Download advanced sedation techniques

S
British Society of Paediatric Dentistry and their
Policy Document on Management of Caries in the
Primary Dentition (Int J of paed dentistry 2001;
11:153-157)
S Current provision of sedation and GA services in paediatric
dentistry is fairly poor in its access and availability.
S Need for such services is indisputable.
S Due to the severe burden on the NHS hospital sector and the high
costs involved with General Anaesthesia in an in-hospital setting:
S Use of sedation as standard or advanced sedation techniques have
become an ever more important option in provision of dental
treatment to children.
S This trend is also seen at international level.
CURRENT UK GUIDELINES IN SEDATION
FOR CHILDREN.
S To ensure safe and appropriate sedation practice, it is important to
consider current UK guidelines.
S However one can not ignore what is going on at international level
in the fast growing field of paediatric sedation.
UK SEDATION GUIDELINES
S NICE guidelines for sedation in children and young people
(December 2010)
S The Scottish National Guidelines on “Conscious Sedation In
Dentistry”. Conscious Sedation in Dentistry Dental Clinical
Guidance.
S Conscious Sedation In The Provision Of Dental Care. Report Of
An Expert Group On Sedation For Dentistry. Standing Dental
Advisory Committee (SDAC) 2003, and the Standing Dental
Advisory Committee guidelines 2007.
INTERNATIONAL SEDATION GUIDELINES
S American Society of Anaesthesiologists Task Force on Sedation
and Analgesia by Non-Anaesthesiologists. Practice Guidelines for
Sedation and Analgesia.
S Guidelines from the South African Society of Anaesthetists
(SASA) on Procedural Sedation and Analgesia in Children. (These
guidelines are children specific and cover all areas important in paediatric
sedation.)
GUIDELINES IN SEDATION:
MAIN FOCUS
S Pre-sedation assessment, communication and patient information
and consent.
S Patient selection: A crucial aspect in paediatric sedation outside of
the operating room. By implication all children do not qualify for
sedation outside the hospital.
S Fasting
S Personnel and training. (The team concept.)
GUIDELINES IN SEDATION:
MAIN FOCUS
S Monitoring
S Documentation
S Equipment necessary in emergency situations
S Drugs and sedation techniques
S Recovery and discharge criteria
APPROACH TO ADVANCED SEDATION AT
TOOTHBEARY
S Dedicated Advanced Sedation Days (Currently 3/month)
S First choice of sedation for all patients: LA/RA
S Only the small minority of patients who can not be treated
through simple sedation techniques are given the option of
intravenous or combination oral sedation.
REPRESENTATION OF ALL CHILDREN
TREATED UNDER IV OR ORAL SEDATION
18
16
14
12
10
COMBIN ORAL
I.V
CONVERT TO IV
8
6
4
2
0
UNDER
2YR
2YRS
OLD
3YRS
OLD
4YRS
OLD
5YRS
OLD
6-8YRS
OLD
OVER
8YRS
REASONS FOR CONSIDERING ADVANCED
SEDATION
S Extensive and complicated dental treatment.
S Age of the child.
S Severe anxiety and behavioural difficulties, especially those who
have had previous traumatic experiences.
S Unable to cope with treatment under behavioural management
techniques or RA.
PATIENT AND PARENTS
S These patients are fully evaluated by the sedation practitioner and
the dental team.
S Parents are fully informed of the treatment options and sedation
plan prior to the sedation day. Effective communication with the
parents remains important.
S Parents are also provided with written information regarding
treatment of the child and sedation, including pre-and postsedation instructions.
S Parents are encouraged to ask questions if they are uncertain
about anything.
PATIENT EVALUATION
S Any potential medical problems or contra-indications for sedation
are:
S Identified from the medical history questionnaire or in
communication with the parents.
S
Communicated to the sedation practitioner before the sedation
appointment in order to consider the way forward.
S
As clearly stated in all sedation guidelines, only children
considered to be ASA 1 or 2 are eligible for sedation.
S All important medical information and full day list is sent to the
sedation practitioner the day before the sedation day.
START OF THE SEDATION DAY
S Team meeting to discuss the day list and any potential problems.
(“Group huddle”)
S On arrival, the child is encouraged to use the play area to relax
and familiarize.
S Simultaneously, all administrative details are double checked with
the parents and informed consent is signed.
PRE-SEDATION PATIENT ASSESSMENT
S
One of the recovery nurses will:

Meet the child and establish rapport

Review medical history.

