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Liege Lourenço-Matharu Nov 2016
Managing the anxious child and sedation for dental paediatric patients
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Aims and objectives
An overview on management of anxious children receiving dental treatment with or without sedation
Behaviour management
• Key factor in providing dental treatment • Based on empathy, child’s well being and best interest • Varied techniques - accepted legally in different
cultures and philosophies • Ongoing learning process throughout our professional
lives
The child and parents
• Attend equipped with learning set of behaviours to cope with situations
• These behaviours will be used in a dental setting
• Some will be helpful, some will make dental treatment difficult
• Parents unrealistic expectations
Behaviour Management Techniques
Tell-show-do Modeling
Distraction Pain control
Parents in or out Empathy
Voice-control Stop sign
Positive reinforcement Time out
When all the above fails…
• Take in consideration treatment needed.
• Is it urgent or can it be stabilised?
• Can pain be managed so to give respite?
• Can treatment be attempted under IS?
• Can treatment be carried out under IV?
• Can treatment be carried out under IN?
• Can the treatment be carried out by OS?
• Should the treatment be carried out under GA?
Sedation
• Poswillo Report (1990) - recommendations to use sedation in preference to GA
• Historically, nitrous oxide has been the technique of choice in the UK
• Little advance in conscious sedation for children has happened since then
Systematic Review
• 65 studies included
• More than 19 agents and combinations
• 37% all studies used supplemental N2O/O2
• 48% studies used papoose-boards
• Modes: oral, sub-mucosal, intranasal, rectal, intravenous, intramuscular, inhalational
Systematic Review
• Over 8 groups of drugs used worldwide for conscious sedation in children
• N2O, benzodiazepines, antihistamines, propofol, opioids, alcohols, barbiturates and ketamine
• Multi-pharmacy increasing the risk of over-sedation or GA
Agents used for children
• Chloral hydrate and hydroxyzine
• Used in the majority of the studies in the USA alone or in combination plus other agents, including nitrous oxide and papoose-board
Agents used for children
Propofol (Anaesthetic induction)
• Needs operator/anaesthetist
• Continuous infusion or operator
controlled infusion and patient
controlled infusion
• Not licensed for use in children
Agents used for children Ketamine
• 10 studies: USA (4), South Africa (3), Norway (1), India (2): 7 oral, 2 rectal and 1 intranasal
• Analgesia, sedation and amnesia
• Side effects: nausea, vomiting, hypersalivation, and agitation/hallucinations (emergence phenomena) less commonly in children
Agents used for children
Sevoflurane – (2 studies)
• Pleasant to inhale, non-irritant
and non-pungent
• Non-polluting
• Needs a calibrated vaporiser
attached to the N2O machine
• Carried out by operator and anaesthetist
Agents used for children
Midazolam • More than 35 studies • Alone or in combination • Oral (13), IV (3), IN (9), IM (1), Submucosal (4) and
rectal (5) • Dosages ranging from 0.2 to 0.7 mg/kg
Which sedation? • General medical history and ASA status
• Past dental/sedation history
• Dental treatment needed
• Anxiety/cooperation assessment
• Social history
• Available and appropriate escort
• Previous GA
• Pre-sedation instructions
• Specific written, valid consent
Sedation Assessment
Indications for Inhalation Sedation
• Mildly anxious children
• Unpleasant procedure
• Medically compromised
• Needle phobia
• Gag reflex
• Other sedation methods contra-indicated
• Alternative to GA
Contra-indications to IS
• Relative contra-indications • Acute and chronic nasal obstruction • 1st trimester of pregnancy • Inability to co-operate or understand
• Absolute contra-indications • Inability to breathe nasally with open mouth • Very severe myasthenia gravis & MS • Very severe chronic obstructive airways
disease • Nasal or facial deformity • Psychiatric disorders & nasal hood phobia
Preparation for IS Sedation
• Parents may attend with other children
• Child must attend with a responsible adult
• Child should be fit and well on the day
• Child able to breath through the nose
• Light meal before appt
• Should take medication at usual time
Quantiflex MDM
Nitrous oxide flow meter Oxygen flow meter Mixture control Flow control
Oxygen flush Air entrainment valve Common gas outlet
N2O Increments
• Start on 100% oxygen
• 10 % N2O for one minute
• 20 % N2O for one minute
• Further increments of 5 % N2O every minute until adequately sedated
Clinical Technique
• Calming mono-tonal voice
• Imagery/visualisation
• Muscle relaxation techniques
• Semi-hypnotic suggestion
• Music
• Ceiling pictures/artwork
• Dimmed lights
Midazolam: IV, IN and OS
• Calms the patient, relaxes skeletal muscles, produces anxiolytic and sedative-hypnotic effects
• Anterograde amnesia
• It is also an anticonvulsant
• In children these effects are similar to those seen in adults
Midazolam: undesirable
• Respiratory depression: muscle relaxant and reduced sensitivity of CNS chemoreceptors
• CV effects: small fall in arterial BP compensated by baroreceptor reflex: (increase pulse rate) - no clinical significance
• It may paradoxically show increased aggression, irritability and anxiety
Midazolam: Indications
• Moderate to severe anxiety
• A movement disorder or a physical,
mental or learning disability
• An increase gag reflex
• An unpleasant or complicated procedure
Midazolam: Contraindications
Relative:
• High BP (very rare in children)
• Alcohol or narcotics dependency
• Recreational drug use
• Impairment of renal or hepatic function
• No escort/or with other children
Midazolam: Contraindications
Absolute:
• Allergy to benzodiazepines
• Pregnancy and breast feeding
• Untreated severe psychiatric disease
• ASA IV and V
Midazolam: Reversal
Flumazenil:
• Benzodiazepine
• Antagonist at the receptors
