Transcript Premedication Pain managment

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.
• Older children and teenagers can use a normal visual analogue
scale of 1–10.
• Mentaly handicaped children - difficult to assess - unusual
changes in behaviour
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.
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
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
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! Watch out in hepatopathy
Useful as a pre-emptive analgesic
No effect on bleeding
IV paracetamol (PERFALGAN) in hospitalised
NSAID - ibuprofen
• Pre-op - ibuprofen 10mg/kg p.o. (syrup)
• Post-op – if needed ibuprofen 5 mg/kg á 6-8 hod. p.o.
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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.
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, steroiddependent or have coexisting nasal polyps.
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.
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
Inhalation sedation- nitrous
oxide 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
Contraindications
• Severe psychiatric disorders , mentaly handicaped
• Obstructive pulmonary disease
• Chronic obstructive airway disease
• Communication problems
• Uncooperating patients
• Pregnancy
• Acute respiratory tract infections
Complications
• nausea, vomiting
• headache
Course of performance
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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
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
Oral sedation
Premedication
• Benzodiazepines (e.g. midazolam)
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Potentiated sedation– ANESTEZIOLOGIST
Chloral hydrate
Hydroxyzine
Promethazine
Ketamine
Midazolam - Dormicum
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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
Course of performance
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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.
Midazolam
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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
Midazolam
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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
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.
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
Discharge criteria after
sedation
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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.