History of recent colds or respiratory
symptoms.

Last food and liquid intake.

Weight and temperature measurements.

Local anesthetic applied to areas for
cannulation. (Even for combined oral sedation
in case of emergency.)
PRE-SEDATION PATIENT ASSESSMENT
S All information is then communicated to the sedation practitioner.
S Sedation Practitioner will:

Meet and discuss the sedation plan with the parents.

Evaluate the patient’s airway (Priority!), and a brief examination
of the heart and lungs.
PRE-SEDATION PATIENT ASSESSMENT
S Special care is taken to look for signs of Upper Respiratory Tract
Infection. (URTI)
S Particularly difficult problem in sedation with children.
S This is an important point as children often suffer from allergic
rhinitis which may be misdiagnosed as a URTI.
S Communication of all the information gathered is essential and
careful documentation is made of all findings.
THE SEDATION TEAM
S The team concept in sedation practice is acknowledged world -
wide.
S The Dentist: ILS trained, sedation training in Germany and USA,
10 years of experience with sedation involvement and GA for
children.
S 3 Dental nurses: ILS trained, all attend SAAD courses.
THE SEDATION TEAM
S Sedation Practitioner: Postgraduate training in Sedation and Pain
Control for standard and advanced sedation techniques, 7 years
experience as a full- time sedationist for children and adults, and
regularly updates knowledge and skills by attending refresher
courses and sedation symposia.
S Recovery nurses (at least 2): Registered Medical Nurses, EPLS
trained, both with years of experience in paediatric anaesthetic
recovery and nursing.
THE SEDATION TEAM
-CONTINIOUS PROFFESSIONAL
DEVELOPMENT
S At Toothbeary, the sedation team must meet the requirements for
safe sedation practice as set out in all sedation guidelines e.g.
qualifications and updating knowledge and skills.
S Regular in-house training sessions focusing on emergency
scenarios, as well as discussions on sedation related topics. (All
documented.)
THE SEDATION TEAM
-CONTINIOUS PROFFESSIONAL
DEVELOPMENT
S Annual clinic appraisal by Prof James Roelofse, Visiting Professor
from University College London, who is also an Executive
Member of the Paediatric Committee of the World Society of
Intravenous Anaesthesia.
S During the clinic appraisal, the sedation practitioner also
undergoes supervised clinical training as stipulated by all sedation
guidelines e.g. the NICE guidelines.
SEDATION EQUIPMENT AND MONITORING
S All necessary dental equipment, including good suctioning units!
S Oxygen (and N2O if needed)
S Clinical monitoring: At least two qualified people take part in the
monitoring of the child.
S Electronic monitoring:
•
Pulse Oximeter (SaO2)
•
NIBP
•
ECG
•
Capnograph
SEDATION EQUIPMENT AND MONITORING
S Fully equipped Resuscitation trolley:
S For Any emergency: A, B, C…
S Emergency drugs
S Spare oxygen cylinder.
S AED (With paediatric converter)
S Infusion pump
SEDATION TECHNIQUE
S In the UK, Conscious Sedation is the only appropriate level of
sedation allowed. (Out of hospital)
S Conscious sedation: Patient has to remain conscious and be able
to respond purposefully to verbal commands.
S In anxious and/or very young children, this can be:
•
Extremely difficult or challenging!
SEDATION TECHNIQUE
S However, at Toothbeary it has been shown to be both possible and
safe to treat children with complex dental needs, using advanced
combination drug sedation.
S This has also been proven by various publications on procedural
sedation in children.
SEDATION TECHNIQUE
S Mainly two sedation techniques are used at Toothbeary on the
dedicated sedation days:
S (A new route of sedation, namely nasal sedation has recently been
introduced and will be discussed in more detail later.)
S Everything discussed in terms of drugs and doses have been
published in evidence based studies.
COMBINED ORAL SEDATION
S Oral sedation in children is a controversial issue but there are
advantages. There is however a proviso for using oral sedation and
that is that the drug must never be administered at home.
S Drugs used: Midazolam and Ketamine.
S Indications for Oral sedation:
•
Small children/young age: Under 3 yrs old. (No cannulation
needed!)
•
Small/ short procedures
•
Parental choice
