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Flashcards in Pharmacologic Behavior Management Techniques Deck (39)
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1

Why do we need pharmacologic management?

  • Safey treat very anxious, fearful, uncooperative patients

2

Reasons for uncooperative behavior:

  • Very young age
    • ex. Pre-cooperative
  • Lack cognitive/emotional developement
    • ex: child with special needs
  • Child's temperament
  • Parenting Style
    • lack of expectations or discipline
  • PTS in medical/dental setting

3

NC Law: Nitrous Oxide under age 13

  • only sedative agent that can be administered under age of 13
  • only need dental liscense, no special permit
  • need informed consent

4

NC Law: Sedative agent other than Nitrous Oxide under 13 y.o.

  • Falls under:
    • Moderate Pediatric Conscious Sedation
      • OR
    • General Anesthesia
  • Grey Areas:
    • Anxiolysis
    • unsupervised premed to children outside office before appointment
      • discouraged by AAPD

5

Goals of Pharmacologic Management

  • Protect the patients safety and welfare
  • minimize:
    • physical discomfort and pain
    • psychological trauma
  • Maximize:
    • amnesia
  • control:
    • anxiety
    • behavior or movement
  • Return patient to a physiologic safe state for discharge

6

Moderate Pediatric Conscious Sedation Permit: requirements

  • required for sedation of patients under 13
    • other than nitrous oxide
  • obtained from NC board of Dental Examiners
  • Include:
    • supervision of CRNA or other personal that administers sedative medications 
      • employed or contracted
    • Thorough knowledge of agents
    • Proper training 
    • planned and documented rational for use of sedation
      • risk-to-benefit analysis
    • Thorough Medical History and Physical Evaluation 
    • informed consent
    • facility with all necessary equipment to handle an emergency
    • Properly trained employees
      • monitoring technique
      • emergency response-PALS or ACLS certification
    • Available mobile emergency medical services

7

Nitrous Oxide

  • least regulated
  • Very effective, but relies on proper patient selection
    • not Moderate to Severe Anxiety
  • in NC, only sedative agent administered in pedo without addtional training or liscense
  • Physiologically safe when administered with oxygen
  • most common side effect-Nausea

8

Advantages of Nitrous Oxide and Oxygen delivery by inhalation

  • Safety
    • impossible to lose consciousness or maintain airway
  • Rapid Onset and Recovery Time
    • due to low blood:gas solubiliity
  • Titratable
    • low blood:gas solubility allows for maximum effect with minimal discomfort
    • 35-50%

9

Nitrous Oxide: Disadvantages

  • Equipment cost
  • lack of patient acceptance
  • Weakness of agent
    • moderate to severe anxiety
  • Contraindications
    • acute otitis media
    • active pulmonary infection
  • Potential Chronic Toxicity
    • dentist and staff
  • Potentiation
    • when used in combo with another sedative agent- can take patient into deeper level than wanted

10

Sedation Patient Selection

  • Successful:
    • mild to moderate fear or anxiety who cooperate
  • Unsuccessful
    • extreme anxiety and uncooperative
    • combative
    • defiant
    • resistant

11

Dental Anesthesiology

  • 2012 ADA voted to be newest recognized dental specialty

12

Minimal Sedation

  • Aka Minimal Conscious Sedation
  • 13 y.o. or older
  • admin: oral or rectal routes
    • 1 pharmacological agent
    • 1 or more doses
    • Does not exceed Maximum recommended dose
  • can combine with nitrous oxide
  • used for behavioral management
  • Minimal depressed levels of consciousness
  • patient retains ability to:
    • independently and continuously maintain an airway 
    • respond normal to tactile stimulation and verbal command

13

Minimal Sedation Regulation in NC

  • Requires moderate sedation permit
    • no additional permit needed
    • Moderate Pediatric Conscious Sedation-Pedo dentists

14

Moderate Sedation

  • 3 subcategories
    • Moderate Conscious Sedation
    • Moderate Conscious Sedation limited to oral routes and nitrous oxide inhalation
    • Moderate Pediatric Conscious Sedation

15

Moderate Conscious Sedation

Subcategory of moderate sedation

  • Drug induced depressed consciousness
  • Patients respond to verbal commands, either alone or w/light tactile stimulation
  • Admin:
    • 13+ y.o.
    • oral, nasal, rectal, or parenteral routes (PORN)
    • Multiple pharm agents
    • multipile doses w/in 24 period
    • Can use w/Nitrous oxide
  • Used for Behavioral control

16

Moderate Conscous Sedation limited to oral routes and nitrous oxide inhalation

  • drug induced depressed consciousness
  • responds purposefully to verbal commands, alone or w/light tactile stimulation
  • Admin:
    • 13+
    • Oral route and nitrous oxide inhalation
    • single or multiple pharm agents
      • single or multiple doses w/in 24 hrs
  • Used for behavioral control

