing face mask
4) Get vitals (HR, RR, BP, HbO2 sat). Epi 0.15 mg IM/SM q 15 minutes PRN,
5) Diphenylhydramine 25 mg IM/SM STAT, then PO Benadryl tid x 2 days
6) Med referral - EMS
What are the differences between allergic rhinitis and upper respiratory infections?
Allergic rhinitis - clear rhinorrhea (nasal discharge), sneezing, conjunctivitis, nasal itching

URI - yellow or green discharge, nasal passages obstructed, fever, cough
Allergic rhinitis meds:

1) PO meds?
2) IN meds?
3) SC or SL meds?
1) Antihistamines (Allegra, Clarinex, Zyrtec), Leukotriene modifiers (Singulair, Accolate)
2) Corticosteroids - beclomethasone, triamcinolone. Decongestants, anticholinergics, ciclesonide (new)
3) Immune modulation
URI General precautions:

1) Potential for infection of...
2) Risks if cough is present?
3) Risks if nasal passages not patent?
1) Whole dental team
2) Irritation of airway more likely, smooth muscle constriction
30 Can't use nitrous/oxygen, hard to breathe with rubber dam in place, post nasal drip when patient is lying down irritates the airway
Sedation precuations if child has URI:

1) How's the airway?
2) If kid has active URI, what should you do?
3) If kid has allergic rhinitis, what should you do?
1) Irritable airway prone to coughing, breath holding, laryngospasm
2) Cx sedation, wait at least 2 weeks to reschedule
3) It may never completely clear in some kids, you shoudl decide if you want to sedate them or go to OR where airway can be protected with an endotrach tube
What are the coughs/symptoms like with:

1) Bronchitis
2) Asthma
3) Croup
1) Dry cough that becomes loose/rattling with time. Yellow sputum produced.
2) Dry/tight/wheezy cough, spasmodic, often noctural, frequent throat clearing is an early manifestation of asthma
3) Bark of seal, sudden onset, URI, inspiratory STRIDOR, hoarse voice
1) 8 things you should ask about to analyze if they have airway obstruction during sleep?

2) What does mouth breathing indicate?
3) What does snoring/stridor indicate? Recent link in snoring and what condition?
4) Decrease in oxygen increases what?
1) sound like APe or A MOUSE?

Apnea? Peaceful sleep? Awaken often? Mouth breathing? Obesity? URI/allergies/asthma? Snore? Enlarged tonsils/adenoids?
2) Nasal obstruction
3) Partial upper airway obstruction. ADHD (7-12 prevalence vs. general population)
4) Arousal
Obstructive sleep apnea:

1) What are kids susceptible to in sedation?
2) What is desensitized, and how is the hypoxemic drive altered?
3) What do they require after sedation?
4) What should they be referred for?
1) Respiratory depression from NARCOTICS (these usually affect hypercapnic drive) (they have possibly altered opioid receptors)
2) Carotid bodies desensitized, lower set point for hypoxemic drive
3) Extensive post-op monitoring
4) Polysomnogram (sleep study)
1) What two areas of the body control ventilation? What are they triggered by?
2) Explain the hypercapnic drive? What drugs affect it and what does this lead to?
3) Explain the hypoxemic drive? What drugs affect it? Patient with what condition rely on hypoxemic drive, so what should you avoid with them?
1) Medulla oblongota - monitor CO2 (capnograph). Carotid bodies - monitor O2 (pulse ox)
2) Elevated CO2 => increased acidosis -> receptors in medulla sense elevation of hydrogen ions => stimulates breathing. OPIOIDS depress hypercapnic drive => respiratory depression
3) Receptors in carotid bodies sense depression of PaO2 => stimulates breathing. SEDATIVES depress hypoxemic drive. Avoid supplemental O2 in COPD patients because they rely on the hypoxemic drive. Giving extra O2 will take away their drive to breathe
1) 3 types of tracheal defects that can affect breathing?
2) What ages should you probably not sedate? Why?
3) Birthwise: Young children with a history of low ___ or history of ___ are a risk for ventilation problems
4) A former pre-term child up to age 6 years may have what kind of disease?
1) Tracheomalacia/stenosis, tracheal scarring (below cricoid after neonatal intubation), former tracheotomy (paradoxical vocal cord closure - learned response during stress - when they take a deep breath, the trachea folds in on itself)
2) <2 years old (<18-24 months) - lack communicative skills and are "pre-cooperative" so they'll need deeper sedation
3) Birth weight, prematurity
4) Residual pulmonary disease (bronchopulmonary dysplasia)
NEUROLOGICAL DISORDERS: What is the difficulty of sedating in a child with a history of:

1) Seizures?
2) Cerebral palsy?
3) Psychiatric/behavior problems?
4) Overall, are the sedative effects predictable?
5) DOC for benzos and ADHD?
1) Increased drug metabolism, competition for plasma protein binding sites, *LA and NARCOTICS* lower the seizure threshold
2) Difficult to assess sedation depth (increased sedative effect)
3) ADHD, autism drug interactions? Emotionally unstable - effect on limbic system?
4) NO!
5) Benzos
1) How do GI disorders like GERD, vomiting, dysphagia, and gastrointestinal motility disorders affect oral agents?
2) How do renal/hepatic disorders affect drugs? How should you manage? What kind of sedation results - over or undersedation?
1) Result in unpredictable bioavailability, increased aspiration risk
2) Unpredictable drug eliminatino because poor metabolism, increased plasma concentration of sedative. Do a consult with nephrologist or gastroenterologist. Over-sedation.
MED HISTORY:

Cardiovascular problems defects? 7
1) Right-to-left and left-to-right shunts
2) CHD
3) Rhythm disturbances
4) Cardiac surgeries - endo prophylaxis
5) HTN
6) Squatting, exercise intolerance
7) Cyanosis
1) A patent foramen ovale occurs in ___% of normal patients. What happens in pts with this condition?
2) How are cardiac defects classified?
3) Which ones should you NOT sedate?
1) Breath holding/coughing causes pressure on the heart (Valsava maneuver), this causes shunting
2) Acyanotic, cyanotic
3) Cyanotic
What are the 2 kinds of acyanotic defects?
1) Obstructive - cause a pressure overald (aortic/pulmonary stenosis), coarctation of aorta

2) Left-to-right shunts - volume overload (VSD, ASD, PDA)
What are the cyanotic cardiac defects?
Right-to-left shunts - Tetralogy of Fallot, transposition of great arteries, tricuspid atresia
1) 6 causes of acute pulmonary hypertension?
2) Pulmonary hypertension from laryngospasm in a patient with patent foramen ovale results in?
1) BLAC + Blue & Coughing => Breath holding, Laryngospasm, Aspiration (fluid/foreign body), Croup, Bronchospasm, Coughing
2) Immediate hypoxemia (causes immediate R to L shunt with hypoxemia)
1) Can narcotics and benzos be used in pts with cardiac defects?
2) What should you consider using?
3) When you're in doubt, what should you do?
4) What shouldn't you use in pts with conduction disorders? What are some conduction disorders and what do they cause?
5) Is antibiotic prophylaxis needed for conduction disorders?
1) Yes, unless they're severely compromised
2) Use of supplemental oxygen
3) Consult the pt's cardiologist regarding sedatives or the need for antibiotic prophylaxis
4) Local anesthetics with epi. Wolf-Parkinson-White (tachycardia), Long QT syndrome (ventricular fibrillation)
5) No
What cardiac conditions need prophylaxis?
- Prosthetic cardiac valve or prosthetic matierla used for cardiac valve repair
- Previous IE
- Congenital heart disease:
- Unrepaired cyanotic CHD
- Completely repaired w/ prosthetic material or device whether placed by surgery or by catheter intervention, during first 6 months after procedure, -
- Repaired CHD with residual defects at site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
- Cardiac transplantation recipients who develop cardiac valvulopathy
1) What are dental procedures for which endocarditis prophylaxis is reasonable?
2) What dental procedures don't need it?
1) Anything that involves manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
2) Routine anesthetic injections through noninfected tissue, radiographs, removable prosth/ortho, shedding deciduous teeth, bleeding from trauma to the lips or oral mucosa
1) **What is the standard prophylaxis for kids**?
1) Amoxicillin 50 mg/kg (2 gram max) PO, 1 hour prior to the dental procedure
2) Ampicillin 50 mg/kg (2 gram max) IV or IM, 30 minutes before the procedure
What is the standard prophylaxis for kids if they're allergic to penicillin?
IF ALLERGIC TO PENICILLIN:
1 hour prior to dental tx:
1) Clindamycin, 20 mg/kg (600 mg max)
2) Cephalexin or cefadroxil, 50 mg/kg (2 g max)
3) Azithromycin or clarithromycin, 15 mg/kg (500 mg max)
What's the standard prophylaxis for kids if they're allergic to penicillin adn can't take oral medications?
30 minutes before the procedure:

1) Clindamycin, 20 mg/kg (600 max) IV/IM
2) Cefazolin 25 mg/kg (1 gram max) IV/IM
1) 2 main hematologic deficiencies and how to tx them? With sickle cell, do you have to be strict on fasting and hydration rules? Is it easier to tx with GA or sedation?
2) Does an indwelling port-a-cath (central line) rqeuire antibiotic prophylaxis?
1) Anemia (sickle cell or iron deficiency), coagulopathy

BASSHH sickle cell - Blood transfusions may be required to decrease SS Hb, Avoid prolonged fasting, Supplemental oxygen, Surgical antibiotic coverage post-up, Hydration! Encourage hydration with clear liquids up to 2 hours before with sickle cell anemia - don't be so strict with NPO guidelines. Easier to tx with sedation becasue GA requires pre-op admit to give hypovolemic transfusions to replace sickle cell hemoglobin.
2) NO, does NOT - provides access for IV sedative agents
1) What do drug interactions in a patient with seizures do to the sedative effect?
2) What do drug interactions in patients with CP do to the sedative effect?
3) Psychiatric/behavioral?
4) A problematic sedation history includes?
1) Lowers sedative effect (causes increased metabolism and protein binding, so less drug is available)
2) Increases - difficult to assess sedation depth
3) Unpredictable
4) Sedation failure, over-sedation, paradoxical reactions, GA reactions/complications
1) 2 components of a patient evaluation?
2) What are the 4 components of the physical assessment, and what do you evaluate with behavioral evaluation?
3) What 4 things do you assess in the respiratory system?
1) Focused physical assessment, and interactive behavioral assessment
2) Airway patency, respiratory function, cardiovascular function, weight/body surface area. Behavioral: temperament and attachment
3) BARE - Breath sounds, Air patency, Respiratory rate, Exchange (nasal, URT, LRT)
1) How do children differ from adults in general?
2) How does the pediatric airway differ from an adult's? (6)
3) Where would a foreign body get stuck in a kid airway vs. an adult airway?
4) How do you assess the oropharynx in kids?
5) 5 abnormalities that may create upper airway obstruction in kids?
1) CRAP! Mini Children - Communication and coping skills, Respiratory capacity, Airway anatomy, Psych/behavioral responses to stress/anxiety, Metabolism rate, Cardiovascular responses
2) FEELS Vocal - Funnel-shaped larynx (subglottic stenosis), Enlarged tonsils and adenoids, Edema influences tracheal diameter and airway resistance, Larynx is more superior (between C2-C3 vs. C4 and C5 in adults) and Vocal chords are slanted
3) Foreign body will be trapped below cricoid ring in kid, above it in adult.
4) Cooperative children - open mouth wide, protrude tongue, have them vocalize a soft "ahh". Uncooperative - lap exam, look while crying or induce gag
5) MOTHH gets stuck in kid's upper airway - Mouth breather due to nasal obstruction, Obesity causes limited neck mobility or oral opening, Tonsils/adenoids large, Hypoplastic development of the jaws, Hypersalivation or infrequent swallowing (CP)
Difficult Airway Assessment Guide?
LEMON

1) Look externally - Facial abnormalities, obesity, class 2 malocclusion, short neck
2) Evaluate 3-3-2 rule: 3 fingers between teeth, 3 fingers between tip of jaw and beginning of neck, 2 fingers between thyroid notch and floor of mandible
3) Mallampatti scale - mouth open + tongue protruded
4) Obstruction
5) Neck mobility
1) Explain Brodsky's classification of tonsils
2) See maximum obstruction between what ages?
3) Who should you refer to if necessary?
4) Presence of enlarged tonsils increase risk fo desat when what 4 things happen?
1) 0 = no obstruction, 1 = <25%, 2 = 25-50%, 3 - 50-75%, 4 - 75%
2) 4-10 y/o
3) ENT
4) 50% of airway blocke,d neck flexion (Moore head-tilt maneuver) applied, Midazolam + 50% nitrous given, 40% nitrous and greater doses of lido are given to younger kids
Conditions that can cause a compromised pediatric airway:

1) Supraglottic infections?
2) Facial cellulitis
3) Tumors?
4) Trauma?
5) Rare?
6) Other?
1) Acute epiglottitis, laryngotracheobronchitis (croup)
2) Ludwig's angina, cavernous sinus thrombosis
3) Laryngeal papillomatosis, lymphangioma
4) Cervical spine/craniofacial injury
5) Juvenile rheumatoid arthritis, TMJ ankylosis, goiter
6) Obesity, GERD, low birth weight
According to Waage et al, what are 3 contributing anatomical factors that affect airway patency?
1) Limited neck mobility - sternomental distance <10 cm when head fully extended, occiput to C1 vertebra <4 mm indicates limited atlanto-occipital joint flexion
2) Limited oral opening - inter-incisal distance <4 cm, limited TMJ movement, deep bite
3) LImited oral cavity capacity and oepning - hypoplasia of the jaws, high-arched palate. Macroglossia, tonsilar hypertrophy, obesity
What are 2 upper airway obstructions that can cause congenital anomalies, and what are the conditions called?
1) Mandibular hypoplasia (Pierre Robin Anomalad, Treacher Collin Syndrome)

2) Maxillary hypoplasia (cleft palate, down syndrome)
7 aspects of Treacher Collins Syndrome?
Ear, Face & Head Droop, CPR!

1) Ear malformation
2) Facial cleft
3) Hypoplasia of the mandible
4) Downward-sloping palpebral fissures
5) Colobomas (congenital scar) of the eyelids
6) Poorly developed supraorbital rims
7) Receding chin
8 things that make a Down Syndrome pt prone to upper airway obstruction
SUCS A LOT:

1) Sleep apnea (30%)
2) URI frequent (lowered immunity)
3) Cardiac defects (40%)
4) Subglottic tracheal stenosis
5) Atlanto-axial dislocation from neck flexion (10-20%)
6) Large tongue, small nares
7) Overweight usually
8) Thick, short neck
According to Unkel:

1) What is antlanto-axial instability associated with?
2) What kind of position should you maintain the neck in?
3) If intubation is planned, what should you take, and what should you minimize and how?
4) What negative things can CAT scans reveal?
5) 6 manifestations of Atlanto-axial instability?
6) What does AAP recommend?
1) Transverse atlantal ligament laxity
2) Neutral
3) CAT scan, minimize cervical movement by using fiberoptic technique
4) Cervical rotation, cord compression
5) Little Necks + PAWS - Loss of sphincter control, Neck discomfort, Paralysis, Abnormal gait, Weakness, Spasticity
6) Screening radiographs on all down's pts aged 3-5 y/o
1) Adult obesity scale?
2) Incidence of obesity? How much has it gone up in past 20 years?
3) What is obesity defined percentile?
4) What is obesity defined by BMI in adults and kids?
5) What BMI is the upper limit for sedation in kids?
6) How do you calculate BMI?
1) 0: <24. 1 (overweight) 24-29. 2 (obese) 30-39. 3 (morbid) 40-55. 4 (super morbid) 56+
2) 17%, tripled in past 20 years
3) Percentile: >85% = overweight, >95% obese
4) Adult BMI = >30, child BMI varies by weight and gender.
5) 26
6) Weight (kg) / height (m)^2
According to Baker and Yagiela's study on upper airway obstruction and childhood obesity?

1) What does increased fat deposition in the neck do to the airway? How does it affect airway resistance, airway compliance, and neck flexion?
2) What are obese kids prone to developing?
3) How does obesity affect the FRC of kids' lungs?
4) What is common post-op?
5) What position is best for tx an obese kid and why?
1) Causes airway compression and creates a more difficult airway to maintain patent. Increases airway resistance, decreases airway compliance, decreases neck flexion
2) Obstructive sleep apnea
3) Reduces FRC - child becomes hypoxic faster
4) Prolonged recovery and post-op hypoxia
5) Upright - normal FRC compared to nonobese when in this position
How does pediatric physiology compare to adults with:

1) Respiratory rate?
2) Alveolar minute ventilation?
3) Heart rate?
4) Oxygen consumption?
5) FRC?
1) Increased (20-24 breaths/minute vs. 12-20 breaths/minute)
2) Increased (100-150 mg/kg/minute vs. 60 mg/kg/minute)
3) Increase (80-120 BPM vs. 60-80 BPM)
4) Increased (5 mL/kg/minute vs. 3 mL/kg/minute)
5) Lower (25 mL/kg vs. 40 mL/kg)
Obese pediatric patients placed in a supine position:

1) Mass loading of the chest wall by adipose tissue compromises what 3 things?
2) How does it affect FRC, and what does it increase a risk for?
3) How does it affect the heart?
4) What drugs should you avoid, and why?
5) What is the ideal position for tx an obese child?
1) Diaphragmatic breathing, reduces chest wall compliance, increases airway resistance
2) Significant decrease in FRC, increases risk for atelectasis (collapse or closure of alveoli resulting in reduced gas exchange)
3) Increase cardiac output, puts them at risk for myocardial hypoxia
4) Narcotics, they're respiratory depressants and decrease FRC and promote CO2 accumulation and O2 deficits
5) Semi-sitting
1) In a study comparing Midazolam IV in obses vs. non-obese adults, what did they find in terms of drug distribution, elimination drug half-life, and potential for respiratory depression when combined with opioids?
2) Does an obese child need an exponentially higher dose of sedative agent to reach plasma concentrations similar to a lean child?
3) Should you determine drug dose solely based on body weight in an obese child?
4) How should you dose them?
5) What did a study find when they compared adverse events in healthy kids vs. obese kids when the triple cocktail oral sedations were used? Overall, did obese kids have a higher incidence of adverse events?
1) 3x increase in total volume of drug distribution, significantly prolonged elimination drug half-life, increased potential for respiratory depression when combined with opioids
2) Needs slightly higher dose due to increased volume of distribution, but not nearly as much as suggested by body weight
3) No! May result in overdose
4) Based on age, because of negative multisystem effects of childhood obesity and the increased potential for desat events
5) SpO2 <95%, vomiting, prolonged recovery (>30 minutes), apnea (no berath sounds/ETCO2 for 25 seconds). YES - higher incidence of adverse events
What is the technique for auscultation of the lungs?
1) Use small size steth, warm before using, press firmly on multiple sites, have child blow against your hand or cough to force deep inspiratory breath. 3 lobes on right, 2 lobes on left, listen everywhere.
Abnormal breath sounds: STRIDOR:

1) Aka? Inspiratory or expiratory?
2) Where is the location?
3) 4 causes?
1) Crowing. Inspiratory: harsh, continuous. Expiratory: loud. UPPER (extra-thoracic) airway obstruction, subglottic or tracheal.
3) stridor Follows Every Cough Sound - Foreign body, Epiglottitis, Croup, Subglottic stenosis
Abnormal breath sounds: RALES:

1) Inspiratory or expiratory? Location?
2) What does it sound like?
3) Cause?
1) Inspiratory, LOWER (intra-thoracic) airway obstructions: harsh, irregular
2) Crackles or crepitations/popping/harsh, irregular
2) Pneumonia, secretions in bronchi
Abnormal breath sounds: WHEEZES

1) Inspiratory or expiratory, how does it sound?
2) How does it sound?
3) Cause?
1) Expiratory **the only expiratory**. Loud and musical, continuous
2) LOWER (intra-thoracic) airway
3) Asthma, constriction of bronchi
Abnormal breath sounds: SNORING:

1) Inspiratory or expiratory
2) Where is the obstruction?
3) What causes it?
1) inspiratory, irregular
2) UPPER airway (extra-thoracic), nasopharyngeal
3) Soft tissue, tongue, foreign body
1) What is the only abnormal breath sound that's expiratory?
2) Which abnormal breath sounds are upper airway, and which are lower?
1) Wheeze
2) Upper: Snoring and stridor (crowing). Lower: Rales and wheeze (the S's are upper)
1) How do you physically assess the nasal cavity with auscultation, and what do you look for visually?
1) Auscultation - breath sound with closed mouth, listen @ lateral border of the superior neck. Visually: look for flaring and deviations, secretions and dischage
1) 4 ways in pediatric respiratory function differs from an adult?
2) What do you look for to see if kids are having breathing problems to see if there's an obstruction?
1) FARD - FRC smaller (greater chance of O2 desat), Airway resistance increased (narrower airway), Respiratory and oxygen consumption rate is higher, Diaphragmatic breatehing is greater due to weaker chest muscles (produces rocking motion during obstruction)
2) Rocking motion on diaphragm
1) What 5 things do you need to assess in a pediatric cardiovascular system?
2) Pediatric cardiac output = __x adults
3) What happens to fingers of kids with congenital cardiac disease?
3) Where do you palpate in a kid to determine HR? Why?
4) How should the child be positioned when you listen to heart sounds?
5) What kind of rhythm is common in kids?
1) Blood RORS! - Blood pressure, Rate, Output, Rhythm, Sounds
2) 2
3) Clubbing
4) Brachial (NOT radial pulse) - this is closer to heart, truer to pulse
5) Supine
6) Sinus arrhythmia
1) What is an innocent heart mumur?
2) What is a pathologic murmur?
3) When should you get an EKG?
1) Musical murmur that occurs during systole, soft and non-radiating pulse
2) Sounds like a breath sound, heard at the time of opening of any valve.
3) When there is a harsh sounding murmur that is not localized or there are bounding pulses
1) 3 things you should look at to evaluate circulation & skin perfusion?
2) 5 baseline vital signs?
1) Temp of extremities, capillary refill (ambient temp), Color (pink? pale? blue? mottled?)
2) BP, HR, RR, HbO2 sat, temp
What is the mean pulse rate in a

1) Newborn
2) 3 mo-2y
3) 2 y - 10 y
4) Over 10
1) 140
2) 130
3) 80
4) 75
1) Is BP the first thing we worry about in vitals?
2) What is a proper fititng cuff like?
3) What happens if cuff is too small? Large?
4) What are Korotkoff sounds?
1) No - lots of other systems have to fail before BP falls (aka pt cyanotic)
2) Cover almost all of upper arm with elbow bent, cuff bladder = 40% of mid-upper arm circumference
3) Too high, too low
4) First sound = systolic, disappearance of first sound = diastolic
Normal BP in children:

1) Infant (6 mo)
2) Toddler (2 y)
3) School age (7 y)
4) Adolescent (15 y)
1) 87-105/53-66
2) 95-105/53-66
3) 97-112/57-71
4) 112-128/66-80 (more adult)
1) Difference between dose and dosage?
2) How do you calculate body surface area?
3) Who has a higher body surface area, and what implications does this have?
4) Total body weight in a newborn is __% fluid, while it's __% fluid in adults
5) how does a higher total body weight in children affect hydration requirements?
6) Signs of dehydration?
7) What role does potassium play?
8) How do you calculate child's dose based on BSA?
1) Dose is what you gave pt. Dosage is determined by weight
2) (0.02 x kg) + .40
3) Kids - rapid heat loss, more susceptible to dehydration
4) 75%, 57%
5) Needs a greater turnover of water, increase in daily fluid requirements
6) Fever, tachycardia, high urine specific gravity, elastic skin
7) Neuromuscular and cardiac function. Essential to monitor electrolyte levels
8) (BSA child/1.73) x adult dose
**Pediatric vital signs of a 3 year old?**

1) Pulse rate:
2) Respiratory rate:
3) BP:
4) Hemo O2 sat:
5) End tidal CO2:
1) 100 (80-120)
2) 20 (18-22)
3) 100/70
4) 98 (95-100)
5) 5-50
As children age, do the following go down or up?
1) HR
2) BP
3) RR
1) Down
2) Up
3) Down
3 components of a behavioral evaluation? (who talking to who)
1) Parent-Dentist interview (development, social/health hx, attitudes + expectations)
2) Indirect observation of Child-Parent (attachment/temperatment, child rearing practices + discipline)
3) Direct Child-Dentist interaction
Developmental milestones of a 12-month old?

1) Communication?
2) Mobility?
3) How do they respond to others?
4) How do they eat?
5) Grasp things?
6) Other behaviors?
1) Vocalizes/gestures or speaks words
2) Crawls/cruise/walk
3) Responsive, affectionate, or aggressive
4) Finger feeds, use cup and spoon independently
5) Precise pincer grasp
6) Imitates, shakes, bangs, throws, waves bye-bye
Developmental milestones of a 24-month old:

1) Communication?
2) Mobility?
3) Stacking blocks?
4) Imitates?
5) What kind of commands can they follow?
1) 20 word vocab, 2 word phrases
2) Can go up/down steps one at a time, kick ball
3) Stack 5-6 blocks
4) Imitates adults
5) 2 step commands
Developmental milestones of a 3-4 year old?

