Pharmacological behaviour management in the child patient

1. 1
Pharmacological
considerations in the child
patient
 Dr.Sucheta Prabhu
Second year PG
14/12/17

2. Questions asked previously
 Short essays
 Drug dosage calculation in children
 Conscious sedation
 Use of midazolam in management of children
 Long essays
 Conscious sedation in pediatric dentistry
 Hospital management in pediatric dentistry
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3. How does a child differ from adults?
3

4. Systems of the body differing4
Low acidity in infants
Lowered secretion of
gastric acid
Low concentration of bile
acids,lipase
Infants and young
children are relatively
deficient in liver enzymes
At risk for toxicity if not
dosed correctly
Vast majority of drugs
excreted via renal system.
Immature renal capacity
hampers excretion.

5. Drug Dosages5

6. Drug Dosages6
• Dilling’s rule
• Gabius’s rule
• Bastedo’s rule
• Catzel’s rule
• Ausberger’s rule

7. Major reasons for use of drugs
in children
Pain & anxiety
Infections
Others
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8. Pain Anxiety
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Direct
response
to an
aversive
stimulus
Unpleasant
feeling/worry
that something
unpleasant
might happen
Childrens’s response to pain is influenced by age,memory of
previous negative dental experience, and coping ability.

9. Recognition of anxiety
Increased
blood pressure
and heart rate
Trembling
Excessive
sweating
Dilated pupils
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10. Sedating children can be
unpredictable.
10

11. Guidelines & Evidence
Unable to determine which drug was most effective. Many
cases have used other physical restraints with nitrous oxide (30-
50%).
11

12. Clinical decision making
Age
Degree of surgical
trauma involved
Current medical
condition
Allergies
Physical status
Airway patency Psychologic status
12

13. Medical status13
ASA Class Patient description
I Normal , healthy patient without underlying
systemic disorder
II Patient with mild systemic disease
III Patient with severe systemic disease, which limits
his/her activity but is not life threatening
IV Patient with severe systemic disease, which limits
his/her activity that is constantly life threatening
V Moribund patient, who is not expected to survive
beyond 24 hours with /without operation
VI Brain dead patient whose organs may be
harvested for transplant
E Emergency patient Grades I-IV €

14. Terminologies
 General anesthesia: Elimination of all sensation
accompanied by loss of consciousness.
 Analgesia: Diminution/elimination of pain in the conscious
patient
 Deep sedation : A controlled ,pharmacologically induced
state of depressed consciousness that retains the patients
ability to independently and continuously maintain airway
and respond appropriately to physical stimulation and
verbal command that is produced.
14

15. Terminologies
 Dissociative anesthesia: Dissociative anesthesia is a form
of anesthesia characterized by catalepsy,
catatonia, analgesia, and amnesia. It does not necessarily
involve loss of consciousness and thus does not always
imply a state of general anesthesia.
 Neuroleptic anesthesia : An intense analgesic and amnesic
state produced by administration of
narcotic and neuroleptic drugs; unconsciousness may
occur, and cardiorespiratory function may be altered.
 Relative analgesia: Used to describe a state of altered
consciousness in which a person is more carefree and
relaxed.
 Other terms : Chemamnesia, Sedamnesia,Twilight
sleep,Comedication.
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16. Conscious
A patient is said to be
conscious if he is capable
of rational response to
command and if he has all
his protective reflexes
intact, including the ability
to maintain and clear his
airway in a patent state.
16
American Association of Anesthesiology

17. Conscious sedation
A medically controlled state of
depressed consciousness that
allows protective reflexes to
be maintained , retains the
patients ability to maintain a
patent airway independently
and continuously, and
appropriate response by the
patient to physical
or verbal command.
17

18. Objectives
Alter patients mood,making him psychologically
acceptant.
Must allow to maintain consciousness throughout the
procedure.
Must result in patient cooperation.
Should raise pain threshold.
Must allow protective reflexes to be intact.
Should produce only small variation in vitals.
18

