Download Sedation and general anesthesia

Conscious sedation:
- These are technique that utilize drugs to induce a
cooperative and conscious state in the case of un
cooperative child patient.
 Objectives of conscious sedation :
1- changes child from fearful condition to conscious
sedation.
2-dental services will be -more comfortable.
-more efficient.
-high quality.
3-promt positive psychological attitude in the patient
toward future care.
 Route of administration :
1-oral route.
2-intravenous route.
3-intramuscular route.
4-subcutaneous route.
5-rectal.
6-inhalation(nitrous oxide gas).
1-Oral route :
-most commonly route for pediatric dentistry ‘syrup’.
-easy, convenient, if its taste is good & delivered in
small volume.
-giving the drug in the office is better than at home for
better supervision.
-Effect is noted after 30 min at least.
-Peak drug effect may require 1 hours or more.
-Duration of action is from 4 to 6 hours.
- Absorption of drugs in stomach and small intestine
no solid food should be taken after midnight before
sedation.
 These recommendations are for two reasons :
1- Drug uptake is maximized when the stomach is
empty.
2- Prevent vomiting which may lead to severe
complications.
 Examples :
- Chloral hydrate.
- Diazepam.
- Promethazine.
- Midazolam.
- Hydroxyzine.
• Advantages of oral route :
1-universally acceptable.
2-ease of administration.
3-Decrease allergic reactions.
 Disadvantages of oral route :
1-patient ‘parents’ compliance.
2-Prolonged onset of action ( 30min. To 1 hr.).
3-Prolonged duration of action.
4-Erratic absorption.
5-Vomiting may occur if child is not fasting.
2- Intravenous route :
- The most efficient method.
- Children must be cooperative despite their anxiety to
be prepared to accept I/V injection.
- Dose 0.1 mg/kg body weight.
- Injected slowly (1-2min.) during which child is
spoken to relaxed.
- Sedation is deepest immediately after injection & for
the next 10min.
- During this period injection of local analgesia is
given and treatment is started.
- Depth of sedation become lighter& patient appears
normal after 1 hr.
- Drug effect may continue for several hours..child
should rest at home for the end of the day.
- This technique is not recommended for child below
6yr.
 Example :
- Ultra short acting barbiturates.
- Narcotic ( Diazepam).

Advantages of I/V route :
1-very rapid effect.
2-dose given in increments until the desired level is
achieved.
3-injected directly into blood stream, so absorption is
not a complicating factors.
 Disadvantages of I/V route :
1-Extravasations of drug into the tissue
Hematoma & allergic reaction.
2-not recommended for very young children.
3- need post-operative recovery & subsequent
restrictions of activities.
4-Injury of blood vessels.
3-intramuscular route :
-Used to produce deep sedation in very uncooperative
young patient.
-site of injections : -upper lat.Quadrant of the buttock.
-ant. Aspect of the upper thigh.
-lat. Aspect of the upper arm.
-Dose 1.5mg/kg weight.
-Examples : -Phenergen.
-Pethidine.
 Advantages of I/M route :
1- absorption into a large muscle is faster than the oral
route.
2-does not require patient cooperation.
3-replace oral & I/V if the patient is afraid of allergy.
 Disadvantages of I/M route :
1-delayed absorption by several factors. (cold, anxious
child).
2-tissue trauma at injection site.
3-annoying the patient.
4-Subcutaneous route:
-It is the injection of drug beneath the skin into the
subcutaneous tissue.
-drug irritating tissues are avoided (diazepam).
-rate of absorption into CVS system varies with the
blood supply to the tissues.
-Limited effect in the dentistry due to slow rate of
absorption.
-thick skin absorption < thin skin absorption.
5-Rectal route :
-Most appropriate for very young children( max.2 yr).
-alternative for those who refuse oral or injection route.
-rapid uptake & fast onset.
-use for reduction of mild anxiety.
 Examples : - Phenobarbital.
-Chloral hydrate.
-Diazepam.
- Never use fixed dose based on an age.
- Doses is based on body weight (e.g 2mg/kg).
- Inhalation analgesia (nitrous oxide) :
-Color less gas.
-Sweet smelling gas.
-Neither explosive nor flammable.
-not soluble in body fluid.
-CNS depressed.
-Quickly absorbed from lungs into the blood stream&
transported to brain& other tissue in the serum.
-Excreted unchanged through lungs.
 Indications of Nitrous oxide :
-Children with mild anxiety & can follow instructions
during nitrous oxide administration.
-Children with short attention span.
-Fearful & apprehensive patients.
-Mentally handicapped.
Notes:
-analgesic properties of nitrous oxide help to raise the
pain threshold & may be used to decrease discomfort
during L.A. Injection.
-Nitrous oxide will not eliminate the need of L.A. In
pain control except for very minor procedure (class
v).
-Nitrous oxide gas is excreted as it is from lungs in
exhaled air.
 Contraindication of Nitrous oxide:
1- upper respiratory tract infection.
2-pulmonary disease ( bronchitis, TB.).
3-Nasal obstruction as it prevent easy breathing from
the nose.
4-Children with history of motion sickness(may vomit
when gas given).
 Advantages of nitrous oxide:
-Rapid onset and recovery .
-Reduce pain and produce a state of relative analgesia.
-Depth of sedation can be controlled.
-Safe and does not react with body fluids.
-Decrease anxiety.
 Disadvantages of nitrous oxide:
-weak agent need increase conc. With moderate or
severely anxious patient.
-inconvenience in some area such as Max. Ant. Teeth as
nasal mask may hide this area.
-Ch. Toxicity
Spontaneous abortion, congenital
malformation, liver disease and kidney disease
 Equipment :
1-Nitrous oxide machine:
a)Flow meter measure oxygen and Nitrous oxide.
b)Fail safe valve cuts off flow of nitrous oxide when
oxygen level drops below 3L/min.
2-Reservoir bag.
3-Nasal inhaler(mask, large, small).
4-Oxygen & Nitrous oxide tanks.
5-Scavenger system& ventilation in the room to clear it
from gas.
 Technique :
-Describe to the patient what nitrous oxide is & how
will feel( e.g. It will make him feel happy & as if he is
floating in air).
-Make sure he can control his feeling & he will not be
put to sleep.
-Encourage the child to breathe through nose.
-Apply face mask.
-Oxygen should begin with 100% oxygen for 3-5 min.
-Conc. Of nitrous oxide increased gradually 5-10%
every 3-5mins. Till reach 30-35% (peak of sedation
after 25-30mins).
- Final concentration70% oxygen & 30% nitrous oxide.
-Close flow meter.
 State of analgesia is reached when:
-Child feels tingling sensation in finger and toes.
-Smiles and follow simple instructions.
-The mouth stays opened easily.
-Sense of detachment, sometime interpreted as a
floating sensation.
-When this state is reached L.A. Is given.
 Recovery from analgesia:
-Inhalation of 100% oxygen for 5 min. Child will
regains his normal state of consciousness.
 Complications following nitrous oxide
analgesia:
-nausea & vomiting.
-Headache and deep sleep.
-patient may become irrational & disoriented.
-If nitrous oxide exceeds 35% & oxygen decrease
Hypoxia of brain (irreversible).
-Over sedation.
-Morbidity and mortality increase with young
age.
 Chronic toxicity :
- Dentist & dental personal exposed to high levels of
nitrous oxide for period > 3 hrs/ wk.
Increase in
hepatic disease was found.
- Depression of bone marrow(leukemia & anemia).
- Liver cirrhosis and renal problems.
Thank you for
your attention