premedication pain managment
DESCRIPTION
Premedication Pain managment. Measurement of pain in children. Observer-based techniques which are useful in pre-verbal children, blood pressure, crying, movement, agitation and verbal expression/body language. Self-reporting of pain is valid in children over 4–5 years of age. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/1.jpg)
PremedicationPain managment
![Page 2: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/2.jpg)
Measurement of pain in children
• Observer-based techniques which are useful in pre-verbal children, blood pressure, crying, movement, agitation and verbal expression/body language.
• Self-reporting of pain is valid in children over 4–5 years of age. • Older children and teenagers can use a normal visual analogue
scale of 1–10.• Mentaly handicaped children - difficult to assess - unusual
changes in behaviour
![Page 3: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/3.jpg)
Analgesia prior to procedures (pre-emptive analgesia)
• ensure adequate systemic and/or local analgesia prior to the commencement of a procedure
• Appropriate time for absorption and effect should be allowed.• A stronger analgesic may be required for the procedure with
regular simple analgesics for the postoperative period.
![Page 4: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/4.jpg)
Routes of administration• Per os - is the preferred route of administration in children. • absorption for most analgesics is generally rapid – within 30min• liquid vs. tablets in younger children, taste - can help greatly with
compliance• Per rectum - in a child who is fasting or not tolerating oral fluids. • peak levels are usually much longer (paracetamol 90–120 min)
- not used in the immunocompromised child due to the risk of infection
• Intranasal or sublingual - as an alternative• Intramuscular injection should be avoided in children• In obese children, the dosage given should be based on ideal
body weight
![Page 5: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/5.jpg)
![Page 6: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/6.jpg)
Paracetamol• pre-op 20 mg / kg po (syrup) • Post-op 15 mg / kg po á 6 hours. • (30 mg / kg as a single dose rectally) maximum 24-hour dose
90mg/kg, followed by 50 mg / kg / d! • from 3.months of age
• ! Watch out in hepatopathy• Useful as a pre-emptive analgesic• No effect on bleeding• IV paracetamol (PERFALGAN) in hospitalised
![Page 7: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/7.jpg)
NSAID - ibuprofen• Pre-op - ibuprofen 10mg/kg p.o. (syrup)• Post-op – if needed ibuprofen 5 mg/kg á 6-8 hod. p.o.
• Effective alone after oral and dental procedures.• Can be used in conjunction with paracetamol.• Have an opioid-sparing effect.• Increase bleeding time due to inhibition of platelet
aggregation.• Useful analgesic once haemostasis has occurred.• Best given if tolerating food and drink.• Can be used in infants over 3 (some authors 6) months of age.
![Page 8: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/8.jpg)
Non-steroidal anti-infl ammatory drugs (NSAIDs)
NSAIDs are contraindicated in children with:• Bleeding or coagulopathies.• Renal disease.• Haematological malignancies, who may have or develop
thrombocytopenia.• Asthma, especially if they are sensitive to asthma, steroid-
dependent or have coexisting nasal polyps.
![Page 9: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/9.jpg)
Sedation in paediatric dentistry
• The choice of a particular technique, sedative agent and route of delivery
• children’s responses are more unpredictable than adults - easily over-sedated
Anatomical differences between the adult and the paediatric airways include:• Children have a relatively larger tongue and epiglottis.• Possible presence of large tonsillar/adenoid mass• The mandible is less developed and retrognathic in children.• Children have smaller lung capacity and reserve.
![Page 10: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/10.jpg)
Patient assessment• Medical and dental history (including medications taken).• Patient medical status (American Society of Anaesthesiologists
(ASA) classifi cation).• History of recent respiratory symptoms or infections.• Assessment of the airway to determine suitability for
conscious sedation or general anaesthesia.• Fasting status• Procedure being performed• Age• Weight• Parent factors
![Page 11: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/11.jpg)
Inhalation sedation- nitrousoxide sedation• Anxiolytic and mild analgesic effect• Anxious but cooperating children • Age - 4 years
Benefits • safe and relatively easy technique. • light sedation. • rapid onset (2-3min) and readily reversible with a short
recovery time (10-15min) • Entonox - titre fixed-N0 50%, 50% O2 • requires only clinical monitoring
![Page 12: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/12.jpg)
Contraindications• Severe psychiatric disorders , mentaly handicaped• Obstructive pulmonary disease• Chronic obstructive airway disease• Communication problems• Uncooperating patients• Pregnancy• Acute respiratory tract infectionsComplications• nausea, vomiting• headache
![Page 13: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/13.jpg)
Course of performance• healthy child (no colds, cough and / or fever),• not fasting, • Entonox - inhalation using a face mask or mouthpiece. • Maximum effect starts usually after 2-5min of uninterrupted
inhalation• Inhalation of Entonox continued intermittently throughout the
performance (application of local anesthesia, tooth extraction, surgery).