19. Indications
Dental Anxiety
Medical,physical,cognitive disability
Involuntary movement conditions
19

20. Clinical guidelines for use of
conscious sedation
Patient evaluation
(ASA)
Informed consent
Monitor baseline
vitals
Preoperative dietary
restrictions
Written instructions
to caregiver
One additional
personnel trained in
BLS
20

21. Appropriate intake of food and
liquids before elective sedation
Ingested mateial NBM
Clear liquids, clear tea, black
coffee
2 hrs
Breast milk 4
Non human milk 6
Light meal : Toast + clear
liquids
6
21

22. Preparation & Setup of
procedures
S= Suction
O=Oxygen supply
A=Airway
P=Pharmacy
M=Monitors
E=Special equipment for a particular use
22

23. Routes of administration
• Easy to administer
• Easy to monitor
• Level of sedation
can not be easily
changed
Oral
• Non invasive
• Drugs have very
rapid onset
• Short recovery
period
Inhalational Parenteral
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• Intravenous
• Intramuscular
• Subcutaneous

24. Oral sedation
Advantages
Ease of administration
Low cost
Decreased adverse reactions
No specialised training
Disadvantages
Patient compliance needed
Prolonged latent period
Inability to titrate
Unpredictable action duration
24

25. Factors influencing drug
absorbtion
Lipid solubility
pH of gastric
tissues
Mucosal surface
area
Gastric
emptying time
Dosage form of
drug
Drug inactivation
Presence of food
in stomach
25

26. Drugs used for preoperative
anxiolysis
Ethyl alcohol
Barbiturates
Benzodiazepines
Non benzodiazepine
anxiolytics
Chloral derivatives
26

27. Oral barbiturates
• 16-24hr CNS
depression
• Phenobarbital
• Sleeping pills
Long acting
• 3-4 hour duration
• Pentobarbital
• Insomnia
Short acting
• Thiopental
• Methohexital
Ultrashort acting
27
Disadvantage: Addictive, develop tolerance,implicated in
suicide attempts

28. Benzodiazepines
Flurazepam
Diazepam
Lorazepam
Midazolam
Prefered in management of preoperative
anxiety .
Advantage: Safety over other sedative-
hypnotics
28

29. Chloral hydrate
Popularly used in pediatric dentistry earlier
Produces GI irritation.
No analgesic properties.
Oral dose 50 mg/kg
Half life 7-9.5 hours.
Rapid onset drowsy sleep within 30-45 minutes.
Diration of action is 2-5 hours
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30. H1 Histamine
Blockers(Antihistamines)
Promethazine
Phenothiazine
Decreased agitation,hyperactivity
Antihistaminic,Antiemetic,sedative property
Does not cause unconsciousness in large doses
Does not depress respiratory , cardiovascular system.
Adverse effect-Drying of mouth,blurred vision
Dose: 12.5-25 mg 1 hour prior
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31. Rationale for use
Reduce anxiety
prior to dental
appointment
To be taken 1
hour HS
Not advocated for
deep level of
sedation since its
not controllable.
Thorough
knowledge of
adverse effects a
must.
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32. Rectal sedation
Advantages
Rapid onset
Non invasive
Low cost
Disadvantages
Does not bypass the
hepatic first pass effect
Lack of control
32

33. Drugs in rectal sedation
Barbiturates
Opiods
Promethazine
Chloral hydrate
Benzodiazepines
Ketamine
Lytic cocktail
(Meperidine+Promethazine+Chlorpromazine)
33

34. Sublingual , Intranasal sedation
 Drug enters directly into systemic circulation avoiding first
pass effect
 Patient cooperation is important.
 Drugs Opiods , sedatives
 Oral submucosal fentanyl citrate (fentanyl lollipop)
 Midazolam(0.2-0.4 mg/kg) and sufentanil (spray)
 Can be used when speed is of essence
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35. Intramuscular sedation
Advantages
Rapid onset
Maximal clinical effect in 30 mins
More reliable absorbtion
Patient cooperation not essential
Disadvantages
Inability to titrate
Inability to reverse action
Prolonged duration of drug effect
Painful injection
35

