ADVANCED - PowerPoint Presentation

Slide1

ADVANCED

SEDATION

TECHNIQUES

A NEW APPROACH AT THE TOOTHBEARY

DENTAL PRACTICE

Slide2

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)

Current

provision of sedation and GA services in paediatric dentistry is fairly poor in its access and

availability.

N

eed

for such services is i

ndisputable

.

Due to the severe

burden on the NHS hospital

sector and

the high costs involved with General Anaesthesia in an in-hospital

setting:

U

se

of sedation as standard or advanced sedation techniques have become an ever more important option in provision of dental treatment to children

.

This

trend is also seen at international level. Slide3

CURRENT UK GUIDELINES IN SEDATION FOR CHILDREN.

To ensure safe and appropriate sedation practice, it is important to consider current UK guidelines.

However one can

not ignore what

is

going on at international level in the fast growing field of paediatric sedation. Slide4

UK SEDATION GUIDELINES

NICE guidelines for sedation in children and young people (December 2010)

The Scottish National Guidelines on “Conscious Sedation In Dentistry”.

Conscious

Sedation in Dentistry Dental Clinical

Guidance.

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. Slide5

INTERNATIONAL SEDATION GUIDELINES

American Society of

Anaesthesiologists Task Force on Sedation and Analgesia by Non-Anaesthesiologists.

Practice Guidelines for Sedation and Analgesia

.

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.) Slide6

GUIDELINES IN SEDATION:

MAIN FOCUS

Pre-sedation assessment, communication and patient information and consent.

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.

Fasting

Personnel and

training.

(The

team

concept.)Slide7

GUIDELINES IN SEDATION:

MAIN FOCUS

MonitoringDocumentation

Equipment necessary in emergency situations

Drugs and sedation techniques

Recovery and discharge criteriaSlide8

APPROACH TO ADVANCED SEDATION AT TOOTHBEARY

Dedicated Advanced Sedation Days (Currently 3/month)

First choice of sedation for all patients: LA/RAOnly the small minority of patients who can not be treated through simple sedation techniques are given the option of intravenous or combination oral sedation.Slide9

REPRESENTATION OF ALL CHILDREN TREATED UNDER IV OR ORAL SEDATIONSlide10

REASONS FOR CONSIDERING ADVANCED SEDATION

Extensive and complicated dental

treatment.Age of the

child.

Severe anxiety and behavioural difficulties,

especially those

who

have had previous traumatic experiences.

Unable to cope with treatment under behavioural management techniques or RA. Slide11

PATIENT AND PARENTS

These patients are fully evaluated by the sedation practitioner and the dental team

. Parents are fully informed of the treatment options and sedation plan prior to the sedation day. Effective communication with the parents remains

important.

Parents

are also provided with written information regarding treatment of the child and sedation, including pre-and post-sedation instructions.

Parents

are encouraged to ask questions if they are uncertain about

anything. Slide12

PATIENT EVALUATION

Any potential

medical problems or contra-indications for sedation are:

Identified

from the medical history questionnaire or in communication with the

parents.

Communicated

to the sedation practitioner before the sedation appointment in order to consider the way forward

.

As clearly stated in all sedation guidelines,

only

children considered to be ASA 1 or

2

are eligible for sedation.

All important medical information and full day list is sent to the sedation practitioner the day before the sedation day. Slide13

START OF THE SEDATION DAY

Team meeting to discuss the day list and any potential problems. (“Group huddle”)

On arrival, the child is encouraged to use the play area to relax and familiarize.

Simultaneously, all administrative details are double checked with the parents and informed consent is signed.

Slide14

PRE-SEDATION PATIENT ASSESSMENT

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.) Slide15

PRE-SEDATION PATIENT ASSESSMENT

All information is then communicated to the sedation practitioner.

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.Slide16

PRE-SEDATION PATIENT ASSESSMENT

Special care is taken to look for signs of Upper Respiratory Tract Infection. (URTI)

Particularly difficult problem in sedation with children.This is an important point as children often suffer from allergic rhinitis which may be

misdiagnosed

as

a URTI.

Communication of all the information gathered is essential and careful documentation is made of all findings.Slide17

THE SEDATION TEAM

The team concept in sedation practice is acknowledged world - wide.

The Dentist: ILS trained, sedation training in Germany and USA, 10 years

of experience

with sedation involvement and GA for

children.

3 Dental nurses: ILS

trained, all attend SAAD

courses. Slide18

THE SEDATION TEAM

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.

Recovery nurses (at least 2): Registered Medical Nurses, EPLS trained, both with years of experience in paediatric anaesthetic recovery and nursing. Slide19

THE SEDATION TEAM

-CONTINIOUS PROFFESSIONAL DEVELOPMENT

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.

R

egular

in-house training sessions focusing on emergency scenarios, as well as discussions on sedation related topics

. (All documented.) Slide20

THE SEDATION TEAM-CONTINIOUS PROFFESSIONAL DEVELOPMENT

A

nnual 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.