• Greater affinity for the BDZ receptor displaces MDZ
Methods for IV
• IV Information leaflet is given
• Emla/Ametop tube and patches are given to patient to place1 hr before appointment
• Consent is taken and appointment arranged
Preparation for IV Sedation
• Parents must not attend with other children
• Child must attend with a responsible adult • Child should be fit and well on the day • Light meal before appt • Should take medication at usual time • Not use public transport to go home
Methods
• Titration according to patient’s response
• Single, multiple extractions, surgical extractions or simple surgical procedures and restorative treatment under LA
Preparation for Oral Sedation
• Parents must not attend with other children • Child must attend with a responsible adult • Child should be fit and well on the day • Light meal 4 to 6 hours before appt • Should take medication at usual time
• Not use public transport to go home
Oral Sedation
• MDZ is given as a flavoured syrup after weight of the child is taken
• Child is encouraged to go to the toilet
• Child is taken to a play area under supervision
• After 10 to 15 minutes parents bring the child to the dental chair
Recovery Play Area
• Patient is taken to recovery • Monitored by one member of
the team • Post-op/sed information given • Patient is discharged when alert
and responsive
Preparation for IN Sedation
• Parents must not attend with other children
• Child must attend with a responsible adult
• Child should be well and have unblocked nose
• Light meal 4 to 6 hours before appt
• Should take medication at usual time
• Not use public transport to go home
Side-effects
• Diplopia
• Hiccups
• Vomiting
• Crying in recovery
• Agitated in recovery
• Lip biting
• Passing water
Recommendations to practice
• The report from the standing committee for sedation classified midazolam sedation for subjects under 12 years as an ‘alternative technique’
• A total of 100 cases of IV or IS sedation over the previous two years are recommended
• Training must be supported by four years of post-registration experience as a dental practitioner in the UK
Follow guidelines
• BSPD: “A Policy Document on Sedation for Paediatric Dentistry”, 1996
• A Conscious Decision: A review of the use of GA and conscious sedation in primary dental care, 2000
• National Clinical Guidelines in Paediatric Sedation, 2002
• Recent Advances in Conscious Sedation, 2003
More guidelines
• Advanced Conscious Sedation Techniques for Paediatric Patients Training Syllabus
• Guidance for Commissioning – NHS England Dental Sedation Services – A Framework Tool
• A Guide to Maintaining Professional Standards in Conscious Sedation for Dentistry
• Safe Practice Scheme: Conscious Sedation Evaluation for Dentistry in the UK
• Conscious Sedation A Referral Guide for Dental Practitioners (in conjunction with DSTG)
And more guidelines… • RCS/RCA - Standing Committee for Sedation, 2007 • The NICE guidelines on sedating children, 2010 • Advanced Sedation, Training syllabus - DSTG, 2011
• IACSD – Intercollegiate Advisory Committee for Sedation in Dentistry guideline, 2015
Information Leaflets
• Create pictorial info for OS, IN, IV and IS patients • IV and IS forms must be given to 12-16 yr olds
• Age appropriate information
Information leaflets
• Need to mention ‘unpredictability’ of MDZ in pt info sheet
• Written info should be in line with NHS guidance reflecting the needs of different group with learning disabilities / where English is not the first language
• Alternatives to sedation
Information leaflets
Indications for sedation must be added:
• Anxiety – need anxiety scale measured
• Traumatic procedure
• Level of coop – need Frankl scale measured
• Nature of clinical procedure
Clinicians providing sedation
• Sedationist's training must be both from accredited courses and supervised practice
• CPD – must have 12 hours every 5 years including for IS
• Competence: minimal 20 IV, 10 OS/IN and 10 IS sedations a year
• If ‘irregular’ sedationist – mentoring and retraining needed
Clinicians providing sedation
• PILS for IS, IV, IN and OS • Nurse must be NEBDN / or equivalent
including for IS • Must know how to deal with respiratory
depression and collapsed airway
• Staff training and scenarios – new staff
Log book for all sedations
• Patients details
• Baseline vital signs
• Sedation agent
• Route
• Dose
• Reversal
• Untoward incidents
Regular scenario team training
• Respiratory depression • Airway support • Unconscious pt
• Obstruction • Vomiting • Failure of sedation • Idiosyncratic response • Delayed recovery • +ve pressure • Ventilation, airway adjuncts
Monitoring
• Level of consciousness
• Depth of sedation
• Airway patency
• Heart Rate and depth, skin colour, cap refill, pulse rate: rhythm vol
• SpO2 reading needed and BP for IV:
1. Pre-op
2. Intra-op
3. Post-op
4. Before discharge
Recovery
Must be supervised and monitored Discharge criteria: • Pt must be orientated in time, place and person • Vital signs stable • no pain / discomfort • HA • Cannula removed • Escort present • Analgesia given post-op • Post-op and post-sed instructions given
Miscellaneous
• Immediate treatment only if in best interest of the child
• Children under 16 must have an escort for IS
• OS and IN - sedation not pre-med, hence cannulation is necessary
Clinical Governance
• Critical incidents must be reported
• Assessment of outcomes will be undertaken through audit and reflection
• Records of equipment maintenance must be retained for inspection
Audits
• Midazolam over sedation
• Untoward events/complaints
• Monitor Sp02
Never events which must be reported centrally
The truth, the whole truth and nothing but the truth
Sedating children is very difficult:
• They have parents • They have no experience with cannulation • They have no experience of being “tipsy” • They have no experience of numbness • They “pretend” to be calm and then panic • They have abundant hormones • They can scream very loud!!! …What really helps is the amnesia…