36. Recommendation & Sites
 Adult patient when inhalation and iv unavailable
 Distuptive patient where other routes proved ineffective
 Route to administer emergency drugs
36

37. Drugs
Anti anxiety and sedative hypnotics
Antihistamines
Barbiturates
Opiod analgesics
Dissociative Anesthetic
NSAID (ketorolac, diclo)
Complications: Nerve damage,
intraarterial injection
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38. Nitrous oxide
1772 Joseph
Priestley
1844 Horace
Wells
1872
Edmund
andrews
20% O2
80% N2O
1960 Harold
Langa into
dentistry
38
Over 160 years of use with safety

39. Advantages
Viable & cost
effective
Peak & depth
control (titrated)
Rapid induction &
recovery
Minimal effect on
CVS, Respiratory,
laryngeal reflex
Limitations
Nausea(acute)
Impotence,liver
toxicity,
abuse(chronic)
Degree of
cooperation from
patients
Bullky equipment
39

40. 40
Indications
Mild-moderate
anxiety
Needle phobia
Gag reflex
Contraindications
Very young
children
Underlying
psychiatric
disorders

41. Nitrous oxide sedation
 Inhalational
 Most frequently used
 CNS: Depressant and
Euphoriant
 Concentration effect
41
Sweet smelling
Colourless
Non-inflammable
Inert gas
Blood gas coefficient 0.47
Rapid onset & recovery
Weak analgesic
MAC 110

42. Guedel’s stages of anesthesia42

43. Equipment43
Free standing
unit
Piped
inhalational
system
Unit head
Reservoir bag
Gas
delivery
system
Safety Features
Minimum O2 is
30%
Automatic gas
cutout
Color coding
Gas pressure
dials
Scavenging,
Alarm

44. Precautions
Efficient scavenging system required. Laminar air
flow recommended.
Nasal hood may have an unacceptable odors so
flavored liquid may be applied.
Diffusion hypoxia may occur as the sedation is
reversed at the termination of the procedure.
44

45. Procedure
Bag is filled with 100% O2 & delivered 2-3 mins
Slowly introduce nitrous oxide
Adjust concentration to 30% nitrous & 70% O2
Post procedure administer 100% O2 for 5 mins
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46. Monitoring during sedation
 Respiratory rate,depth
 Pulse
 Responsiveness
 Body temperature
46

47. Signs & symptoms of optimal
sedation
Symptoms
• Lightheadedness
• Tingling
• Wave of warmth
• Numbness
• Euphoria
• Lightness/Heaviness in
extremities
• Analgesia
Signs
• BP,HR slight elevation early on,
return to baseline.
• Respiration smooth
• Flushing of face, extremities
• Decreased muscle tone
47

48. Clinical indicators of over
sedation
Patient persistently closes mouth
Spontaneous mouth breathing
Complains of nausea
Fails to respond rationally , gives sluggish response
Becomes sleepy
Speaks incoherently or dreams
Becomes uncooperative
48

49. Recovery & Discharge
CVS function & Airway patency
are satisfactory and stable
Presedation level responsiveness
established
State of hydration adequate
49

50. Psychomotor effects
 Bender Visual Motor Gestalt test
 Determines visiomotor capacity of child
50

51. Instructions to parents
 Any change in health to be
reported within 7 days before
treatment .
 Seek advice if vomiting persists
, temperature is elevated
beyond 24 hours
51

52. Special indications for Nitrous
oxide sedation
Cardiovascular disease Can minimise risk of MI
Cerebrovascular disease Stress/anxiety reduction
Heaptic disease No hepatic biotransformation,
can be safely used .
Epilepsy& seizure Useful to avoid stress
52
Brown DM. Aiding in administration of nitrous oxide
analgesia.Idaho state board of dentistry 2005