During the clinic appraisal, the sedation practitioner also

undergoes supervised clinical training as stipulated by all sedation guidelines e.g. the NICE

guidelines.Slide21

SEDATION EQUIPMENT AND MONITORING

All necessary dental equipment, including

good suctioning

units!

Oxygen (and N2O if needed)

Clinical monitoring: At least

two qualified people take part in the monitoring of the

child.

Electronic monitoring:

Pulse Oximeter

(SaO2)

NIBP

ECG

CapnographSlide22

SEDATION EQUIPMENT AND MONITORING

Fully equipped Resuscitation trolley:

For Any emergency: A, B, C…Emergency drugsSpare oxygen cylinder.

AED (With

paediatric

converter)

Infusion pumpSlide23

SEDATION TECHNIQUE

In the UK,

Conscious Sedation is the only appropriate level of sedation allowed. (Out of hospital)Conscious sedation: Patient has to remain conscious and be able to respond purposefully to verbal commands.

In anxious and/or very young children, this can be:

Extremely difficult or challenging!Slide24

SEDATION TECHNIQUE

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.

This

has

also been proven

by various publications on procedural sedation in children.Slide25

SEDATION TECHNIQUE

M

ainly two sedation techniques are used at Toothbeary on

the

dedicated sedation days:

(A new route of sedation, namely nasal sedation has recently been introduced and will be discussed in more detail later.)

Everything discussed

in terms of drugs and doses have been published in evidence based studies. Slide26

COMBINED ORAL SEDATION

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.

Drugs used: Midazolam and Ketamine.

Indications for Oral sedation:

Small children/young age: Under 3

yrs

old. (No cannulation needed!)

Small/ short procedures

Parental choiceSlide27

INTRAVENOUS (IV) SEDATION

Indications for IV Sedation:

Children older than 3

years.

Difficult/ extensive dental treatment required.

Behavioural problems/ Severe anxiety

.Slide28

INTRAVENOUS (IV) SEDATION

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 P

ropofol

as a

bolus.

Propofol continuous infusion (6-10mg/kg/h), and titrated to

effect. If using TCI (Target Controlled Infusion),

then the dose of P

ropofol

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.Slide29

SEDATION TECHNIQUES

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.

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.

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.

Treatment sessions usually

last from 30 minutes to 90 minutes, with the average around 45min.Slide30

AIRWAY MANAGEMENT

A

irway 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

.

Slide31

AIRWAY MANAGEMENT

Upper

Respiratory Tract infections can complicate airway management significantly in children. The sedation practitioner must be alert to this possibility. Slide32

AIRWAY MANAGEMENT

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. Slide33

AIRWAY MANAGEMENT

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.Slide34

POST-SEDATION RECOVERY

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.Slide35

POST-SEDATION RECOVERY

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.

)

The

child is usually not stimulated in the recovery room and may slip into deeper levels of sedation.

The

trained and highly experienced medically trained nurses in the recovery area are aware of this possibility

.

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.Slide36

POST-SEDATION RECOVERY

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.

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/ bleedingSlide37

POST-SEDATION COMMUNICATION

Parents are fully informed of the postoperative care and any special instructions.

Parents are also given after hours contact numbers, including a mobile number, and what to do in case of a medical emergency.

Parents will be contacted the next morning

to complete

a post sedation review over the

phone.

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).

This

approach contributes to a positive experience (successful visit, she/he will

remember for months afterwards)

for the child.

All

these findings are recorded in the patient’s sedation notes.Slide38

SAFETY AND EFFICACY

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

.

Furthermore,

they

have been very successful in

their

treatment plans as demonstrated by the following graphs: Slide39

PROBLEMS DURING ADVANCED SEDATIONSlide40

PROCEDURES UNDER ADVANCED SEDATIONSlide41

ADAVANCED SEDATION PATIENTSSlide42

THOUGHTS ON THE SEDATION PRACTICES AT TOOTHBEARY

A

very specialized sedation service.

E

mphasis

on the importance of using specialized and trained

staff.

C

ontinuous

professional

development: Aim to

attend as many sedation symposia

as

possible

.

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.Slide43

FOR THE FUTURE…

Nasal Midazolam & Ketamine:

Many studies have been done on drug delivery via the nasal route.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.

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.Slide44

FOR THE FUTURE…

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.Slide45

FOR THE FUTURE…

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.Slide46

FOR THE FUTURE…

Since the start of August 2012:

Started using a combination of Midazolam 0.3mg/kg and Ketamine 5mg/kg.

Using the MAD device for nasal delivery.

Very promising results.

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.Slide47

FOR THE FUTURE…

Bispectral Index (BIS) Monitor:

Another potential objective monitoring tool of the level of consciousness during sedation.

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.Slide48

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.Slide49