1) Mobility?
2) Care skills?
3) Knows what about themselves?
4) Behavior?
1) Up and down stairs w/out support, kicks balls, jumps in place
2) Self-care skills
3) Name, age, gender
4) Early imaginative behavior
Developmental milestones of a 5 year old?

1) Dress?
2) Draw?
3) Reading?
4) Geometry?
50 Play?
1) Dresses themselves
2) Draw person w/ head/body/arms/legs
3) Recognizes letters of the alphabet
4) Copies triangle/square
5) Plays make believe and dress up, interactive games with peers and can follow rules
1) What can you profile about a child from observation?
2) What interactions give you clues about the child's temperament?
3) What does a high intensity attachment to parent signal?
4) Easy temperament vs. difficult temperament in terms of biologic function, new stimuli, adaptability, moods, reactions?
1) Child-parent interactions, child's communication and coping skills, temperament and attachment
2) Child's interaction w/ environment, initial response to new situations
3) Emotional immaturity, insecurity
4) Easy - highly regular in biologic function, positive approach to new stimuli, rapidly adaptable, frequent positive moods, low/mildly intense rxns. Difficult - irregular in biologic function, withdraw from new stimuli, slow adaptation, high frequency of negative moods, frequent intense negative rxns
Behavior:

1) Parental report of child's ____ when meeting _____ is associated with negative behavior during dental tx.
2) What best predicts child's distress at parent separation?
3) Parental report of their child as "___" was correlated to a less successful sedation with midazolam and poorer amnesia
4) Analysis of temperament can be a strong/modest/weak predictor of child's behavior during initial oral exam
5) What are the two components of temperament that are predictive of behavior during sedation
6) Children with poor interactive behavior and high heart rates pre-operatively exhibited ____ and ___ intraoperatively.
7) T or F: Pre-operative interactive behavior and heart rate was judged predictive of intraoperative behavior during sedation
1) Anxiety, unfamiliar people
2) Shyness
3) Shy
4) Modest
5) Approachability, adaptability
6) Poorer behavior and higher heart rates
7) T
1) What factors are included on the Ohio State University Behavioral Rating Scale?
2) Ext: About what % of parents report pain? _% gave pain relievers? __% obtained relief from analgesics? Biggest pain-related crying behavior?
3) What are the 4 OTC analgesics for children for mild to moderate pain, poor side effects, and dosages?
4) Should you alternate acetaminophen and ibuprofen?
5) Why is Ibuprofen more advantageous to use?
1) Quiet, crying (fearful tears or defiant screams), struggling (combative, hyperactive, or uncontrolled mvmt), crying and struggling
2) ~36%, ~56%, 92%, crying (80%)
3) Aspirin (Bayer/Excedrin) - GI intolerance, Reye's syndrome, platelet inhibition

Naproxen (Aleve): slow onset, usually only for chronic pain, dose q8-12 hours

Acetaminophen (Tylenol, Tempra): hepatotoxicity, poor anti-inflammatory dose. 15 mg/kg q 4-6 hrs

Ibuprofen (Motrin, Advil, PediaProfen) - less side effects, dose = 10 mg/kg q 6-8 hrs

4) Only if ibuprofen alone isn't working. This combo is usually for fever
5) Anti-inflammatory, lower dose, longer application than acetaminophen
Prescribed analgesics for kids with moderate to severe pain:

1) What's in Tylenol with codeine elixir? Dose?
2) Tablets? Dose?
3) Codeine: what is the __% bioavailability? Is this good or bad efficacy? Where does it act? What is it metabolized to and where? What is the regimen?
4) Where does Tylenol work?
5) Should you prescribe Tylenol + codeine based on weight?
1) 120 mg acetaminophen + 12 mg codeine. 1 tsp for 3-6 y/o, 2 tsp for 6-9 y/o
2) 300 mg acetaminophen + 7.5 mg (#1), 15 mg (#2), 30 mg (#3), 60 mg (#4). 6-9 yo #2, 9-12 yo #3
3) 65%, poor efficacy. Acts on CNS to add sedation. Metabolized to morphine in liver, given strictly q 6 hrs in young children due to overdose precaution
4) Peripherally
5) NO
1) What is Roxicet? What is the pediatric dose mg/kg? How many mL do you give to a 15 kg child?
2) 4 reasons for giving preop analgesics?
3) What do pre-op analgesics do for 3rd molar exts? What drug was superior?
4) How effective are preop analgesics in kids?
1) Acetaminophen 325 mg + oxycodone 5 mg, tablets or oral suspension. 0.1-0.15 mg/kg. 15 kg child, give 1.5-2 mL q 6 hr PO
2) Poor post-op compliance to instructions (based on erroneous assumption about higher pain tolerance in children), fail to recognize kid's in pain, don't have medication available, and if postponed until pain intensifies post-op, absorption further delays effectiveness
3) Delay pain onset, decrease pain intensity, reduces amount and strength of post-op analgesic needed. Ibuprofen
4) Less effective for post-ext pain (maybe lower prevalence of reported pain, or reduced inflammatory response - greater vascularity, reduced PMN chemotaxis, less collagen matrix)
1) 4 requirements for pt to be sedated - rest/meds/diet?
2) What is the fasting requirement?
3) Is gastric emptying rapid or slow? How long does it usually take?
4) What is avg gastric fluid volume? Does BMI affect it?
5) Do clear liquids 2 hrs before surgery influence emesis? Can we relax the protocol - what would be the benefits?
1) Well-rested, healthy for 2 weeks prior to sedation, medicated with usual daily meds, starved
2) Can eat light foods (cereal/milk) until 6 hours prior (no meats or fats), clear liquids until 2 hrs prior to procedure (gatorade, water, apple juice, plain jello, popsicles - reduce dehydration and gastric pH), routine meds acceptable with sip of water
3) Rapid, 2 hrs
4) 1 mL/kg, BMI does NOT affect it
5) No effect on residual gastric volume. Kid less irritable, normovolemic, less hypoglycemic
Pre-sedation instructions to parent:

1) What to wear?
2) What to bring?
3) What not to bring?
4) Why do you need to tell parents to control the kid's anxiety?
5) Does parent presence in the operatory have an effect on the child's anxiety level?
6) What needs to be in the process and paper trail?
1) Loose clothes - no tights or tight pants, no toe nail polish
2) Adult helper, blanket/stuffed animal, change of clothes (nitrous, loose sphincter)
3) Other kids, food and drinks
4) Reduced anxiety = increased pain threshold, lowered required sedative dose
5) No, but it does on the parent's
6) Verbal and written information (information brochures, written discharge instructions, answered all questions) Written documentation that information was received, all questions answered
In the state of Florida, who may legally consent for minors who are under 18 and not married?
1) Natural or ADOPTIVE parent
2) Court appointed guardian or awarded permanent custody
3) Relative awarded an "Order for Temporary Custody" or "Power of Attorney" obtained with NOTARIZED PARENTAL CONSENT
4) Department of HRS, if all parental rights have been terminated
In the state of Florida, who can NOT consent for minors? What if they're married under the age of 18?
1) Foster parent
2) Grandparent, aunt, uncle, etc.
3) Anyone with an informal arrangement with the parent to provide consent

Married under age of 18 = emanicpated minor
What needs to be elaborated in informed consent?
1) HIDE IID - Have a witness, Identify person who will admin sedation, Disclose risks, complications, dnagers, Encourage second opinions/ask questions, Identify alternatives and their risks/benefits, It is the non-delegable duty of the doctor, Describe nature of sedation procedure and method of administration
1) What do you have to do to obtain verbal permission over the phone?
2) Foreign language consent?
1) Be reasonably assured that the person has the right of consent, you document phone number and name in record, and conversation must be "witnessed" by 2 staff persons (someone not directly involved w/ care)
2) Use a Shands Hospital interpreter using a conference call
1) What are the risks you need to disclose?
2) What are the paradoxical reactions you need to prepare the parent for?
3) Final checklist before sedation?
1) PENN PC - Paradoxical response, Emergence delirium, Nausea/vomiting, No guarantee of successful outcome (60%), Potential need for restraints/mouth prop, Cardiac/respiratory depression
2) DECAD - Disinhibitin, Excitation, Combativeness, Anger, Dysphoria
3) DANCADI - Documentation of previous sedations/anesthetics? Active/inactive medical issues addressed? Necessary med consult completed? Current meds recorded/administered? Acute illnesses ruled out (2 weeks before appt?)? Dietary instructions followed? Informed consent obtained?