INTRAVENOUS (IV) SEDATION
S Indications for IV Sedation:
•
Children older than 3 years.
•
Difficult/ extensive dental treatment required.
•
Behavioural problems/ Severe anxiety.
INTRAVENOUS (IV) SEDATION
S A combination of drugs:
•
Midazolam (low dose, usually 0.5mg -1mg in total)
•
Ketofol (Ketamine 5mg/ Propofol 9mg per ml mixture) for induction and
intermittent boluses as needed. The dose used is 0.25 mg/kg of
ketamine…..this dose will give about 0.5mg/kg Propofol as a bolus.
•
Propofol continuous infusion (6-10mg/kg/h), and titrated to effect. If using
TCI (Target Controlled Infusion), then the dose of Propofol is 1 – 2 ųg/ml,
again titrated to effect. It must be remembered that children need higher
doses for effective sedation but recovery then also may take longer.
•
Total dosage of Ketamine usually does not exceed 1mg/kg per hour.
SEDATION TECHNIQUES
S By using a combination of drugs, rather than just a single drug, less of each
drug is used as when a drug is given alone. This approach also leads to a
lower incidence of side effects.
S During treatment under sedation, the value of clinical monitoring is crucial.
Never leave the child alone. Special attention to monitoring of the airway and
breathing is crucial.
S As can be expected with conscious sedation, patient movement is sometimes
possible. This is sometimes more troublesome for the dentist and the
implications should be discussed with the dentist.
S Treatment sessions usually last from 30 minutes to 90 minutes, with the
average around 45min.
AIRWAY MANAGEMENT
S Airway management in dental patients especially, can be a
problem for various reasons:
•
The airway is shared with the dentist, and dental equipment.
•
Water from the drill may flood the pharynx with possible
laryngospasm. It is probably wise to check the amount of water
from the drill, before sedation starts.
•
Secretions……..children often have allergic rhinitis which may
cause excessive secretions.
•
Depression of the lower jaw by the dentist may cause airway
obstruction.
AIRWAY MANAGEMENT
S Upper Respiratory Tract infections can complicate airway
management significantly in children. The sedation practitioner
must be alert to this possibility.
AIRWAY MANAGEMENT
S To deal with all these potential hazards associated with the airway
and paediatric dental sedation, use:
•
Moderate extension of the head by putting a pillow/cushion
under the shoulders may help in preventing airway obstruction.
•
Good suction (sometimes up to 3 different suction tubes)
•
Small yellow sponges to absorb water and blood in the mouth
•
A rubber dam.
AIRWAY MANAGEMENT
S It is very important though to
remember that these patients
are done under conscious
sedation and that any
manipulation of the mouth or
airway, the use of dental
equipment or aids, like the
rubber dam, still has to be done
in a careful and gentle way, so
as not to disturb the patient’s
level of consciousness.
POST-SEDATION RECOVERY
S
As soon as the treatment is
completed, the patient will be
transferred to one of the recovery
rooms, where the patient will be
placed in:
•
The recovery position and
monitored
•
Continuous Sa02 monitoring with
recovery nurse at the patient’s side.
•
Parents are then invited to join the
patient in recovery.
POST-SEDATION RECOVERY
S The recovery phase has the potential of being the weak link in the
whole sedation procedure. (As has been pointed out in a recent article
by Dr Michael Sury (Consultant Paediatric Anaesthetist, GOSH,
Continuing Education in Anaesthesia, Critical Care and Pain (2012)
12 (3): 152-156.)
S The child is usually not stimulated in the recovery room and may slip
into deeper levels of sedation.
S The trained and highly experienced medically trained nurses in the
recovery area are aware of this possibility.
S Usually following the treatment, the patient will sleep undisturbed for
around 20 to 30 minutes before they will wake spontaneously. The
recovery nurse never leaves the patient unattended.
POST-SEDATION RECOVERY
S Intravenous cannulas are normally left in place until the patient
has recovered to the point where the need for any reversal drugs or
other emergency medication is unlikely.
S Most patients will remain in recovery for around 30 minutes to 1
hour, by which time they will be:
•
Fully conscious (and cannula removed)
•
Normal pulse rate and SaO2
•
No nausea/ vomiting/ pain/ bleeding
POST-SEDATION COMMUNICATION
S Parents are fully informed of the postoperative care and any special
instructions.
S Parents are also given after hours contact numbers, including a mobile
number, and what to do in case of a medical emergency.
S Parents will be contacted the next morning to complete a post sedation
review over the phone.
S The dentist will reassess them 10-14 days after the sedation (to get feedback
about sickness, nightmares, behavioural changes ) and to reassess the dental
status (check extraction wounds, crown margins, dental hygiene).
S This approach contributes to a positive experience (successful visit, she/he
will remember for months afterwards) for the child.
SAFETY AND EFFICACY
S Over the last 12 months, the Toothbeary team has successfully
sedated and treated around 150 patients, with no serious adverse
events, nor any escalation in care.
S Furthermore, they have been very successful in their treatment
plans as demonstrated by the following graphs:
PROBLEMS DURING ADVANCED SEDATION
COMPLICATIONS DURING SEDATION
MOVEMENT
5%
COUGHING
5%
Convert to IV
6%
VOMITTING
1%
NONE
83%
PROCEDURES UNDER ADVANCED
SEDATION
Space
maintainers
2%
Procedures under Advanced Sedation
Extractions
17%
Fillings
39%
Fissure Sealants
20%
Crowns
22%
ADAVANCED SEDATION PATIENTS
Sedation sessions required to complete treatment
Required second
session
3%
Completed in 1
session
97%
THOUGHTS ON THE SEDATION PRACTICES
AT TOOTHBEARY
S A very specialized sedation service.
S Emphasis on the importance of using specialized and trained
staff.
S Continuous professional development: Aim to attend as many
sedation symposia as possible.
S Toothbeary works closely with specialists in this field of paediatric
sedation, like Prof James Roelofse, who helps to improve and
evolve their service. This forms part of the quality control, an also
their vision for the future.
FOR THE FUTURE…
S Nasal Midazolam & Ketamine:
S Many studies have been done on drug delivery via the nasal route.
S A recent study by Roelofse et al compared the use of a
combination of Sufentanil/Midazolam vs. Ketamine/Midazolam
administered intra-nasally for its analgesic efficacy and safety in
sedation for preschool children undergoing multiple extractions.
S The outcome was that there seem to be no difference in analgesic,
sedative and safety effects from either combination, and that both
provided adequate post-extraction pain relief.
FOR THE FUTURE…
S Studies like these have encouraged a closer look at this form of
sedation, and also because of obvious and proven/published
advantages:
•
Ease of administration. (No needles/ bitter tasting medication)
•
Good absorption and bioavailability.
•
Rapid onset of sedation (10-20 minutes).
•
Parental acceptance.
•
Acceptable rates of side effects. (Extremely low at sub-anesthetic
doses)
•
No demonstrable prolonged recovery.
FOR THE FUTURE…
S Important to note: Intra-nasal administration of these drugs can still
potentially induce deeper levels of sedation, and should therefor only
be used by persons trained and experienced in delivery of advanced
sedation techniques.
FOR THE FUTURE…
S Since the start of August 2012:
S Started using a combination of Midazolam 0.3mg/kg and Ketamine
5mg/kg.
S Using the MAD device for nasal delivery.
S Very promising results.
S This has now replaced combination oral sedation as a choice of
sedation at Toothbeary, as it has already shown to be far more
effective and acceptable to both parents and patients.
FOR THE FUTURE…
S Bispectral Index (BIS) Monitor:
S Another potential objective monitoring tool of the level of
consciousness during sedation.
S Some recent studies have shown a good correlation between the
BIS level during sedation and already validated and established
sedation scoring systems like the Modified Wilson Scale.
CONCLUSION
The Toothbeary Dental Practice enjoys:
•
Providing parents and patients with choice.
•
Be accessible to a wider section of the population than is mostly
available in the private medical sector.
•
Deliver a safe and effective medical service.
•
Strive to keep up with the best international practices in dentistry
and advanced sedation.
S