17

Moderate Pediatric Conscious Sedation

  • drug induced depressed consciousness
  • respond purposefully to verbal commands, alone or w/light tactile stimulation
  • Admin:
    • 13+
    • oral, nasal, rectal, parenteral (PORN)\
    • single or multiple pharm agents
    • single or multiple doses w/24 hr period
    • can use w/nitrous oxide

18

Educational requirement for Moderate Conscious Sedation or Moderate Pediatric Conscious Sedation Permit

  • Dentist must meet 1:
    • Option1:
      • 60 hrs didactic training including:
        • Pediatric Advanced Life Support (PALS)
        • Intravenous conscious sedation
      • Manage 10 pts supervised w/ intravenous sedation
    • Option 2:
      • Pre-doctoral dental or post-grad program w/
        • intravenous conscious sedation equivalent to one above
    • Option 3:
      • Internship or residency w/:
        • intravenous conscious sedation equivalent to one above
  • Moderate Pediatric Conscioius Sedation requires in addition:
    • Board approved pedo dental degree
    • pediatric residency program
      • OR 
    • equivalent hours of CE dental anesthesia

19

Facility Requirements for Moderate Conscious Sedation Permit

  • Operatory big enough for:
    • emergency equipment and personal
    • effective management of emergencies
  • CPR board or dental chair w/o enhancements
  • Lighting
  • Suction equipment
    • non-electric back-up suction
  • Positive Oxygen Delivery system
    • Full face mosk for adults and peds 
    • back-up E-cylinder
    • portable Oxygen tank seperate from central system
  • oral and nasal airways
    • various sizes
  • BP monitor
  • Pulse Oximeter
  • Automatic External Defibrillator (AED)
  • IV set up
  • Syringes
  • Tourniquet and Tape

20

Emergency Medications Required for Moderate Conscous Sedation Permit

  • Epinephrine
  • Atropine
  • Narcotic Antagonist (Naloxone)
  • Antihistamine
  • Corticosteroid
  • Nitroglycerine
  • Bronchodilator
  • Antiemetic
  • Benzodiazepine antagonist (Flumazenil)
  • 50% dextrose

21

Additional Requirements for Moderate Conscious sedation permit

  • Maintenance of sedation records for 10 yrs
  • Demonstrate:
    • Proper monitoring
      • sedation & recovery
    • Drug dose calculation and admin
    • Medical Emergencies management
    • Sterile Technique
    • CPR certified personel use
    •  

22

Moderate Conscious Sedation Permit: emergency management of what situations

  • Laryngospasm
  • Bronchospasm
  • Emesis and aspiration
  • Respiratory depression and arrest
  • Angina pectoris
  • MI
  • Allergic reactions
  • Convulsions
  • Syncope
  • Bradycardia
  • Insulin Shock
  • Cardiac Arrest

23

Deep Sedation

  • Drug Induced depressed consciousness w/partial loss of protective reflexes
  • Can't maintain airway independently
  • can't respond purposefully to verbal command

24

Deep Sedation Permit Requirements

  • General Anesthesia Permit
    • No further exam needed 

25

Unintentional Deep Sedation

  • Situation has to be infrequent and unintetional
  • important for moderate sedation to be trained to deal with patient
  • Causes:
    • hyper-responder to meds
    • exhaustion/lack of sleep
    • potentiation w/other agents
      • nitrous oxide

26

General Anesthesia

  • controlled state of depressed conscioussnes due to pharm agents w/ partial or complete loss of protective reflexes
  • can't
    • maintain airway
    • respond purposefully to physical stimuli or verbal commands

27

General Anesthesia Permit requirements

at least 1

  • 1 year of advanced anesthesiology training
  • Oral Surgeon
  • Diplomate status or eligible for exam by American Board of Oral Surgeons
  • Fellow of American Society of Anesthesiology
  • Dentist admin General Anesthesia 5 yrs before NC law-Feb 1, 1990

28

Sedation Technique: Patient Selection

  • unsuccessful behavior guidance
  • ASA 1 or 2 patients
  • Patients below the age of reason
    • pre or uncooperative
  • Extent of treatment needs
  • Older patients w/poor experiences or coping abilities
  • Travel distance of patient/family
    • even w/no behavior problems
  • Developemental delay or compromising medical condition

29

Sedation Technique: Medical History--> Issues to consider

  • Respiratory issues
    • asthma
    • allergies
    • acute infection
  • Diseases affecting
    • cardiovacular
    • neuromuscular
    • hepatic
    • renal
  • Current Meds w/OTC
  • Previous sedations or general anesthesia
  • Ventilator use at birth
    • especially for premature
    • suggests bronchopulmonary dysplasia
  • Sleep apnea and/or snoring
    • suggests-airway obstruction
  • Family history of disease or adverse response to medications
    • malignant hyperthermia

30

Sedation Technique: Physical Assessment

  • must be done before sedation or GA
  • Includes:
    • General Physical conditions
    • Vital Signs
      • HR, Respiratory Rate, BP
    • Vital Statistics
      • height and weight
    • Airway
      • must have unobstructed airway
    • risk assessment