53. Issues surrounding nitrous
oxide
Potential
biohazard from
long term
exposure to trace
anesthetic gas.
Scavenging nasal
hood a must
Monitoring of
trace nitrous
oxide
Recreational
abuse
53

54. Intravenous sedation
William
Harvey(1578)
Pierre ore
chloral hydrate
iv(1872)
Emil fisher :
Barbiturates(1900)
Neils
jorgenson(1945)
54

55. Intravenous sedation agents
Indications
Mostly adults
Traumatic surgical
procedures
Contraindications
Allergies
Impaired
renal/hepatic
systems
55
Children below 16 years to be cautiously approached

56. Advantage
Rapid onset
Titration possible
Recovery period
short
Motor disturbances
less
Disadvantage
Venipuncture
needed
More intensive
monitoring
Recovery not
complete
Most agents cannot
be reversed
56

57. Drugs used for intravenous
sedation
Benzodiazepines : Diazepam
Midazolam
Propofol
57

58. Benzodiazepines
 Discovered in Switzerland by Hoffman-La Roche
58
Clinical effects
1.Induction of
conscious sedation for
20-30mins.
2.Anterograde amnesia
3.Muscle relaxation
4.Anticonvulsant action
5.Minimal CVS & RS
depression when
titrated slowly.
Side effects
1.Respiratory depression
2.Cardiovascular
depression
3.Tolerance

59. Diazepam/Lorazepam
First BZD used in intravenous sedation practice
Almost insoluble in water
Metabolised in liver, eliminated via kidneys
Half life =43 hours
Dose=0.1-0.2 mg/kg
Limitation: Long recovery period
59

60. Midazolam
Agent of choice for iv sedation in dentistry.
Acute detachment, retrograde amnesia
Lipid soluble, readily penetrates BBB
Half life 1.9 hours
Rapid action, more potent
Dose 0.07-0.1 mg/kg
Slight cardiovascular,respiratory depression
Angry child syndrome (paradoxic increased aggression)
60

61. Propofol
2,6 diisopropylphenol
Elimintion half life 30-50 minutes
Dose:6-9mg/kg/hr
Narrower margin of safety
Rapid onset and recovery
May have central depressant effects
Less residual postoperative “Hangover”
61

62. Ketamine
Synthesized by Parke-Davis
Phencyclidine derivative
Causes dissociative analgesia(blank stare)
Maintains CVS stability ,muscle tone, airway reflexes
Iv dose 1mg/kg
May cause increased ICT, tachycardia , postemergence delirium(vivid
nightmares)
Recreational drug. Chronic use impairs cognitive ability,memory loss.
62

63. Reversal agents63
Flumazenil
BZD reversal
Dose-0.01mg/kg
upto 4 times

64. Equipment for intravenous
sedation
64

65. Technique for intravenous
sedation
65

66. 66

67. Titration of agent
 0.5ml (1mg) over 15 secs
 Pause for 1 minute
 Followed by 1mg over 1minute till signs visible.
67
Signs
Slurred /Slowed speech
Relaxed demaneour
Delayed response to commands
Positive Eve’s sign(Motor coordination)
Verril’s sign

68. Local complications
 Extravenous injection
 Intraarterial injection
 Postoperative haematoma
68

69. Emergency equipment69
oxygen cylinder oral airways nasal airways
ambu bag suction equipment

70. Emergency Drugs70

71. References
 1.Marwah N. Textbook of pediatric dentistry.3rd edn.
 2.Tandon S. Textbook of Pedodontics. 2nd edn. Paras
medical publishers 2009
 3.Malamed S. Sedation :A guide to patient management.4th
edn.Mosby
 4.Girdler N.M.Clinical sedation in dentistry.Wiley-Blackwell
publication 2009
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