use of relative analgesia as sedation for child oral care

Dr Marietjie Weakley

19 January 2019

Use of Relative Analgesia as Sedation for Child Oral Care in Private Practice

BEHAVIOUR MANAGEMENT

PHARMACOLOGICAL

NON-PHARMACOLOGICAL

PHARMACOLOGICAL BM

LOCAL ANAESTHESIA

CONSCIOUS SEDATION

ORAL

(Dormicum- Midazolam)

INHALATION

(Nitrous)

IM

(Ketamine)

IV

(Anaesthesiologist)

GENERAL ANAESTHESIA

PHARMACOLOGICAL BM

LOCAL ANAESTHESIA

CONSCIOUS SEDATION

ORAL

(Midazolam)

RELATIVE - OR INHALATION SEDATION

(Nitrous Oxide)

IM

(Ketamine)

IV

(Anaesthesiologist)

GENERAL ANAESTHESIA

RELATIVE/INHALATION SEDATION: NITROUS OXIDE

OUTLINE • Guidelines AAPD

• PAN Sedation

• Objectives

• Advantages

• Disadvantages

• Contra-Indications

• Pre-Operative Care & Instructions

• Safety Precautions

• Technique – Monitor – Documentation

• Post Sedation

PAN SEDATIONPSYCHOTROPIC ANALGESIC NITROUS OXIDE FOR CONSCIOUS SEDATION

• Psychotropic = Anxiolytic, Mood elevating, Anti-stress

• Conscious Sedation = Free of fear, Apprehension, Anxiety

• Patient always maintains

✓Airway

✓Normal laryngeal and cough reflexes

✓Respond appropriately to physical or verbal commands

• Goal - Relax with Minimal Analgesia

• Minimize Anxiety – Minimize Pain!

Prof Mark Gillman

OBJECTIVES

• Reduce or eliminate anxiety

• Reduce untoward movement and reaction to dental treatment

• Enhance communication and patient cooperation

• Raise the pain reaction threshold

• Increase tolerance for longer appointments

• Aid in treatment of the mentally/physically disabled or medically compromised patient

• Reduce gagging

• Potentiate the effect of sedatives.

• ADA: Guidelines on Use of Nitrous Oxide for Paediatric Dental Patients

• Adopted 2005, Revised 2009, 2013

ADVANTAGES

• No IV

• Non irritant

• Rapid uptake

• Anxiolytic

• Compatible with medical conditions/ medications

• Can titrate (control over dosage)

• Reversible (flush out nitrous oxide)

AAPD: Guidelines on Use of Nitrous Oxide for Paediatric Dental Patients

DISADVANTAGES

• Lack of potency

• Dependant largely on psychological reassurance / patient acceptance

• Interference of the nasal hood with injection to anterior maxillary region

• Patient must be able to breathe through the nose (Claustrophobics?) –blocked nose/crying

• Nitrous oxide pollution and potential occupational health hazard

• Staff training and space in practice

• Cost: Expensive


S

ABSOLUTE CONTRA-INDICATIONS:

• Chronic obstructive pulmonary diseases /hypertension

• Cardio Vascular disease (congenital heart problems)

• Treatment with bleomycin sulfate (Cancer Patients)


OTHER CONTRA-INDICATIONS:

(Patient should be ASA 1 or 2)

• Severe emotional disturbances or drug-related dependencies

• Motion sickness/ history of nausea and vomiting with anaesthesia

• Ear, nose & throat infections

• NO CRYING! Not work on an uncooperative child!

• Chest infections


PRE-OPERATIVE CARE & INSTRUCTIONS

• Full Medical History to exclude Contra-indications

• Change in child’s health prior to appointment, e.g.: chest, ear & nasal infection

• Light meal/drink 2 hours before

• Empty bladder before

• No siblings

• TELL – SHOW – DO with mask – practice at home (nebuliser)


SAFETY PRECAUTIONS

• Excellent safety record - adverse effects rare

• Training

• Good patient selection

• Fail safe equipment, scavenging system

• Basic life support training and emergency cart/kit

• Different sizes

• Able to resuscitate non-breathing, unconscious patient

• Positive pressure oxygen cylinder – 10L/m 60 min


TELL - SHOW - DO!!!

POSITION PATIENT CORRECTLY

OPEN AIRWAY

Courtesy of: Dr Nicoline Potgieter: University of Pretoria, RSA

SCAVENGER OUT THE WINDOW


CONNECT MACHINE TO 02 AND N20 SUPPLY


oxygen

N20

CONNECT VENTILATION BAG TO MACHINE


CONNECT 02 AND N20 MASK-PIPES TO MACHINE

To nose piece

To machine


STERILE MASK


CONNECT MASK TO MASK-PIPES


CORRECT PLACEMENT

•SEAL WELL AROUND NOSE

•STABALIZE BEHIND HEADREST

•NOT TOO TIGHT OR TOO LOOSE


INCORRECT PLACEMENTUPSIDE DOWN

POOR SEAL


TECHNIQUE

• 100% oxygen introduced for 3-5 min – 3-6L/min flow rate

• Bag should pulsate gently with each breath and should not be either over- or under inflated.

• Titrate:

- Introduce N2O in 10% intervals every 60 sec

- N20 concentration should not exceed 50%

- After treatment N20 decrease in 10% intervals

- 100% Oxygen administered for 5 min

(to prevent diffusion hypoxia: headache/disorientation)

- Record all procedural information in patients file


MONITOR

• Continual clinical observation of the patient’s:

• Responsiveness

• Colour

• Respiratory rate and rhythm

• Pulse oximeter- saturation

• Should not drop but stay stable

• If drop more than 3% → give pure Oxygen

• Minimum 95% → give pure Oxygen

• Signs for over/under sedation


SUCCESSFUL SEDATION

• Peripheral tingling

•Warm, floaty, relaxed feeling

•Visual effects

• Smiling and possible giggling

•Responds to verbal command

•Eyelids relaxed

•No uncomfortable movements


OVER SEDATION

•Mouth closing

•Uncooperativeness

•Un-coordinated movements

•Laughing/giddiness

•Nausea/ vomiting

• Feeling of impending doom

•Higher incidence of adverse effects with:

o longer administration of N20/Oxygen

o fluctuations in N20 levels

o increased concentrations of N20


DOCUMENTATION

•CONSENT

•REASON FOR N20 SEDATION

• E.g. previous attempt did not work

• PRE-OPERATIVE INSTRUCTIONS GIVEN

• PULSE OXIMETER BEFORE

•CONCENTRATION AND DURATION OF N20/02

• Flow rate (l/min)

• Percentage N20 and time administered

• 100% oxygenation time

• PULSE OXIMETER AFTER

NB


Patient is relaxed = Mom is relaxed = Dentist is relaxed!

HUGE PRACTICE BUILDER!

KIDS LOVE REWARDS & PRAISE!

POST APPOINTMENT

• Praise

• Present/token/sticker

• Certificate

Thank you for your kind attention!

THE END

Dr Marietjie Weakley

Cell: +27 79 755 3810

[email protected]

mailto:[email protected]

use of relative analgesia as sedation for child oral care

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