• After treatment - child is kept under supervision in a room of about 5 to 10 minutes or until his attention and motor coordination are sufficiently restored
![Page 14: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/14.jpg)
Conscious sedation• patient who is awake, responsive and able to communicate• maintenance of protective reflexes• ! conscious sedation, deep sedation and/or general
anaesthesia is a continuum• Pulse oximetry• Age and size-appropriate equipment and medications for
resuscitation
![Page 15: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/15.jpg)
Oral sedation
Premedication• Benzodiazepines (e.g. midazolam)
• Potentiated sedation– ANESTEZIOLOGIST• Chloral hydrate• Hydroxyzine• Promethazine• Ketamine
![Page 16: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/16.jpg)
Midazolam - Dormicum• short-acting benzodiazepine • rapid patient recovery - extra sleep 2-3 hours • dosage ranges from 0.3 mg - 0.7 mg / kg • We 0.5 mg / kg • P.o. Dormicum tablets 7.5 mg or Midazolam 1 ml amp
• effects: • Sedative, hypnotic, anxiolytic, anterograde amnesia,
myorelaxant
![Page 17: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/17.jpg)
Course of performance• The child must be healthy (no fever, cough, fever), • Fasting for min. 3 hours (6hrs). • With parent - short-term hospitalization,• midazolam administered as a solution or tablets (0.5 mg/kg) • under the supervision of accompanying person on a bed in
sleep-room. • onset of effect of midazolam - within 20-45 minutes the
followed by dental procedures (tooth extraction / s, tooth decay treatment, surgery)
• Recovery period 2-3hrs - under the supervision of accompanying person on a bed in sleep-room.
![Page 18: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/18.jpg)
Midazolam• drugs given orally cannot be titrated accurately• hepatic metabolism• an overdose cannot be easily reversed• oral sedation requires cooperation from the child to ingest the
medication• Never re-dose• Per rectum - more reliable and controllable absorption, but
requires cooperation, bad compliance• Intranasal - whether the drug is absorbed directly from the
blood stream or there is direct uptake to the central nervous system, requires a higher level of training and monitoring
![Page 19: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/19.jpg)
Midazolam• Intravenous sedation• requires a highly trained team• specialist anaesthetist• monitoring, adequate facilities and recovery options• controllable and may be readily reversible• inappropriate form of drug administration in extremely
anxious children• IV sedation - in a hospital environment or accredited dental
surgeries
![Page 20: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/20.jpg)
Suitable procedures for midazolam sedation• Short procedures that require approximately 30 minutes duration.• Primary teeth extractions or up to two permanent molars.• 1–2 quadrants of restorative dentistry.• Short surgical procedures with good access in the mouth.not suitable for sedation• 3–4 quadrants of restorative dentistry• Extractions of permanent molars in each quadrant (invasive
procedure and bleeding from all four quadrants make airway management more difficult).
• Obese children• Parents who may not provide adequate care to the child
postoperatively.
![Page 21: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/21.jpg)
Midazolam - complications• In rare cases, complications may occur in the form of so-called paradoxical
reactions (manifested as tearfulness, hyperactivity, agitation, refusal to aggressive behavior)
• or vomiting.
Symptoms of midazolam overdose can include:• Ataxia• Dysarthria• Nystagmus• Slurred speech• Somnolence (difficulty staying awake)• Mental confusion• Hypotension• Respiratory arrest• Vasomotor collapse
![Page 22: Premedication Pain managment](https://reader035.vdocument.in/reader035/viewer/2022062222/568166d5550346895ddae771/html5/thumbnails/22.jpg)
Discharge criteria after sedation
• Self-maintenance of airway.• Easily rousable and able to converse.• No ataxia, can walk properly.• Tolerating oral fl uids.• Discharge in the care of a responsible adult with appropriate
information about• after-hours contact if a problem arises.